Migraine

Back Clinic Chiropractic and Physical Therapy Migraine Team. Migraine is a genetic neurological disease, characterized by episodes called Migraine attacks. They are quite different from regular headaches which are non-migrainous. About 100 million people suffer from headaches in the U.S. And 37 million of these people suffer migraines. The World Health Organization estimates that 18 percent of women and 7 percent of men in the U.S. suffer from these headaches. Migraines are called primary headaches because the pain is not caused by a disorder or disease i.e. a brain tumor or head injury.

Some cause pain only on the right side or left side of the head. While others result in pain everywhere. Migraine sufferers can have moderate or severe pain but usually can’t participate in regular activities because of the pain. When a migraine strikes, a quiet dark room may help with the symptoms. They can last for four hours or can last for days. The range of time someone is affected by an attack is actually longer than the headache itself. This is because there is a pre-monitory or build-up, and then a post-drome that can last for one to two days.

Psychology, Headache, Back Pain, Chronic Pain and Chiropractic in El Paso, TX

by spinedoctors | Back Pain, Chiropractic, Chronic Pain, Migraine, Physical Rehabilitation, Randomized Controlled Trial, Stress, Treatments

Everyone experiences pain from time to time. Pain is a physical feeling of discomfort caused by injury or illness. When you pull a muscle or cut your finger, for instance, a signal is sent through the nerve roots to the brain, signaling you that something is wrong in the body. Pain may be different for everyone and there are several ways of feeling and describing pain. After an injury or illness heals, the pain will subside, however, what happens if the pain continues even after you’ve healed?

Chronic pain is often defined as any pain which lasts more than 12 weeks. Chronic pain can range from mild to severe and it can be the result of previous injury or surgery, migraine and headache, arthritis, nerve damage, infection and fibromyalgia. Chronic pain can affect an individual’s emotional and mental disposition, making it more difficult to relieve the symptoms. Research studies have demonstrated that psychological interventions can assist the chronic pain recovery process. Several healthcare professionals, like a doctor of chiropractic, can provide chiropractic care together with psychological interventions to help restore the overall health and wellness of their patients. The purpose of the following article is to demonstrate the role of psychological interventions in the management of patients with chronic pain, including headache and back pain.

The Role of Psychological Interventions in the Management of Patients with Chronic Pain

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Abstract

Chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient�s physiological state, thoughts, emotions, behaviors, and sociocultural influences. A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain. Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress � improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, psychologists can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives.

Keywords: chronic pain management, psychology, multidisciplinary pain treatment, cognitive behavioral therapy for pain

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Dr. Alex Jimenez’s Insight

Chronic pain has previously been determined to affect the psychological health of those with persistent symptoms, ultimately altering their overall mental and emotional disposition. In addition, patients with overlapping conditions, including stress, anxiety and depression, can make treatment a challenge. The role of chiropractic care is to restore as well as maintain and improve the original alignment of the spine through the use of spinal adjustments and manual manipulations. Chiropractic care allows the body to naturally heal itself without the need for drugs/medications and surgical interventions, although these can be referred to by a chiropractor if needed. However, chiropractic care focuses on the body as a whole, rather than on a single injury and/or condition and its symptoms. Spinal adjustments and manual manipulations, among other treatment methods and techniques commonly used by a chiropractor, require awareness of the patient’s mental and emotional disposition in order to effectively provide them with overall health and wellness. Patients who visit my clinic with emotional distress from their chronic pain are often more susceptible to experience psychological issues as a result. Therefore, chiropractic care can be a fundamental psychological intervention for chronic pain management, along with those demonstrated below.

Introduction

Pain is a ubiquitous human experience. It is estimated that approximately 20%�35% of adults experience chronic pain.[1,2] The National Institute of Nursing Research reports that pain affects more Americans than diabetes, heart disease, and cancer combined.[3] Pain has been cited as the primary reason to seek medical care in the United States.[4] Furthermore, pain relievers are the second most commonly prescribed medications in physicians� offices and emergency rooms.[5] Further solidifying the importance of adequate assessment of pain, the Joint Commission on the Accreditation of Healthcare Organizations issued a mandate requiring that pain be evaluated as the fifth vital sign during medical visits.[6]

The International Association for the Study of Pain (IASP) defines pain as �an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage�.[7] The IASP�s definition highlights the multidimensional and subjective nature of pain, a complex experience that is unique to each individual. Chronic pain is typically differentiated from acute pain based on its chronicity or persistence, its physiological maintenance mechanisms, and/or its detrimental impact on an individual�s life. Generally, it is accepted that pain that persists beyond the expected period of time for tissue healing following an injury or surgery is considered chronic pain. However, the specific timeframe constituting an expected healing period is variable and often difficult to ascertain. For ease of classification, certain guidelines suggest that pain persisting beyond a 3�6 month time window is considered chronic pain.[7] Nevertheless, classification of pain based solely on duration is a strictly practical and, in some instances, arbitrary criterion. More commonly, additional factors such as etiology, pain intensity, and impact are considered alongside duration when classifying chronic pain. An alternative way to characterize chronic pain has been based on its physiological maintenance mechanism; that is, pain that is thought to emerge as a result of peripheral and central reorganization. Common chronic pain conditions include musculoskeletal disorders, neuropathic pain conditions, headache pain, cancer pain, and visceral pain. More broadly, pain conditions may be primarily nociceptive (producing mechanical or chemical pain), neuropathic (resulting from nerve damage), or central (resulting from dysfunction in the neurons of the central nervous system).[8]

Unfortunately, the experience of pain is frequently characterized by undue physical, psychological, social, and financial suffering. Chronic pain has been recognized as the leading cause of long-term disability in the working- age American population.[9] Because chronic pain affects the individual at multiple domains of his/her existence it also constitutes an enormous financial burden to our society. The combined direct and indirect costs of pain have been estimated to range from $125 billion to $215 billion, annually.[10,11] The widespread implications of chronic pain include increased reports of emotional distress (eg, depression, anxiety, and frustration), increased rates of pain-related disability, pain-related alterations in cognition, and reduced quality of life. Thus, chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient�s physiological state, thoughts, emotions, behaviors, and sociocultural influences.

Pain Management

Given the widespread prevalence of pain and its multi-dimensional nature, an ideal pain management regimen will be comprehensive, integrative, and interdisciplinary. Current approaches to the management of chronic pain have increasingly transcended the reductionist and strictly surgical, physical, or pharmacological approach to treatment. Current approaches recognize the value of a multidisciplinary treatment framework that targets not only nociceptive aspects of pain but also cognitive-evaluative, and motivational-affective aspects alongside equally unpleasant and impacting sequelae. The interdisciplinary management of chronic pain typically includes multimodal treatments such as combinations of analgesics, physical therapy, behavioral therapy, and psychological therapy. The multimodal approach more adequately and comprehensively addresses pain management at the molecular, behavioral, cognitive-affective, and functional levels. These approaches have been shown to lead to superior and long-lasting subjective and objective outcomes including pain reports, mood, restoration of daily functioning, work status, and medication or health care use; multimodal approaches have also been shown to be more cost-effective than unimodal approaches.[12,13] The focus of this review will be specifically on elucidating the benefits of psychology in the management of chronic pain.

Dr. Jimenez performing physical therapy on a patient.

Patients will typically initially present to a physician�s office in the pursuit of a cure or treatment for their ailment/acute pain. For many patients, depending on the etiology and pathology of their pain alongside biopsychosocial influences on the pain experience, acute pain will resolve with the passage of time, or following treatments aimed at targeting the presumed cause of pain or its transmission. Nonetheless, some patients will not achieve resolution of their pain despite numerous medical and complementary interventions and will transition from an acute pain state to a state of chronic, intractable pain. For instance, research has demonstrated that approximately 30% of patients presenting to their primary-care physician for complaints related to acute back pain will continue to experience pain and, for many others, severe activity limitations and suffering 12 months later.[14] As pain and its consequences continue to develop and manifest in diverse aspects of life, chronic pain may become primarily a biopsychosocial problem, whereby numerous biopsychosocial aspects may serve to perpetuate and maintain pain, thus continuing to negatively impact the affected individual�s life. It is at this point that the original treatment regimen may diversify to include other therapeutic components, including psychological approaches to pain management.

Psychological approaches for the management of chronic pain initially gained popularity in the late 1960s with the emergence of Melzack and Wall�s �gate-control theory of pain�[15] and the subsequent �neuromatrix theory of pain�.[16] Briefly, these theories posit that psychosocial and physiological processes interact to affect perception, transmission, and evaluation of pain, and recognize the influence of these processes as maintenance factors involved in the states of chronic or prolonged pain. Namely, these theories served as integral catalysts for instituting change in the dominant and unimodal approach to the treatment of pain, one heavily dominated by strictly biological perspectives. Clinicians and patients alike gained an increasing recognition and appreciation for the complexity of pain processing and maintenance; consequently, the acceptance of and preference for multidimensional conceptualizations of pain were established. Currently, the biopsychosocial model of pain is, perhaps, the most widely accepted heuristic approach to understanding pain.[17] A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain.[17] As the utility of a broader and more comprehensive approach to the management of chronic pain has become evident, psychologically-based interventions have witnessed a remarkable rise in popularity and recognition as adjunct treatments. The types of psychological interventions employed as part of a multidisciplinary pain treatment program vary according to therapist orientation, pain etiology, and patient characteristics. Likewise, research on the effectiveness of psychologically based interventions for chronic pain has shown variable, albeit promising, results on key variables studied. This overview will briefly describe frequently employed psychologically based treatment options and their respective effectiveness on key outcomes.

Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. As such, they target the frequently overlooked behavioral, emotional, and cognitive components of chronic pain and factors contributing to its maintenance. Informed by the framework offered by Hoffman et al[18] and Kerns et al,[19] the following frequently employed psychologically-based treatment domains are reviewed: psychophysiological techniques, behavioral approaches to treatment, cognitive behavioral therapy, and acceptance-based interventions.

Psychophysiological Techniques

Biofeedback

Biofeedback is a learning technique through which patients learn to interpret feedback (in the form of physiological data) regarding certain physiological functions. For instance, a patient may use biofeedback equipment to learn to recognize areas of tension in their body and subsequently learn to relax those areas to reduce muscular tension. Feedback is provided by a variety of measurement instruments that can yield information about brain electrical activity, blood pressure, blood flow, muscle tone, electrodermal activity, heart rate, and skin temperature, among other physiological functions in a rapid manner. The goal of biofeedback approaches is for the patient to learn how to initiate physiological self-regulatory processes by achieving voluntary control over certain physiological responses to ultimately increase physiological flexibility through greater awareness and specific training. Thus a patient will use specific self-regulatory skills in an attempt to reduce an undesired event (eg, pain) or maladaptive physiological reactions to an undesired event (eg, stress response). Many psychologists are trained in biofeedback techniques and provide these services as part of therapy. Biofeedback has been designated as an efficacious treatment for pain associated with headache and temporomandibular disorders (TMD).[20] A meta-analysis of 55 studies revealed that biofeedback interventions (including various biofeedback modalities) yielded significant improvements with regard to frequency of migraine attacks and perceptions of headache management self-efficacy when compared to control conditions.[21] Studies have provided empirical support for biofeedback for TMD, albeit more robust improvements with regard to pain and pain-related disability have been found for protocols that combine biofeedback with cognitive behavioral skills training, under the assumption that a combined treatment approach more comprehensively addresses the gamut of biopsychosocial problems that may be encountered as a result of TMD.[22]

Behavioral Approaches

Relaxation Training

It is generally accepted that stress is a key factor involved in the exacerbation and maintenance of chronic pain.[16,23] Stress can be predominantly of an environmental, physical, or psychological/emotional basis, though typically these mechanisms are intricately intertwined. The focus of relaxation training is to reduce tension levels (physical and mental) through activation of the parasympathetic nervous system and through attainment of greater awareness of physiological and psychological states, thereby achieving reductions in pain and increasing control over pain. Patients can be taught several relaxation techniques and practice them individually or in conjunction with one another, as well as adjuvant components to other behavioral and cognitive pain management techniques. The following are brief descriptions of relaxation techniques commonly taught by psychologists specializing in the management of chronic pain.

Diaphragmatic breathing. Diaphragmatic breathing is a basic relaxation technique whereby patients are instructed to use the muscles of their diaphragm as opposed to the muscles of their chest to engage in deep breathing exercises. Breathing by contracting the diaphragm allows the lungs to expand down (marked by expansion of abdomen during inhalation) and thus increase oxygen intake.[24]

Progressive muscle relaxation (PMR). PMR is characterized by engaging in a combination of muscle tension and relaxation exercises of specific muscles or muscle groups throughout the body.[25] The patient is typically instructed to engage in the tension/relaxation exercises in a sequential manner until all areas of the body have been addressed.

Autogenic training (AT). AT is a self-regulatory relaxation technique in which a patient repeats a phrase in conjunction with visualization to induce a state of relaxation.[26,27] This method combines passive concentration, visualization, and deep breathing techniques.

Visualization/Guided imagery. This technique encourages patients to use all of their senses in imagining a vivid, serene, and safe environment to achieve a sense of relaxation and distraction from their pain and pain-related thoughts and sensations.[27]

Collectively, relaxation techniques have generally been found to be beneficial in the management of a variety of types of acute and chronic pain conditions as well as in the management of important pain sequelae (eg, health-related quality of life).[28�31] Relaxation techniques are usually practiced in conjunction with other pain management modalities, and there is considerable overlap in the presumed mechanisms of relaxation and biofeedback, for instance.

Operant Behavior Therapy

Operant behavior therapy for chronic pain is guided by the original operant conditioning principles proposed by Skinner[32] and refined by Fordyce[33] to be applicable to pain management. The main tenets of the operant conditioning model as it relates to pain hold that pain behavior can eventually evolve into and be maintained as chronic pain manifestations as a result of positive or negative reinforcement of a given pain behavior as well as punishment of more adaptive, non-pain behavior. If reinforcement and the ensuing consequences occur with sufficient frequency, they can serve to condition the behavior, thus increasing the likelihood of repeating the behavior in the future. Therefore, conditioned behaviors occur as a product of learning of the consequences (actual or anticipated) of engaging in the given behavior. An example of a conditioned behavior is continued use of medication � a behavior that results from learning through repeated associations that taking medication is followed by removal of an aversive sensation (pain). Likewise, pain behaviors (eg, verbal expressions of pain, low activity levels) can be become conditioned behaviors that serve to perpetuate chronic pain and its sequelae. Treatments that are guided by operant behavior principles aim to extinguish maladaptive pain behaviors through the same learning principles that these may have been established by. In general, treatment components of operant behavior therapy include graded activation, time contingent medication schedules, and use of reinforcement principles to increase well behaviors and decrease maladaptive pain behaviors.

Graded activation. Psychologists can implement graded activity programs for chronic pain patients who have vastly reduced their activity levels (increasing likelihood of physical deconditioning) and subsequently experience high levels of pain upon engaging in activity. Patients are instructed to safely break the cycle of inactivity and deconditioning by engaging in activity in a controlled and time-limited fashion. In this manner, patients can gradually increase the length of time and intensity of activity to improve functioning. Psychologists can oversee progress and provide appropriate reinforcement for compliance, correction of misperceptions or misinterpretations of pain resulting from activity, where appropriate, and problem-solve barriers to adherence. This approach is frequently embedded within cognitive-behavioral pain management treatments.

Time-contingent medication schedules. A psychologist can be an important adjunct healthcare provider in overseeing the management of pain medications. In some cases, psychologists have the opportunity for more frequent and in-depth contact with patients than physicians and thus can serve as valuable collaborators of an integrated multidisciplinary treatment approach. Psychologists can institute time-contingent medication schedules to reduce the likelihood of dependence on pain medications for attaining adequate control over pain. Furthermore, psychologists are well equipped to engage patients in important conversations regarding the importance of proper adherence to medications and medical recommendations and problem-solve perceived barriers to safe adherence.

Fear-avoidance. The fear-avoidance model of chronic pain is a heuristic most frequently applied in the context of chronic low back pain (LBP).[34] This model draws largely from the operant behavior principles described previously. In essence, the fear-avoidance model posits that when acute pain states are repeatedly misinterpreted as danger signals or signs of serious injury, patients may be at risk of engaging in fear-driven avoidance behaviors and cognitions that further reinforce the belief that pain is a danger signal and perpetuate physical deconditioning. As the cycle continues, avoidance may generalize to broader types of activity and result in hypervigilance of physical sensations characterized by misinformed catastrophic interpretations of physical sensations. Research has shown that a high degree of pain catastrophizing is associated with maintenance of the cycle.[35] Treatments aimed at breaking the fear-avoidance cycle employ systematic graded exposure to feared activities to disconfirm the feared, often catastrophic, consequences of engaging in activities. Graded exposure is typically supplemented with psychoeducation about pain and cognitive restructuring elements that target maladaptive cognitions and expectations about activity and pain. Psychologists are in an excellent position to execute these types of interventions that closely mimic exposure treatments traditionally used in the treatment of some anxiety disorders.

Though specific graded exposure treatments have been shown to be effective in the treatment of complex regional pain syndrome type I (CRPS-1)[36] and LBP[37] in single-case designs, a larger-scale randomized controlled trial comparing systematic graded exposure treatment combined with multidisciplinary pain program treatment with multidisciplinary pain program treatment alone and with a wait-list control group found that the two active treatments resulted in significant improvements on outcome measures of pain intensity, fear of movement/injury, pain self-efficacy, depression, and activity level.[38] Results from this trial suggest that both interventions were associated with significant treatment effectiveness such that the graded exposure treatment did not appear to result in additional treatment gains.[38] A cautionary note in the interpretation of these results highlights that the randomized controlled trial (RCT) included a variety of chronic pain conditions that extended beyond LBP and CRPS-1 and did not exclusively include patients with high levels of pain-related fear; the interventions were also delivered in group formats rather than individual formats. Although in-vivo exposure treatments are superior at reducing pain catastrophizing and perceptions of harmfulness of activities, exposure treatments seem to be as effective as graded activity interventions in improving functional disability and chief complaints.[39] Another clinical trial compared the effectiveness of treatment-based classification (TBC) physical therapy alone to TBC augmented with graded activity or graded exposure for patients with acute and sub-acute LBP.[40] Outcomes revealed that there were no differences in 4-week and 6-month outcomes for reduction of disability, pain intensity, pain catastrophizing, and physical impairment among treatment groups, although graded exposure and TBC yielded larger reductions in fear-avoidance beliefs at 6 months.[40] Findings from this clinical trial suggest that enhancing TBC with graded activity or graded exposure does not lead to improved outcomes with regard to measures associated with the development of chronic LBP beyond improvements achieved with TBC alone.[40]

Cognitive-Behavioral Approaches

Cognitive-behavioral therapy (CBT) interventions for chronic pain utilize psychological principles to effect adaptive changes in the patient�s behaviors, cognitions or evaluations, and emotions. These interventions are generally comprised of basic psychoeducation about pain and the patient�s particular pain syndrome, several behavioral components, coping skills training, problem-solving approaches, and a cognitive restructuring component, though the exact treatment components vary according to the clinician. Behavioral components may include a variety of relaxation skills (as reviewed in the behavioral approaches section), activity pacing instructions/graded activation, behavioral activation strategies, and promotion of resumption of physical activity if there is a significant history of activity avoidance and subsequent deconditioning. The primary aim in coping skills training is to identify current maladaptive coping strategies (eg, catastrophizing, avoidance) that the patient is engaging in alongside their use of adaptive coping strategies (eg, use of positive self-statements, social support). As a cautionary note, the degree to which a strategy is adaptive or maladaptive and the perceived effectiveness of particular coping strategies varies from individual to individual.[41] Throughout treatment, problem-solving techniques are honed to aid patients in their adherence efforts and to help them increase their self-efficacy. Cognitive restructuring entails recognition of current maladaptive cognitions the patient is engaging in, challenging of the identified negative cognitions, and reformulation of thoughts to generate balanced, adaptive alternative thoughts. Through cognitive restructuring exercises, patients become increasingly adept at recognizing how their emotions, cognitions, and interpretations modulate their pain in positive and negative directions. As a result, it is presumed that the patients will attain a greater perception of control over their pain, be better able to manage their behavior and thoughts as they relate to pain, and be able to more adaptively evaluate the meaning they ascribe to their pain. Additional components sometimes included in a CBT intervention include social skills training, communication training, and broader approaches to stress management. Via a pain-oriented CBT intervention, many patients profit from improvements with regard to their emotional and functional well-being, and ultimately their global perceived health-related quality of life.

Dr. Alex Jimenez engaging in fitness exercise and physical activity.

CBT interventions are delivered within a supportive and empathetic environment that strives to understand the patient�s pain from a biopsychosocial perspective and in an integrated manner. Therapists see their role as �teachers� or �coaches� and the message communicated to patients is that of learning to better manage their pain and improve their daily function and quality of life as opposed to aiming to cure or eradicate the pain. The overarching goal is to increase the patients� understanding of their pain and their efforts to manage pain and its sequelae in a safe and adaptive manner; therefore, teaching patients to self-monitor their behavior, thoughts, and emotions is an integral component of therapy and a useful strategy to enhance self-efficacy. Additionally, the therapist endeavors to foster an optimistic, realistic, and encouraging environment in which the patient can become increasingly skilled at recognizing and learning from their successes and learning from and improving upon unsuccessful attempts. In this manner, therapists and patients work together to identify patient successes, barriers to adherence, and to develop maintenance and relapse-prevention plans in a constructive, collaborative, and trustworthy atmosphere. An appealing feature of the cognitive behavioral approach is its endorsement of the patient as an active participant of his/her pain rehabilitation or management program.

Research has found CBT to be an effective treatment for chronic pain and its sequelae as marked by significant changes in various domains (ie, measures of pain experience, mood/affect, cognitive coping and appraisal, pain behavior and activity level, and social role function) when compared with wait-list control conditions.[42] When compared with other active treatments or control conditions, CBT has resulted in notable improvements, albeit smaller effects (effect size ~ 0.50), with regard to pain experience, cognitive coping and appraisal, and social role function.[42] A more recent meta-analysis of 52 published studies compared behavior therapy (BT) and CBT against treatment as usual control conditions and active control conditions at various time-points.[43] This meta-analysis concluded that their data did not lend support for BT beyond improvements in pain immediately following treatment when compared with treatment as usual control conditions.[43] With regard to CBT, they concluded that CBT has limited positive effects for pain disability, and mood; nonetheless, there are insufficient data available to investigate the specific influence of treatment content on selected outcomes.[43] Overall, it appears that CBT and BT are effective treatment approaches to improve mood; outcomes that remain robust at follow-up data points. However, as highlighted by several reviews and meta-analyses, a critical factor to consider in evaluating the effectiveness of CBT for the management of chronic pain is centered on issues of effective delivery, lack of uniform treatment components, differences in delivery across clinicians and treatment populations, and variability in outcome variables of interest across research trials.[13] Further complicating the interpretation of effectiveness findings are patient characteristics and additional variables that may independently affect treatment outcome.

Acceptance-Based Approaches

Acceptance-based approaches are frequently identified as third-wave cognitive-behavioral therapies. Acceptance and commitment therapy (ACT) is the most common of the acceptance-based psychotherapies. ACT emphasizes the importance of facilitating the client�s progress toward attaining a more valued and fulfilling life by increasing psychological flexibility rather than strictly focusing on restructuring cognitions.[44] In the context of chronic pain, ACT targets ineffective control strategies and experiential avoidance by fostering techniques that establish psychological flexibility. The six core processes of ACT include: acceptance, cognitive defusion, being present, self as context, values, and committed action.[45] Briefly, acceptance encourages chronic pain patients to actively embrace pain and its sequelae rather than attempt to change it, in doing so encouraging the patient to cease a futile fight directed at the eradication of their pain. Cognitive defusion (deliteralization) techniques are employed to modify the function of thoughts rather than to reduce their frequency or restructure their content. In this manner, cognitive defusion may simply alter the undesirable meaning or function of negative thoughts and thus decrease the attachment and subsequent emotional and behavioral response to such thoughts. The core process of being present emphasizes a non-judgmental interaction between the self and private thoughts and events. Values are utilized as guides for electing behaviors and interpretations that are characterized by those values an individual strives to instantiate in everyday life. Finally, through committed action, patients can realize behavior changes aligned with individual values. Thus, ACT utilizes the six core principles in conjunction with one another to take a holistic approach toward increasing psychological flexibility and decreasing suffering. Patients are encouraged to view pain as inevitable and accept it in a nonjudgmental manner so that they can continue to derive meaning from life despite the presence of pain. The interrelated core processes exemplify mindfulness and acceptance processes and commitment and behavior change processes.[45]

Results of research on the effectiveness of ACT-based approaches for the management of chronic pain are promising, albeit still warranting further evaluation. A RCT comparing ACT with a waitlist control condition reported significant improvements in pain catastrophizing, pain-related disability, life satisfaction, fear of movements, and psychological distress that were maintained at the 7 month follow-up.[46] A larger trial reported significant improvements for pain, depression, pain-related anxiety, disability, medical visits, work status, and physical performance.[47] A recent meta-analysis evaluating acceptance-based interventions (ACT and mindfulness-based stress reduction) in patients with chronic pain found that, in general, acceptance-based therapies lead to favorable outcomes for patients with chronic pain.[48] Specifically, the meta-analysis revealed small to medium effect sizes for pain intensity, depression, anxiety, physical wellbeing, and quality of life, with smaller effects found when controlled clinical trials were excluded and only RCTs were included in the analyses.[48] Other acceptance-based interventions include contextual cognitive-behavioral therapy and mindfulness-based cognitive therapy, though empirical research on the effectiveness of these therapies for the management of chronic pain is still in its infancy.

Expectations

An important and vastly overlooked common underlying element of all treatment approaches is consideration of the patient�s expectation for treatment success. Despite the numerous advances in the formulation and delivery of effective multidisciplinary treatments for chronic pain, relatively little emphasis has been placed on recognizing the importance of expectations for success and on focusing efforts on enhancement of patients� expectations. The recognition that placebo for pain is characterized by active properties leading to reliable, observable, and quantifiable changes with neurobiological underpinnings is currently at the vanguard of pain research. Numerous studies have confirmed that, when induced in a manner that optimizes expectations (via manipulation of explicit expectations and/or conditioning), analgesic placebos can result in observable and measurable changes in pain perception at a conscious self-reported level as well as a neurological pain-processing level.[49,50] Analgesic placebos have been broadly defined as simulated treatments or procedures that occur within a psychosocial context and exert effects on an individual�s experience and/or physiology.[51] The current conceptualization of placebo emphasizes the importance of the psychosocial context within which placebos are embedded. Underlying the psychosocial context and ritual of treatment are patients� expectations. Therefore, it is not surprising that the placebo effect is intricately embedded in virtually every treatment; as such, clinicians and patients alike will likely benefit from recognition that therein lies an additional avenue by which current treatment approaches to pain can be enhanced.

It has been proposed that outcome expectancies are core influences driving the positive changes attained through the various modes of relaxation training, hypnosis, exposure treatments, and many cognitive-oriented therapeutic approaches. Thus, a sensible approach to the management of chronic pain capitalizes on the power of patients� expectations for success. Regrettably, too often, health care providers neglect to directly address and emphasize the importance of patients� expectations as integral factors contributing to successful management of chronic pain. The zeitgeist in our society is that of mounting medicalization of ailments fueling the general expectation that pain (even chronic pain) ought to be eradicated through medical advancements. These all too commonly held expectations leave many patients disillusioned with current treatment outcomes and contribute to an incessant search for the �cure�. Finding the �cure� is the exception rather than the rule with respect to chronic pain conditions. In our current climate, where chronic pain afflicts millions of Americans annually, it is in our best interest to instill and continue to advocate a conceptual shift that instead focuses on effective management of chronic pain. A viable and promising route to achieving this is to make the most of patients� positive (realistic) expectations and educate pain patients as well as the lay public (20% of whom will at some future point become pain patients) on what constitutes realistic expectations regarding the management of pain. Perhaps, this can occur initially through current, evidence-based education regarding placebo and nonspecific treatment effects such that patients can correct misinformed beliefs they may have previously held. Subsequently clinicians can aim to enhance patients� expectations within treatment contexts (in a realistic fashion) and minimize pessimistic expectations that deter from treatment success, therefore, learning to enhance their current multidisciplinary treatments through efforts guided at capitalizing on the improvements placebo can yield, even within an �active treatment�. Psychologists can readily address these issues with their patients and help them become advocates of their own treatment success.

Emotional Concomitants of Pain

An often challenging aspect of the management of chronic pain is the unequivocally high prevalence of comorbid emotional distress. Research has demonstrated that depression and anxiety disorders are upward to three times more prevalent among chronic pain patients than among the general population.[52,53] Frequently, pain patients with psychiatric comorbidities are labeled �difficult patients� by healthcare providers, possibly diminishing the quality of care they will receive. Patients with depression have poorer outcomes for both depression and pain treatments, compared with patients with single diagnoses of pain or depression.[54,55] Psychologists are remarkably suited to address most of the psychiatric comorbidities typically encountered in chronic pain populations and thus improve pain treatment outcomes and decrease the emotional suffering of patients. Psychologists can address key symptoms (eg, anhedonia, low motivation, problem-solving barriers) of depression that readily interfere with treatment participation and emotional distress. Moreover, irrespective of a psychiatric comorbidity, psychologists can help chronic pain patients process important role transitions they may undergo (eg, loss of job, disability), interpersonal difficulties they may be encountering (eg, sense of isolation brought about by pain), and emotional suffering (eg, anxiety, anger, sadness, disappointment) implicated in their experience. Thus, psychologists can positively impact the treatment course by reducing the influence of emotional concomitants that are addressed as part of therapy.

Conclusion

Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain are abundant. These include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress-improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, a psychologist can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives. Additional benefits of an integrated and holistic approach to the management of chronic pain may include increased rates of return to work, reductions in health care costs, and increased health-related quality of life for millions of patients throughout the world.

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Footnotes

Disclosure: No conflicts of interest were declared in relation to this paper.

In conclusion, psychological interventions can be effectively used to help relieve symptoms of chronic pain along with the use of other treatment modalities, such as chiropractic care. Furthermore, the research study above demonstrated how specific psychological interventions can improve the outcome measures of chronic pain management. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

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EXTRA IMPORTANT TOPIC: Managing Workplace Stress

Migraine Pain & Lumbar Herniated Disc Treatment in El Paso, TX

by spinedoctors | Cohort Studies, Herniated Disc, Migraine, Randomized Controlled Trial, Spinal Decompression Treatments, Treatments

One of the most prevalent causes of lower back pain and sciatica may be due to the compression of the nerve roots in the low back from a lumbar herniated disc, or a ruptured disc in the lumbar spine. Common symptoms of lumbar herniated discs include varying intensities of pain, muscle spasms or cramping, sciatica and leg weakness as well as loss of proper leg function. While these may not appear to be closely associated with each other, a lumbar herniated disc may also affect the cervical spine, manifesting symptoms of migraine and headache. The purpose of the following articles is to educate patients and demonstrate the relation between migraine pain and lumbar herniated disc, further discussing the treatment of these two common conditions.

A Critical Review of Manual Therapy Use for Headache Disorders: Prevalence, Profiles, Motivations, Communication and Self-Reported Effectiveness

Abstract

Background

Despite the expansion of conventional medical treatments for headache, many sufferers of common recurrent headache disorders seek help outside of medical settings. The aim of this paper is to evaluate research studies on the prevalence of patient use of manual therapies for the treatment of headache and the key factors associated with this patient population.

Methods

This critical review of the peer-reviewed literature identified 35 papers reporting findings from new empirical research regarding the prevalence, profiles, motivations, communication and self-reported effectiveness of manual therapy use amongst those with headache disorders.

Results

While available data was limited and studies had considerable methodological limitations, the use of manual therapy appears to be the most common non-medical treatment utilized for the management of common recurrent headaches. The most common reason for choosing this type of treatment was seeking pain relief. While a high percentage of these patients likely continue with concurrent medical care, around half may not be disclosing the use of this treatment to their medical doctor.

Conclusions

There is a need for more rigorous public health and health services research in order to assess the role, safety, utilization and financial costs associated with manual therapy treatment for headache. Primary healthcare providers should be mindful of the use of this highly popular approach to headache management in order to help facilitate safe, effective and coordinated care.

Keywords: Headache, Migraine, Tension headache, Cervicogenic headache, Manual therapy, Physical therapy, Chiropractic, Osteopathy, Massage

Background

The co-occurrence of tension headache and migraine is very high [1]. Respectively, they are the second and third most common disorders worldwide with migraine ranking as the seventh highest specific cause of disability globally [2] and the sixteenth most commonly diagnosed condition in the US [3]. These common recurrent headache disorders place a considerable burden upon the personal health, finances and work productivity of sufferers [3�5] with migraine further complicated by an association with cardiovascular and psychiatric co-morbidities [6, 7].

Preventative migraine drug treatments include analgesics, anticonvulsants, antidepressants and beta-blockers. Preventative drug treatments for tension-type headaches can include analgesics, NSAIDs, muscle relaxants and botulinum toxin as well as anticonvulsants and antidepressants. While preventative drug treatments are successful for a significant proportion of sufferers, headache disorders are still reported as under-diagnosed and under-treated within medical settings [8�16] with other studies reporting sufferers can cease continuing with preventative headache medications long-term [9, 17].

There is a number of non-drug approaches also utilized for the prevention of headaches. These include psychological therapies such as cognitive behavioral therapy, relaxation training and EMG (electromyography) biofeedback. In addition, there is acupuncture, nutritional supplementation (including magnesium, B12, B6, and Coenzyme Q10) and physical therapies. The use of physical therapies is significant, with one recent global survey reporting physical therapy as the most frequently used �alternative or complementary treatment� for headache disorders across many countries [18]. One of the most common physical therapy interventions for headache management is manual therapy (MT), [19�21] which we define here as treatments including �spinal manipulation (as commonly performed by chiropractors, osteopaths, and physical therapists), joint and spinal mobilization, therapeutic massage, and other manipulative and body-based therapies� [22].

Positive results have been reported in many clinical trials comparing MT to controls [23�27], other physical therapies [28�30] and aspects of medical care [31�34]. More high quality research is needed however to assess the efficacy of MT as a treatment for common recurrent headaches. Recent systematic reviews of randomized clinical trials of MT for the prevention of migraine report a number of significant methodological short-comings and the need for more high quality research before any firm conclusions can be made [35, 36]. Recent reviews of MT trials for tension-type headache and cervicogenic headache are cautious in reporting positive outcomes and the strong need for further robust research [37�41]. Despite the limited clinical evidence there has been no critical review of the significant use of MT by headache populations.

Methods

The aim of this study is to report from the peer-reviewed literature; 1) the prevalence of MT use for the treatment of common recurrent headaches and 2) factors associated with this use across several key themes. The review further identifies key areas worthy of further research in order to better inform clinical practice, educators and healthcare policy within this area.

Design

A comprehensive search of peer-reviewed articles published in English between 2000 and 2015 reporting new empirical research findings of key aspects of MT use among patients with migraine and non-migraine headache disorders was undertaken. Databases searched were MEDLINE, AMED, CINAHL, EMBASE and EBSCO. The key words and phrases used were: �headache�, �migraine�, �primary headache�, �cephalgia�, �chronic headache� AND �manual therapy�, �spinal manipulation�, �manipulative therapy�, �spinal mobilization�, �chiropractic�, �osteopathy�, �massage�, �physical therapy� or �physiotherapy� AND then �prevalence�, �utilization� or �profile� was used for additional searches against the previous terms. The database search was accompanied by a hand search of prominent peer-reviewed journals. All authors accessed the reviewed literature (data) and provided input to analysis.

Due to the focus of the review, literature reporting randomized control trials and similar clinical research designs were excluded as were articles identified as letters, correspondence, editorials, case reports and commentaries. Further searches were undertaken of the bibliographies in the identified publications. All identified articles were screened and only those reporting new empirical findings on MT use for headache in adults were included in the review. Articles identified and selected for the review were research manuscripts mostly within epidemiological and health economics studies. The review includes papers reporting MT use pooled with the use of other therapies, but only where MT patients comprised a large proportion (as stated) of the included study population. Results were imported into Endnote X7 and duplicates removed.

Search Outcomes, Analyses and Quality Appraisal

Figure 1 outlines the literature search process. The initial search identified 3286 articles, 35 of which met the inclusion criteria. Information from each article was organized into a review table (Table 1) to summarise the findings of the included papers. Information is reported under two selected headache groups and within each individual MT profession – chiropractic, physiotherapy, osteopathy and massage therapy � where sufficient detail was available.

Figure 1: Flow Chart of Study Selection.

Table 1: Research-based studies of manual therapy use for headache disorders.

An appraisal of the quality of the articles identified for review was conducted using a quality scoring system (Table 2) developed for the critical appraisal of health literature used for prevalence and incidence of health problems [42] adapted from similar studies [43�45]. This scoring system was applicable to the majority of study designs involving surveys and survey-based structured interviews (29 of the 35 papers) but was not applicable to a small number of included studies based upon clinical records, secondary analysis or practitioner characteristics.

Two separate authors (CM and JA) independently searched and scored the articles. Score results were compared and any differences were further discussed and resolved by all the authors. The quality score of each relevant article is reported in Table 3.

Results

The key findings of the 35 articles were grouped and evaluated using a critical review approach adapted from previous research [46, 47]. Based on the limited information available for other headache types, prevalence findings are reported within one of two categories – either as �migraine� for papers reporting studies where the population was predominately or entirely made up of migraine patients or as �headache� for papers where the study population was predominately other headache types (including tension-type headaches, cluster headaches, cervicogenic headache) and/or where the headache type was not clearly stated. Ten papers reported findings examining prevalence rates for the �migraine� category alone, 18 papers reported findings examining prevalence for the �headache� category alone and 3 papers reported findings for both categories. Based on the nature of the information available, prevalence use was categorised by manual therapy providers. The extracted data was then analysed and synthesized into four thematic categories: prevalence; profile and motivations for MT use; concurrent use and order of use of headache providers; and self-reported evaluation of MT treatment outcomes.

Prevalence of MT Use

Thirty-one of the reviewed articles with a minimum sample size (>100) reported findings regarding prevalence of MT use. The prevalence of chiropractic use for those with migraine ranged from 1.0 to 36.2% (mean: 14.4%) within the general population [19�21, 48�52] and from 8.9 to 27.1% (mean: 18.0%) within headache-clinic patient populations [53, 54]. The prevalence of chiropractic use for those reported as headache ranged from 4 to 28.0% (mean: 12.9%) within the general population [20, 48, 51, 55�57]; ranged from 12.0 to 22.0% (mean: 18.6%) within headache/pain clinic patient populations [58�60] and from 1.9 to 45.5% (mean: 9.8%) within chiropractic patient populations [61�69].

The prevalence use of physiotherapy for those with migraine ranged from 9.0 to 57.0% (mean: 24.7%) within the general population [19, 20, 48, 52] and from 4.9 to 18.7% (mean: 11.8%) within headache-clinic patient populations [54, 70]. The prevalence use of physiotherapy for those reported as headache ranged from 12.2 to 52.0% (mean: 32.1%) within the general population [20, 48] and from 27.8 to 35.0%% (mean: 31.4%) within headache/pain clinic populations [60, 70].

Massage therapy use for those with migraine ranged from 2.0 to 29.7% (mean: 15.6%) within the general population [49, 50, 71] and from 10.1 to 56.4% (mean: 33.9%) within headache-clinic populations [53, 54, 72, 73]. Massage/acupressure use for those reported as headache within headache/pain clinic patient populations ranged from 12.0 to 54.0% (mean: 32.5%) [58�60, 70].

Osteopathy use for those with migraine was reported as 1% within the general population [49]; as 2.7% within a headache-clinic patient population [53] and as 1.7% within an osteopathy patient population [74]. For headache the prevalence was 9% within a headache/pain clinic population [60] and ranged from 2.7 to 10.0% (mean: 6.4%) within osteopathy patient populations [74, 75].

The combined prevalence rate of MT use across all MT professions for those with migraine ranged from 1.0 to 57.0% (mean: 15.9%) within the general population; ranged from 2.7 to 56.4% (mean: 18.4%) within headache-clinic patient populations and was reported as 1.7% in one MT patient population. The combined prevalence rate of MT use across all MT professions for those reported as headache ranged from 4.0 to 52.0% (mean: 17.7%) within the general population; ranged from 9.0 to 54.0% (mean: 32.3%) within headache-clinic patient populations and from 1.9 to 45.5% (mean: 9.25%) within MT patient populations.

Profile and Motivations for MT Use

While patient socio-demographic profiles were not reported within headache populations that were exclusively using MT, several studies report these findings where MT users made up a significant percentage of the non-medical headache treatments utilized by the study population (range 40% � 86%: mean 63%). While findings varied for level of income [58, 70] and level of education, [70, 72, 73] this patient group were more likely to be older [70, 72], female [20], have a higher rate of comorbid conditions [58, 70, 76] and a higher rate of previous medical visits [20, 58, 70] when compared to the non-user group. Overall, this group were reported to have a higher level of headache chronicity or headache disability than non-users [20, 54, 58, 70, 72, 77].

Several studies within headache-clinic populations report patient motivations for the use of complementary and alternative headache treatments where MT users made up a significant proportion of the study population (range 40% � 86%: mean 63%) [58, 70, 72, 78]. From these studies the most common motivation reported by study patients was �seeking pain relief� for headache which accounted for 45.4% � 84.0% (mean: 60.5%) of responses. The second most common motivation was patient concerns regarding the �safety or side effects� of medical headache treatment, accounting for 27.2% � 53.0% (mean: 43.8%) of responses [58, 70, 72]. �Dissatisfaction with medical care� accounted for 9.2% � 35.0% (mean: 26.1%) of responses [58, 70, 72].

A limited number of reviewed papers (all from Italy) report on the source of either the referral or recommendation to MT for headache treatment [53, 58, 59]. From these studies, referral from a GP to a chiropractor ranged from 50.0 to 60.8% (mean: 55.7%), while referral from friends/relatives ranged from 33.0 to 43.8% (mean: 38.7%) and self-recommendation ranged from 0 to 16.7% (mean: 5.6%). For massage therapy, referral from a GP ranged from 23.2 to 50.0% (mean: 36.6%), while referral from friends/relatives ranged from 38.4 to 42.3% (mean: 40.4%) and self-recommendation ranged from 7.7 to 38.4% (mean: 23.1%). For acupressure, referral from a GP ranged from 33.0 to 50.0% (mean: 41.5%), while referral from friends/relatives was reported as 50% and self-recommendation ranged from 0 to 16.6% (mean: 8.3%). One study reported findings for osteopathy where referral from both GP�s and friends/relatives was reported as 42.8% and self-recommendation was reported as 14.4%. Overall, the highest proportion of referrals within these studies was from GPs to chiropractors for chronic tension-type headache (56.2%), cluster headache (50%) and migraine (60.8%).

Concurrent Use and Order of Use of Headache Providers and Related Communication of MT Users

Several studies report on the concurrent use of medical headache management with complementary and alternative therapies. In those studies where the largest percentage of the patient population were users of MT�s (range 57.0% � 86.4%: mean 62.8%), [58, 70, 78] concurrent use of medical care ranged between 29.5% and 79.0% (mean: 60.0%) of the headache patient population.

These studies further report on the level of patient non-disclosure to medical providers regarding the use of MT for headache. Non-disclosure ranged between 25.5 and 72.0% (mean: 52.6%) of the patient population, with the most common reason for non-disclosure reported as the doctor �never asking�, ranging from 37.0 to 80.0% (mean: 58.5%). This was followed by a patient belief that �it was not important for the doctor to know� or �none of the doctor�s business�, ranging from 10.0 to 49.8% (mean: 30.0%). This was followed by a belief that either �the doctor would not understand� or �would discourage� these treatments, ranging from 10.0 to 13.0% (mean: 11.5%) [53, 77].

One large international study reported the ordering of the typical provider of headache care by comparing findings between several countries for migraine patients [21]. Primary care providers followed by neurologists were reported as the first and second providers for migraine treatment for nearly all countries examined. The only exception was Australia, where those with chronic migraine selected chiropractors as typical providers at equal frequency to neurologists (14% for both) while those with episodic migraine selected chiropractors at a greater frequency to neurologists (13% versus 5%). Comparatively, chiropractors were selected as the typical provider for those with chronic migraine by 10% in USA and Canada, 1% in Germany and 0% for UK and France. Chiropractors were selected as the typical provider for those with episodic migraine by 7% in USA, 6% in Germany, 4% in Canada and by 1% in both the UK and France.

Self-Reported Effectiveness of MT Treatment Outcomes

Several headache and pain-clinic population studies provide findings for the self-reported effectiveness of MT headache treatment. For chiropractic, patient self-reporting of partially effective or fully effective headache relief ranged from 27.0 to 82.0% (mean: 45.0%) [53, 58�60, 78]. For massage therapy, patient self-reporting of partially effective or fully effective headache relief ranged from 33.0 to 64.5% (mean: 45.2%)[53, 58, 60, 73, 78], and for acupressure this ranged from 33.4 to 50.0% (mean: 44.5%) [53, 58, 59]. For osteopathy and physiotherapy, one study reported effectiveness as 17 and 36% respectively [60].

When results are combined across all MT professions the reporting of MT as either partially or fully effective ranged from 17.0 to 82.0% (mean 42.5%) [53, 58�60, 73, 78]. In addition, one general population study provides findings for the self-reported effectiveness for chiropractic and physiotherapy at 25.6 and 25.1% respectively for those with primary chronic headache and 38 and 38% respectively for those with secondary chronic headache [79].

Discussion

This paper provides the first critical integrative review on the prevalence and key factors associated with the use of MT treatment for headaches within the peer-reviewed literature. While study methodological limitations and lack of data prevent making strong conclusions, these findings raise awareness of issues of importance to policy-makers, educators, headache providers and future research.

Our review found that MT use was generally higher within medical headache-clinic populations when compared to general populations. However, the use of individual MT providers does vary between different regions and this is likely due to a number of factors including variation in public access, healthcare funding and availability of MT providers. For example, the use of physiotherapy for some headache types may be relatively higher in parts of Europe [20, 60] while the use of chiropractors for some headache types may be relatively higher in Australia and the USA [19, 21]. Overall, the prevalence use of MT for headache appears to be substantial and likely to be the most common type of physical therapy utilized for headache in many countries [19�21, 49]. More high quality epidemiological studies are needed to measure the prevalence of MT use across different headache types and sub-types, both within the general population and clinical populations.

Beyond prevalence, data is more limited regarding who, how and why headache patients seek MT. From the information available however, the healthcare needs of MT headache patients may be more complex and multi-disciplinary in nature compared to those under usual medical care alone. Socio-demographic findings suggest that users of MT and other complementary and alternative therapies have a higher level of headache disability and chronicity compared to non-users. This finding may correlate with the higher prevalence of MT users within headache-clinic populations and a history of more medical appointments. This may also have implications for future MT trial designs both in terms of the selection of trial subjects from inside versus outside MT clinical settings and the decision to test singular MT interventions versus MT in combination with other interventions.

Limited information suggests that a pluralistic approach toward the use of medical and non-medical headache treatments such as MT is common. While findings suggest MT is sought most often for reasons of seeking headache relief, the evidence to support the efficacy of MT for headache relief is still limited. MT providers must remain mindful of the quality of the evidence for a given intervention for a given headache disorder and to inform patients where more effective or safer treatment interventions are available. More research is needed to assess these therapies individually and through multimodal approaches and for studies to include long-term follow-up.

Information limited to Italy, suggests referral from GPs for MT headache treatment can be common in some regions, while this is less likely to widespread given the issue of patient non-disclosure to medical doctors regarding the use of this treatment in other studies. High quality healthcare requires open and transparent communication between patients and providers and between the providers themselves. Non-disclosure may adversely influence medical management should unresponsive patients require further diagnostic investigations [80] or the implementation of more effective approaches to headache management [81] or prevents discussion in circumstances where MT may be contraindicated [82]. Primary headache providers may benefit from paying particular attention to the possibility of non-disclosure of non-medical headache treatments. Open discussion between providers and patients about the use of MT for headache and the associated outcomes may improve overall patient care.

Future Research

Despite the strong need for more high quality research to assess the efficacy of MT as a treatment for headache, the substantial use of MT brings attention to the need for more public health and health services research within this area of headache management. The need for this type of research was identified in a recent global report on the use of headache-related healthcare resources [18]. Furthering this information can lead to improvements in healthcare policy and the delivery of healthcare services.

The substantial use of physical therapies such as MT has been under-reported within many of the national surveys reporting headache-related healthcare utilization [3, 5, 83�85]. Regardless, the role of physical therapies in headache management continues to be assessed, often within mainstream and integrated headache management settings [86�89]. Continuing this research may further our understanding of the efficacy and outcomes associated with a more multidisciplinary approach to headache management.

Further to this is the need for more research to understand the healthcare utilization pathways associated with those patients who use MT in their headache management. Little is known about the sociodemographic background, types of headaches, level of headache disability and comorbidities more common to this patient population. In turn, such information can provide insights that may be valuable to provider clinical decision-making and provider education.

Limitations

The design and findings of our review has a number of limitations. The design of the review was limited by a search within English language journals only. As a result, some research on this topic may have been missed. While the quality scoring system adopted for this review requires further validation, the data we collected was limited by the low to moderate quality of available papers which averaged 6.4 out of 10 points (Table 3). The low scoring was largely due to significant methodological issues and the small sample size associated with much of the collected papers. Much of the data on this topic was heterogeneous in nature (telephone, postal surveys and face-to-face interviews). There was a lack of validated practitioner and patient questionnaires to report findings, such as for questions on prevalence, where the time frames utilized varied between �currently�, �last 12 months� and �ever�.

Data on the prevalence of MT use for headache was limited particularly within individual MT provider populations when compared to data found within the general population and headache-clinic populations. Many studies assessed the use of MT for headache without identifying headache types. Only one study inside an MT population had reported the percentage of patients attending for reasons of migraine alone (osteopathy). The prevalence of MT use for headache was reported most within chiropractic patient population studies, however information was limited on the types of headache. We found no studies reporting the prevalence of headache patients within physiotherapy or massage therapy patient populations using our search terms.

A lack of data for some themes necessitated providing findings pooled with users of other non-medical headache providers. Data within many geographical regions was very limited with the most limited data was on the source of referral to MT headache providers (three papers from Italy only). These limitations support the call for more research to be focused exclusively within MT populations and different regional areas before stronger conclusions can be drawn.

Conclusion

The needs of those with headache disorders can be complex and multi-disciplinary in nature. Beyond clinical research, more high quality public health and health services research is needed to measure and examine a number of issues of significance to the delivery and use of MT�s within headache management. With unmet needs still remaining for many who suffer recurrent headaches, clinicians should remain cognizant of the use of MT�s and remain open to discussing this approach to headache management in order to ensure greater safety, effectiveness and coordination of headache care.

Acknowledgements

Not applicable.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors while the first author on this paper receives a PhD scholarship made available by the Australian Chiropractors� Association.

Availability of Data and Materials

Not applicable (all data is reported in article).

Authors’ Contributions

CM, JA and DS designed the paper. CM carried out the literature search, data collection and selection. CM and DS provided the analysis and interpretation. CM and JA wrote the drafts. All authors contributed to the critical review and intellectual content. All authors read and approved the final manuscript.

Competing Interests

The authors declare that they have no competing interests.

Consent for Publication

Not applicable.

Ethics Approval and Consent to Participate

Not applicable.

Publisher�s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Abbreviations

MT Manual therapy
EMG Electromyography

Contributor Information

Ncbi.nlm.nih.gov/pmc/articles/PMC5364599/

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

A staggering 15% of the population suffers from migraines, a debilitating condition which affects an individual’s ability to engage in everyday activities. Although widely misunderstood by researches today, I believe that migraine pain can be a symptom of a much bigger underlying health issue. Lumbar herniated discs, or ruptured discs in the lumbar spine, are a common cause of lower back pain and sciatica. When the soft, gel-like center of a lumbar herniated disc compresses the nerve roots of the low back, it can result in symptoms of pain and discomfort, numbness and weakness in the lower extremities. What’s more, a lumbar herniated disc can unbalance the structure and function of the entire spine, eliciting symptoms along the cervical spine that could ultimately trigger migraines. People who constantly experience migraine pain often have to carefully go about their day in hopes of avoiding the blaze of another painful episode. Fortunately, many migraine pain and lumbar herniated disc treatment methods are available to help improve as well as manage the symptoms. Other treatment options can also be considered before surgical interventions.

Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT)

Abstract

Study Design

Concurrent prospective randomized and observational cohort studies.

Objective

To assess the 8-year outcomes of surgery vs. non-operative care.

Summary of Background Data

Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical to non-operative treatment remain controversial.

Methods

Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting SPORT eligibility criteria enrolled into prospective randomized (501 participants) and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual non-operative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain (BP) and Physical Function (PF) scales and the modified Oswestry Disability Index (ODI – AAOS/Modems version) assessed at 6 weeks, 3 and 6 months, and annually thereafter.

Results

Advantages were seen for surgery in intent-to-treat analyses for the randomized cohort for all primary and secondary outcomes other than work status; however, with extensive non-adherence to treatment assignment (49% patients assigned to non-operative therapy receiving surgery versus 60% of patients assigned to surgery) these observed effects were relatively small and not statistically significant for primary outcomes (BP, PF, ODI). Importantly, the overall comparison of secondary outcomes was significantly greater with surgery in the intent-to-treat analysis (sciatica bothersomeness [p > 0.005], satisfaction with symptoms [p > 0.013], and self-rated improvement [p > 0.013]) in long-term follow-up. An as-treated analysis showed clinically meaningful surgical treatment effects for primary outcome measures (mean change Surgery vs. Non-operative; treatment effect; 95% CI): BP (45.3 vs. 34.4; 10.9; 7.7 to 14); PF (42.2 vs. 31.5; 10.6; 7.7 to 13.5) and ODI (?36.2 vs. ?24.8; ?11.2; ?13.6 to ?9.1).

Conclusion

Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operatively treated patients; there was little to no degradation of outcomes in either group (operative and non-operative) from 4 to 8 years.

Keywords: SPORT, intervertebral disc herniation, surgery, non-operative care, outcomes

Introduction

Lumbar discectomy for relief of sciatica in patients with intervertebral disc herniation (IDH) is a well-researched and common indication for spine surgery, yet rates of this surgery exhibit considerable geographic variation.[1] Several randomized trials and large prospective cohorts have demonstrated that surgery provides faster pain relief and perceived recovery in patients with herniated disc.[2�6] The effect of surgery on longer term outcomes remains less clear.

In a classic RCT evaluating surgery versus non-operative treatment for lumbar IDH, Weber et al. showed a greater improvement in the surgery group at 1 year that was statistically significant; there was also greater improvement for surgery at 4 years, although not statistically significant, but no apparent difference in outcomes at 10 years.[2] However, a number of patients in the non-operative group eventually underwent surgery over that time, complicating the interpretation of the long-term results. The Maine Lumbar Spine Study, a prospective observational cohort, found greater improvement at one year in the surgery group that narrowed over time, but remained significantly greater in the surgical group for sciatica bothersomeness, physical function, and satisfaction, but no different for work or disability outcomes.[3] This paper reports 8-year results from the Spine Patient Outcomes Research Trial (SPORT) based on the continued follow-up of the herniated disc randomized and observational cohorts.

Methods

Study Design

SPORT is a randomized trial with a concurrent observation cohort conducted in 11 US states at 13 medical centers with multidisciplinary spine practices. The human subjects committees at each participating institution approved a standardized protocol for both the observational and the randomized cohorts. Patient inclusion and exclusion criteria, study interventions, outcome measures, and follow-up procedures have been reported previously.[5�8]

Patient Population

Men and women were eligible if they had symptoms and confirmatory signs of lumbar radiculopathy persisting for at least six weeks, disc herniation at a corresponding level and side on imaging, and were considered surgical candidates. The content of pre-enrollment non-operative care was not pre-specified in the protocol.[5�7] Specific enrollment and exclusion criteria are reported elsewhere.[6,7]

A research nurse at each site identified potential participants, verified eligibility and used a shared decision making video for uniformity of enrollment. Participants were offered enrollment in either the randomized trial or the observational cohort. Enrollment began in March of 2000 and ended in November of 2004.

Study Interventions

The surgery was a standard open discectomy with examination of the involved nerve root.[7,9] The non-operative protocol was �usual care� recommended to include at least: active physical therapy, education/counseling with home exercise instruction, and non-steroidal anti-inflammatory drugs if tolerated. Non-operative treatments were individualized for each patient and tracked prospectively.[5�8]

Study Measures

Primary endpoints were the Bodily Pain (BP) and Physical Function (PF) scales of the SF-36 Health Survey[10] and the AAOS/Modems version of the Oswestry Disability Index (ODI)[11] as measured at 6 weeks, 3 and 6 months, and annually thereafter. If surgery was delayed beyond six weeks, additional follow-up data was obtained 6 weeks and 3 months post-operatively. Secondary outcomes included patient self-reported improvement; work status; satisfaction with current symptoms and care;[12] and sciatica severity as measured by the sciatica bothersomeness index.[13,14] Treatment effect was defined as the difference in the mean changes from baseline between the surgical and non-operative groups.

Statistical Considerations

Initial analyses compared means and proportions for baseline patient characteristics between the randomized and observational cohorts and between the initial treatment arms of the individual and combined cohorts. The extent of missing data and the percentage of patients undergoing surgery were calculated by treatment arm for each scheduled follow-up. Baseline predictors of time until surgical treatment (including treatment crossovers) in both cohorts were determined via a stepwise proportional hazards regression model with an inclusion criterion of p < 0.1 to enter and p > 0.05 to exit. Predictors of missing follow-up visits at yearly intervals up to 8 years were separately determined via stepwise logistic regression. Baseline characteristics that predicted surgery or a missed visit at any time-point were then entered into longitudinal models of primary outcomes. Those that remained significant in the longitudinal models of outcome were included as adjusting covariates in all subsequent longitudinal regression models to adjust for potential confounding due to treatment selection bias and missing data patterns.[15] In addition, baseline outcome, center, age and gender were included in all longitudinal outcome models.

Primary analyses compared surgical and non-operative treatments using changes from baseline at each follow-up, with a mixed effects longitudinal regression model including a random individual effect to account for correlation between repeated measurements within individuals. The randomized cohort was initially analyzed on an intent-to-treat basis.[6] Because of cross-over, additional analyses were performed based on treatments actually received. In these as-treated analyses, the treatment indicator was a time-varying covariate, allowing for variable times of surgery. Follow-up times were measured from enrollment for the intent-to-treat analyses, whereas for the as-treated analysis the follow-up times were measured from the beginning of treatment (i.e. the time of surgery for the surgical group and the time of enrollment for the non-operative group), and baseline covariates were updated to the follow-up immediately preceding the time of surgery. This procedure has the effect of including all changes from baseline prior to surgery in the estimates of the non-operative treatment effect and all changes after surgery in the estimates of the surgical effect. The six-point sciatica scales and binary outcomes were analyzed via longitudinal models based on generalized estimating equations[16] with linear and logit link functions respectively, using the same intent-to-treat and adjusted as-treated analysis definitions as the primary outcomes. The randomized and observational cohorts were each analyzed to produce separate as-treated estimates of treatment effect. These results were compared using a Wald test to simultaneously test all follow-up visit times for differences in estimated treatment effects between the two cohorts.[15] Final analyses combined the cohorts.

To evaluate the two treatment arms across all time-periods, the time-weighted average of the outcomes (area under the curve) for each treatment group was computed using the estimates at each time period from the longitudinal regression models and compared using a Wald test.[15]

Kaplan-Meier estimates of re-operation rates at 8 years were computed for the randomized and observational cohorts and compared via the log-rank test.[17,18]

Computations were done using SAS procedures PROC MIXED for continuous data and PROC GENMOD for binary and non-normal secondary outcomes (SAS version 9.1 Windows XP Pro, Cary, NC). Statistical significance was defined as p < 0.05 based on a two-sided hypothesis test with no adjustments made for multiple comparisons. Data for these analyses were collected through February 4, 2013.

Results

Overall, 1,244 SPORT participants with lumbar intervertebral disc herniation were enrolled (501 in the randomized cohort, and 743 in the observational cohort) (Figure 1). In the randomized cohort, 245 were assigned to surgical treatment and 256 to non-operative treatment. Of those randomized to surgery, 57% had surgery by 1 year and 60% by 8 years. In the group randomized to non-operative care, 41% of patients had surgery by 1 year and 48% by 8 years. In the observational cohort, 521 patients initially chose surgery and 222 patients initially chose non-operative care. Of those initially choosing surgery, 95% received surgery by 1 year; at 8 years 12 additional patients had undergone primary surgery. Of those choosing non-operative treatment, 20% had surgery by 1 year and 25% by 8 years. In both cohorts combined, 820 patients received surgery at some point during the first 8 years; 424 (34%) remained non-operative. Over the 8 years, 1,192 (96%) of the original enrollees completed at least 1 follow-up visit and were included in the analysis (randomized cohort: 94% and observational cohort 97%); 63% of initial enrollees supplied data at 8 years with losses due to dropouts, missed visits, or deaths (Figure 1).

Figure 1: Exclusion, enrollment, randomization and follow-up of trial participants.

Patient Characteristics

Baseline characteristics have been previously reported and are summarized in Table 1.[5,6,8] The combined cohorts had an overall mean age of 41.7 with slightly more men than women. Overall, the randomized and observational cohorts were similar. However, patients in the observational cohort had more baseline disability (higher ODI scores), were more likely to prefer surgery, more often rated their problem as worsening, and were slightly more likely to have a sensory deficit. Subjects receiving surgery over the course of the study were: younger; less likely to be working; more likely to report being on worker�s compensation; had more severe baseline pain and functional limitations; fewer joint and other co-morbidities; greater dissatisfaction with their symptoms; more often rated their condition as getting worse at enrollment; and were more likely to prefer surgery. Subjects receiving surgery were also more likely to have a positive straight leg test, as well as more frequent neurologic, sensory, and motor deficits. Radiographically, their herniations were more likely to be at the L4�5 and L5-S1 levels and to be posterolateral in location.

Table 1: Patient baseline demographic characteristics, comorbidities and health status measures according to study cohort and treatment received.

Surgical Treatment and Complications

Overall surgical treatment and complications were similar between the two cohorts (Table 2). The average surgical time was slightly longer in the randomized cohort (80.5 minutes randomized vs. 74.9 minutes observational, p=0.049). The average blood loss was 75.3cc in the randomized cohort vs. 63.2cc in the observational, p=0.13. Only 6 patients total required intra-operative transfusions. There were no perioperative mortalities. The most common surgical complication was dural tear (combined 3% of cases). Re-operation occurred in a combined 11% of cases by 5 years, 12% by 6 years, 14% by 7 years, and 15% by 8 years post-surgery. The rates of reoperation were not significantly different between the randomized and observational cohorts. Eighty-seven of the 119 re-operations noted the type of re-operation; approximately 85% of these (74/87) were listed as recurrent herniations at the same level. One death occurred within 90 days post-surgery related to heart surgery at another institution; the death was judged to be unrelated and was reported to the Institutional Review Board and the Data and Safety Monitoring Board.

Cross-Over

Non-adherence to treatment assignment affected both treatment arms: patients chose to delay or decline surgery in the surgical arm and crossed over to surgery in the non-operative arm. (Figure 1) Statistically significant differences of patients crossing over to non-operative care within 8 years of enrollment were that they were older, had higher incomes, less dissatisfaction with their symptoms, more likely to have a disc herniation at an upper lumbar level, more likely to express a baseline preference for non-operative care, less likely to perceive their symptoms as getting worse at baseline, and had less baseline pain and disability (Table 3). Patients crossing over to surgery within 8 years were more dissatisfied with their symptoms at baseline; were more likely to perceive they were getting worse at baseline; more likely to express a baseline preference for surgery; and had worse baseline physical function and more self-rated disability.

Table 3: Statistically significant predictors of adherence to treatment among RCT patients.

Main Treatment Effects

Intent-to-Treat Analysis In the intention-to-treat analysis of the randomized cohort, all measures over 8 years favored surgery but there were no statistically significant treatment effects in the primary outcome measures (Table 4 and Figure 2). In the overall intention-to-treat comparison between the two treatment groups over time (area-under the curve), secondary outcomes were significantly greater with surgery in the intention-to-treat analysis (sciatica bothersomeness (p=0.005), satisfaction with symptoms (p=0.013), and self-rated improvement (p=0.013)) (Figure 3) Improvement in sciatica bothersomeness index was also statistically significant in favor of surgery at most individual time point comparisons (although non-significant in years 6 and 7) (Table 4).

Figure-2-Primary-Outcomes-in-the-Randomized-and-Observational-Cohorts

Figure 2: Primary outcomes (SF-36 Bodily Pain and Physical Function, and Oswestry Disability Index) in the randomized and observational cohorts during 8 years of follow-up.

Figure-3-Secondary-Outcomes-in-the-Randomized-and-Observational-Cohorts.

Figure 3: secondary outcomes (Sciatica Bothersomeness, Satisfaction with Symptoms, and Self-rated Global Improvement) in the randomized and observational cohorts during 8 years of follow-up.

Table 4: Primary analysis results for years 1 to 8. Intent-to-treat for the randomized cohort and adjusted* analyses according to treatment received for the randomized and observational cohorts combined.

As-Treated Analysis The adjusted as-treated effects seen in the randomized and observational were similar. Accordingly, the cohorts were combined for the final analyses. Treatment effects for the primary outcomes in the combined as-treated analysis were clinically meaningful and statistically significant out to 8 years: SF-36 BP 10.9 p < 0.001 (95% CI 7.7 to 14); SF-36 PF 10.6 p<0.001 (95% CI 7.7 to 13.5); ODI ?11.3 p<0.001 (95% CI ?13.6 to ?9.1) (Table 4). The footnote for Table 4 describes the adjusting covariates selected for the final model.

Results from the intent-to-treat and as-treated analyses of the two cohorts are compared in Figure 2. In the combined analysis, treatment effects were statistically significant in favor of surgery for all primary and secondary outcome measures (with the exception of work status which did not differ between treatment groups) at each time point (Table 4 and Figure 3).

Loss-to-Follow-Up

At the 8-year follow-up, 63% of initial enrollees supplied data, with losses due to dropouts, missed visits, or deaths. Table 5 summarized the baseline characteristics of those lost to follow-up compared to those retained in the study at 8-years. Those who remained in the study at 8 years were – somewhat older; more likely to be female, white, college educated, and working at baseline; less likely to be disabled, receiving compensation, or a smoker; less symptomatic at baseline with somewhat less bodily pain, better physical function, less disability on the ODI, better mental health, and less sciatica bothersomeness. These differences were small but statistically significant. Table 6 summarizes the short-term outcomes during the first 2 years for those retained in the study at 8 years compared to those lost to follow-up. Those lost to follow-up had worse outcomes on average; however this was true in both the surgical and non-operative groups with non-significant differences in treatment effects. The long-term outcomes are therefore likely to be somewhat over-optimistic on average in both groups, but the comparison between surgical and non-operative outcomes appear likely to be un-biased despite the long-term loss to follow-up.

Table 5: Patient baseline demographic characteristics, comorbidities, and health status measures according to patient follow-up status as of 02/01/2013 when the IDH8yr data were pulled.

Table 6: Time-weighted average of treatment effects at 2 years (AUC) from adjusted* as-treated randomized and observational cohorts combined primary outcome analysis, according to treatment received and patient follow-up status.

Discussion

In patients with a herniated disc confirmed by imaging and leg symptoms persisting for at least 6 weeks, surgery was superior to non-operative treatment in relieving symptoms and improving function. In the as-treated analysis, the treatment effect for surgery was seen as early as 6 weeks, appeared to reach a maximum by 6 months and persisted over 8 years; it is notable that the non-operative group also improved significantly and this improvement persisted with little to no degradation of outcomes in either group (operative and non-operative) between 4 and 8 years. In the longitudinal intention-to-treat analysis, all the outcomes showed small advantages for surgery, but only the secondary outcomes of sciatica bothersomeness, satisfaction with symptoms, and self-rated improvement were statistically significant. The persistent small benefit in the surgery group over time has made the overall intention-to-treat comparison more statistically significant over time despite high levels of cross-over. The large effects seen in the as-treated analysis after adjustments for characteristics of the crossover patients suggest that the intent-to-treat analysis may underestimate the true effect of surgery since the mixing of treatments due to crossover can be expected to create a bias toward the null in the intent-to-treat analyses.[4,19] Loss to follow-up among patients who were somewhat worse at baseline and with worse short-term outcomes probably leads to overly-optimistic estimated long-term outcomes in both surgery and non-operative groups but unbiased estimates of surgical treatment effects.

Comparisons to Other Studies

There are no other long-term randomized studies reporting the same primary outcome measures as SPORT. The results of SPORT primary outcomes at 2 years were quite similar to those of Peul et al but longer follow up for the Peul study is necessary for further comparison.[4,20] In contrast to the Weber study, the differences in the outcomes in SPORT between treatment groups remained relatively constant between 1 and 8 years of follow-up. One of the factors in this difference may be the sensitivity of the outcome measures � for example, sciatica bothersomeness, which was significantly different out to 8 years in the intention-to-treat, may be a more sensitive marker of treatment success than the general outcome measure used by Weber et al.[2]

The long-term results of SPORT are similar to the Maine Lumbar Spine Study (MLSS).[21] The MLSS reported statistically significantly greater improvements at 10 years in sciatica bothersomeness for the surgery group (?11.9) compared to the nonsurgical groups (?5.8) with a treatment effect of ?6.1 p=0.004; in SPORT the improvement in sciatica bothersomeness in the surgical group at 8 years was similar to the 10 year result in MLSS (?11) though the non-operative cohort in SPORT did better than their MLSS counterparts (?9.1) however the treatment effect in SPORT, while smaller, remained statistically significant (?1.5; p<0.001) due to the much larger sample size. Greater improvements in the non-operative cohorts between SPORT and MLSS may be related to differences in non-operative treatments over time, differences between the two cohorts since the MLSS and did not require imaging confirmation of IDH.

Over the 8 years there was little evidence of harm from either treatment. The 8-year rate of re-operation was 14.7%, which is lower than the 25% reported by MLSS at 10 years.[22]

Limitations

Although our results are adjusted for characteristics of cross over patients and control for important baseline covariates, the as-treated analyses presented do not share the strong protection from confounding that exists for an intent-to-treat analysis.[4�6] However, However, intent-to-treat analyses are known to be biased in the presence of noncompliance at the level observed in SPORT, and our adjusted as-treated analyses have been shown to produce accurate results under reasonable assumptions about the dependence of compliance on longitudinal outcomes.[23] Another potential limitation is the heterogeneity, of the non-operative treatment interventions, as discussed in our prior papers.[5,6,8] Finally, attrition in this long-term follow-up study meant that only 63% of initial enrollees supplied data at 8 years with losses due to dropouts, missed visits, or deaths; based on analyses at baseline and at short-term follow-up, this likely leads to somewhat overly-optimistic estimated long-term outcomes in both treatment groups but an unbiased estimation of surgical treatment effect.

Conclusions

In the intention-to-treat analysis, small, statistically insignificant surgical treatment effects were seen for the primary outcomes but statistically significant advantages for sciatica bothersomeness, satisfaction with symptoms, and self-rated improvement were seen out to 8 years despite high levels of treatment cross-over. The as-treated analysis combining the randomized and observational cohorts, which carefully controlled for potentially confounding baseline factors, showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 8 years compared to patients treated non-operatively. The non-operative group, however, also showed substantial improvements over time, with 54% reporting being satisfied with their symptoms and 73% satisfied with their care after 8 years.

Acknowledgments

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (U01-AR45444; P60-AR062799) and the Office of Research on Women�s Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention grant funds were received in support of this work. Relevant financial activities outside the submitted work: consultancy, grants, stocks.

This study is dedicated to the memories of Brieanna Weinstein and Harry Herkowitz, leaders in their own rights, who simply made the world a better place.

Footnotes

Other comorbidities include: stroke, diabetes, osteoporosis, cancer, fibromyalgia, cfs, PTSD, alcohol, drug dependency, heart, lung, liver, kidney, blood vessel, nervous system, hypertension, migraine, anxiety, stomach, bowel

In conclusion, individuals who suffer from migraine pain require the most effective type of treatment in order to help improve as well as manage their symptoms, particularly if their migraines were elicited from a lumbar herniated disc. The purpose of the following articles was to associate the two conditions with each other and demonstrate the results of the research above. Various treatment options can be considered before surgery for migraine pain and lumbar herniated disc 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

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

by spinedoctors | 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.

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.

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

Patients meeting the following criteria were excluded.

Main complaint other than neck pain or radiating pain
Concomitant musculoskeletal complaint (e.g. low back pain, knee pain)
Cause of neck pain unrelated to cervical IDH (e.g. spinal tumor, pregnancy, rheumatoid arthritis)
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

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.

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, 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 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

Additional Topics: Neck Pain

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Manual Therapy for Migraine Treatment In El Paso

by spinedoctors | 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.

Randomized Controlled Trials

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

Massage Therapy

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

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

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

Additional Topics: Neck Pain

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13. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther. 1998;21:511�519. [PubMed]

14. Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther. 2000;23:91�95. doi: 10.1016/S0161-4754(00)90073-3. [PubMed] [Cross Ref]

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Chiropractic Migraine Pain Treatment vs. Medication | El Paso, TX

by spinedoctors | Chiropractic, Functional Medicine, Migraine

Migraine pain is among one of the most common and debilitating conditions of the human population. As a result, many migraine cases are often misdiagnosed, leading to their improper treatment. With the proper treatment, however, a patient’s overall health and wellness as well as their quality of life may improve considerably. In addition, patient education is essential to help patients take appropriate self-care measures and for them to learn how to cope with the chronic nature of their condition. Chiropractic spinal manipulative therapy and the use of medication has been previously compared to determine the effectiveness of each for migraine pain. The purpose of the following article is to demonstrate the efficacy of each migraine pain treatment.

A Case Series of Migraine Changes Following a Manipulative Therapy Trial

Abstract

Objective: To present the characteristics of four cases of migraine, who were included as participants in a prospective trial on chiropractic spinal manipulative therapy for migraine.
Method: Participants in a migraine research trial, were reviewed for the symptoms or clinical features and their response to manual therapy.
Results: The four selected cases of migraine responded dramatically to SMT, with numerous self reported symptoms being either eliminated or substantially reduced. Average frequency of episodes was reduced on average by 90%, duration of each episode by 38%, and use of medication was reduced by 94%. In addition, several associated symptoms were substantially reduced, including nausea, vomiting, photophobia and phonophobia.
Discussion: The various cases are presented to assist practitioners making a more informed prognosis.
Key Indexing Terms (MeSH): Migraine, diagnosis, manual therapy.

Introduction

Migraine, in its various forms, affects approximately 12 to 15% of people throughout the world, with an estimated incidence in the USA of 6% of males and 18% of females (1). Depending on the severity of a migrainous attack it is apparent that most, if not all, of the body systems can be affected (2). Consequently migraine poses a substantial threat to regular sufferers, which debilitates them to varying degrees from slight to severe (3).

One early definition of migraine highlights some potential difficulties in research assessing treatment for migraine. �A familial disorder characterised by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting. In some cases they are preceded by, or associated with neurological and mood disturbances. All of the above characteristics are not necessarily present in each attack or in each patient� (4). (Migraine and headache of the World Federation of Neurology in 1969).

Some of the more common symptoms of migraine include headache, an aura, scotoma, photophobia, phonophobia, scintillations, nausea and/or vomiting (5).

The source of pain in migraines is to found in the intra- and extracranial blood vessels (6). The blood vessel walls are pain sensitive to distension, traction or displacement. The idiopathic dilation of cranial blood vessels, together with an increase in a pain-threshold-lowering substance, result in headache for migraine headache (7).

Migraine has been shown to be reduced following chiropractic spinal manipulative therapy (8-18). In addition, other research suggests a potential role of musculoskeletal conditions in the aetiology of migraine (19-22). A misdiagnosis of migraine or cervicogenic headache could give a misleading positive result for improvement (23). Therefore, an accurate diagnosis needs to be made, based on standard accepted taxonomy.

A new classification system of headaches has been developed by the Headache Classification Committee of the International Headache Society (IHS), which contains a main category covering migraine (24). However, this taxonomy system still has several areas of potential overlap or controversy regarding the diagnosis of the headache (23).

This paper presents three cases of migraine with aura (MA) and one of migraine without aura (MW), detailing their symptoms, clinical features and response to chiropractic Spinal Manulative Therapy (SMT). The authors hope to enhance practitioners knowledge for migraine conditions that may respond favourably with SMT.

Features of Migraine

The IHS defines migraines as having at least two of the following: unilateral location, pulsating quality, moderate or severe intensity, aggravated by routine physical activity. During the headache the person must also experience either nausea &/or vomiting, and photophobia &/or phonophobia (24). In addition, there is no suggestion either by history, physical or neurological examination that the person has a headache listed in groups 5-11 of their classification system (23-25).

A previous study by the author has detailed features of the different classifications of migraine (8). The aura is the distinguishing feature between the old classifications of common (MW) and classic migraine (MA) (24). It has�been described by migraine sufferers as an opaque object, or a zigzag line around a cloud, even cases of tactile hallucinations have been recorded (6,7). The most common auras consist of homonymous visual disturbances, unilateral parathesias &/or numbness, unilateral weakness, aphasia or unclassifiable speech difficulty.

The potential mechanisms for the different migraine types are poorly understood. There have been a number of aetiologies proposed in the literature, but none seem to be able to explain all the potential symptoms experienced by migraine sufferers (26). The IHS describe changes in blood composition and platelet function as a triggering role. Processes which occur in the brain act via the trigemino-vascular system and the intra and extracranial vasculature and perivascular spaces (24).

Methodology

Based on a previous reported study (9) which involved 32 subjects who received chiropractic SMT for MA, three cases are presented which were selected due to the significant changes the patient experienced.

People with migraines were advertised for participation in the study, via the radio and newspapers within a local region of Sydney. All applicants completed a questionnaire, developed from Vernon (27) and has been reported in a previous study (9).

The participants to take part in the trial were selected according to responses in the questionnaire of specific symptoms. The criteria for MA diagnosis was compliance with at least 5 out of the following indicators: reaction to pain requiring cessation of activities or the need to seek a quiet dark area; pain located around the temples; pain described as throbbing; associated symptoms of nausea, vomiting, aura, photophobia or phonophobia; migraine precipitated by weather changes; migraine aggravated by head or neck movements; previous diagnosis of migraine by a specialist; and a family history of migraine.

Participants also had to experience migraine at least once a month, but not daily and the migraines could not have been initiated by trauma. Participants were excluded from the study if there were contra-indications to SMT, such as meningitis or cerebral aneurysm. In addition, participants with temporal arteritis, benign intracranial hypertension or space occupying lesions, were also excluded due to safety aspects.

The trial was conducted over six months, and consisted of 3 stages: two months pre-treatment, two months treatment, and two months post treatment. Participants completed diaries during the entire trial noting the�frequency, intensity, duration, disability, associated symptoms and use of medication for each migraine episode. In addition, clinic records were compared to their diary entries of migraine episodes. Concurrently, the subjects were contacted by telephone by the author every two weeks and asked to describe the migraine episodes for comparison to their diaries.

A detailed history of the patients� subjective pain features was taken during the initial consultation. This included the type of pain, duration, onset, severity, radiation, aggravating and relieving factors. The history also included medical features, a systems review for potential pathologies, previous treatments and its effects. Assessment of subluxation included: orthopaedic and neurological testing, segmental springing, mobility measures such as visual estimation of range of motion, assessment of previous radiographs, specific chiropractic vertebral testing procedures, as well as response of the patient to SMT.

In addition, several vascular investigations were performed where indicated, which include: vertebral artery test, manipulative provocation test, blood pressure assessment, and abdominal aortic aneurysm screening.

During the treatment period, the subjects continued to record migraine episodes in their diary, and receive telephone calls from the authors. Treatment consisted of short amplitude, high velocity spinal manipulative thrusts, or areas of fixation determined by the physical examination. Comparison was made of initial baseline episodes of migraine prior to commencement of the study and at six months following its cessation.

Case 1

A 25 year old, 65kg Caucasian male presented with neck pain which had commenced in early childhood, that he felt may have been related to his prolonged birth. During the history the patient stated that he suffered a regular migraine headaches (3-4 per week) which he supposed was related to a motor vehicle accident, two years prior to his presentation. He reported that his �migraine� symptoms were a unilateral throbbing headache, an aura, nausea, vomiting, vertigo, and photophobia. Sleep tended to alleviate the symptoms and he required Allegren medication (25mg) on a daily basis.

From diaries the patient was required to complete in the study, a migraine would occur 14 times a month, last an average 12.5 hours and he could perform duties after 8 hours. In addition a visual analogue scale score (VAS) for an average episode was 8.5 out of a possible maximum score of ten, corresponding to a description of �terrible� pain.

On examination, he was found to have sensitive suboccipital and upper cervical musculature, and decreased range of motion at the joint between the occiput and first cervical vertebra, the atlanto-occipital facet joint (Occ-C1), coupled with pain on flexion and extension of the cervical spine. He also had significant reduction in thoracic spine motion and an increase in thoracic kyphosis.

Treatment

The patient received chiropractic adjustments (described above) to his Occ-C1 joint, upper thoracic spine and the affected hypertonic musculature. An initial course of 16 diversified chiropractic treatments was conducted as part of a research program that the patient was participating in. The program involved recording several features for every migraine episode, including visual analogue scores, duration, medication and time before they could return to normal activities. In addition, he was shown some stretches and other exercises for his neck muscles and proved compliant.

Outcome

The patient reported a dramatic improvement after the course of treatment and had noticeably reduced frequency and intensity of migraines. This had continued when the patient was contacted at a period of 6 months after the study had ceased (Fig 1). At that point the patient reported having 2 migraines a month, with a VAS score of 5 out of ten, and the average duration had fallen to 7 hours (Fig�s 1-3). In addition, he now used no medication and noted that he no longer experienced nausea, vomiting, photophobia or phonophobia (Table 1).

Table 1 Review of Selected Cases Presenting with Migraine

Case 2

A 43 year old female university clerk presented complaining of chronic recurring headaches each lasting on average five days, sinus trouble due to allergy, and disturbed vision. The patient stated she experienced �migraines� which had been occurring since the age of eight. During the migraines she experienced nausea, visual disturbances, photophobia, phonophobia and scotoma. The pain usually began around her right eye but would often change to the left temple. She did not describe the pain as throbbing and the pain only stopped activities on a few occasions each year.

The patient stated she experienced the migraines once a month, except during springtime, when the migraines would occur at least once a week. She had been prescribed hormone replacement therapy (HRT) for twelve months following menopause, which had not changed the migraines. She also reported a VAS score of eight for an average episode and that an average episode lasted between six to eight hours.

In her history she reported that she had experienced many falls while horse riding between the ages of eight to ten. However, she believed that no bones were broken at the time of the falls, although this was not confirmed by radiographs at the time of injury. She had two children and was active, currently playing tennis, walking and was a keen gardener. Her past treatment included non- prescription medication for her sinus problems (Teldane),�however this did not seem to relieve the migraine. The patient stated she had previously had pethadine injections due to the severity of the migraines.

On examination she had an increased thoracic kyphosis, associated Trapezius hypertonicity and trigger points. She exhibited slight scoliosis (negative on Adams test) in the lumbar and thoracic regions. The patient also had moderate limitation in cervical spine mobility, notably in left lateral flexion and right rotation.

Treatment

Treatment consisted of diversified chiropractic spinal adjustments, especially to the C1-2, T5-6, L4-5 joints to correct the restriction of movement. Vibrator massage, and infra-red therapy were used to complement the�treatment, releasing muscles spasm of the region before the adjustments were delivered. The patient was given 14 treatments over the two months of the research trial. Following the initial treatment she experienced some moderate neck pain which resolved following the next session.

Figure 1 Changes in Frequency of Migraine Episodes for the Four Cases

Figure 2 Changes in VAS Scores of Migraines for the Four Cases

Figure 3 Changes in Duration of Migraines for the Four Cases

Figure 4 Changes in Medication of Migraines for the Four Cases

Outcome

When contacted six months following the study, the patient stated the migraines had not experienced a migraine in the last four months. The last episode she had noted a VAS score reduced to four, the average duration had reduced to three days and she had now reduced her medication to nil (Fig�s 1-4). In addition, she now experienced minor nausea, no photophobia or phonophobia, and she had substantially improved neck�mobility. She had continued to have chiropractic treatment at a frequency of once a month, following the end of the research trial.

Case 3

A 21 year old female, 171cm tall Caucasian presented with a chief complaint of severe migraines. Each episode lasted two to four hours, at a frequency of three to four episodes per week, and they had occurred for five years. The patient reported moderate posterior neck and shoulder pain, associated with the migraines. She also believed the initial migraine to be induced by stress and subsequent episodes were also aggravated by emotional stress. The patient reported no other health problems except very mild hypotension, for which she was not taking medication.

The patient�s migraines were located in the frontal, temporal and occipital regions bilaterally. No symptoms occurred premonitory to the onset of her migraines, nor did she experience visual disturbances prior to or during the migraine episodes. She described the pain as a constant dull ache, which was local and she did not complain of any parathesias.

At the initial visit, she rated each migraine between 4 and 5 on a VAS of 1-10. She also noted she experienced nausea, vomiting, dizziness, photophobia and phonophobia.

The cervical ranges of motion were restricted, predominantly in right rotation. Palpation findings were obvious at trapezius, suboccipital and supra scapulae muscles due to increased tone, colour and temperature. Motion palpation indicated restricted movement of the C1-2 facet joint on the right side. Further palpation of the supra scapular and suboccipital indicated myofibrotic tissue. Neurological tests such as Rhombergs, and vertebrobasilar (Maines) test, were negative.

Treatment

The initial treatment was muscle stripping technique aided by a masseter machine massage across the muscle fibres of the trapezius, suprascapularis and temporal regions. The patient also had a cervical adjustment of C1- 2, and adjustment to the T3-4 & T4-5 segments.

The patient was seen three days later, at which point she reported that her neck was less painful. However, she still complained of right neck pain and dizziness. Examination revealed passive motion restriction at C1-2 motion segment. Her thoracic spine was found to be restricted at segment T5-6. In addition, she had mild to moderate hypertonicity in suboccipital and cervical paraspinal muscles and supra scapular area. She was again treated�with adjustments and soft tissue technique. The C1-2 restriction to the right was adjusted with a cervical adjustment. The T5-6 restriction was also adjusted and the myofibrotic tissues were treated with the masseter.

The patient returned four days later. She reported that her migraine had improved. She no longer experienced the symptoms of a non-classical migraine. However, the pressure sensation was still present around her head, but less so than prior to the commencement of treatment. No neck pain was reported. Examination revealed a passive motion restriction of C1-2 motion segment. There was hypertonicity in the suboccipital and supra scapular muscles. The patient was treated with a cervical adjustment at C1-2 and muscle work on the above muscle groups. Neck stretching exercises were also advised.

Table 2 Changes in Outcome Measures of Migraine Episodes for the Mean of the Four Cases

The patient was seen a total of thirteen times over a two month period, and stated that her migraine episodes had reduced significantly at the last treatment. In addition, she was no longer experiencing neck pain. Examination revealed passive motion restriction at the C1-2 motion segment, which was reduced by adjustment.

Outcome

The patient was contacted six months after the trial for a follow-up, at which point she reported she had experienced a reduction of migraine episodes to once every two months. However, her VAS scores for an average episode was now 5.5, but the duration of an average episode was reduced by 50%. In addition, she noted a reduction in photophobia and phonophobia, but still experienced some dizziness. The patient also noted a reduction in use of medication from three Nurofen a week (12 per month) to three per month, representing a 75% reduction (Fig�s 1- 4).

Case 4

A 34 year old, 75kg Caucasian male presented with neck pain and migraines which had commenced after he had hit his head whilst surfing at a beach. This incident occurred when the patient was 19 years old but the patient said the migraines had peaked at 25 years of age. The patient stated that at 25 years of age he suffered a�migraine headaches (three to four times per week) but now in the last year prior to his presentation he experienced them twice a week. He reported that his migraines started in the suboccipital region, and radiated to his right eye. He also reported they were a unilateral throbbing headache, an aura, nausea, vomiting, vertigo, and photophobia. The patient stated taking aspirin and mersyndol medication approximately four to five times a week.

The patient reported that an average episode lasted twelve to eighteen hours and he could perform duties after eight to ten hours. In addition a visual analogue scale score (VAS) for an average episode was 7.0 out of a possible maximum score of ten, corresponding to a description of �moderate� pain. He also reported that he had osteopathic treatment approximately three years earlier, which had given some short term relief, however, physiotherapy had proven ineffective.

On examination, he was found to have significant reduction in thoracic spine motion and an increase in thoracic kyphosis, and decreased range of motion at the joint between the first and second cervical vertebra (C1- 2), the atlanto-occipital facet joint (Occ-C1), coupled with pain on flexion and extension of the cervical spine. He also had sensitive suboccipital and upper cervical musculature, especially the upper Trapezius muscle.

Treatment

The patient received chiropractic diversified adjustments to his C1-2 joint, upper thoracic spine and the affected hypertonic musculature. After a course of 14 treatments (conducted as part of a research program) the patient found he was experiencing one migraine per fortnight. The patient also reported that the nausea had decreased and that the aura was less significant.

The patient reported the improvement after the initial treatment had continued when the patient was contacted 6 months after the study had ceased. At that point the patient reported having one migraine a month, and that the VAS score had fallen to 6 out of ten. However, the average duration and return to normal activities time had remain the same as before the treatment had commenced. The patient reported that he now used only one medication per month and that he no longer experienced nausea, vomiting, and the aura (Fig�s 1-4).

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

“How does the effectiveness of chiropractic care and the use of medication vary when it comes to migraine pain?”�Chiropractic migraine pain treatment, such as chiropractic spinal manipulative treatment or spinal manipulation, is commonly utilized to help improve as well as manage migraine symptoms. Many healthcare professionals also frequently use medication, such as amitriptyline, to help relieve migraine symptoms although this treatment option may only temporarily relieve the symptoms rather than treat the condition from the source. Chiropractic care and the use of medication can be used together to help increase the relief of the treatments, as recommended by a healthcare professional. Several evidence-based studies, like the ones in the article, have demonstrated the effectiveness of chiropractic migraine pain treatment, however, more research studies are required to determine their specific result on migraine pain management. Furthermore, other research studies have shown that medication may be as effective as chiropractic spinal manipulative treatment but was associated with more side effects. Common side effects of medications like amitriptyline include: drowsiness, dizziness, dry mouth, blurred vision, constipation, trouble urinating or weight gain. Additional assessments on the effectiveness of spinal manipulation and amitriptyline is needed.

Conclusion

These four case studies highlight an apparent significant reduction in disability associated with migraines (Table 1). The conclusions are limited however, because the study does not contain a control group for comparison of placebo effect. Therefore chiropractic SMT appears to have significantly reduced migraine disability for these individuals.

Practitioners need to be critically aware of diagnostic criteria when presenting studies or case studies on effectiveness of their treatment (8). This is especially important in presentation of migraine and manipulative therapy research (12, 23).

Changes in outcome measures of migraine episodes for the mean of the four cases revealed some interesting findings (Table 2 ). As can be seen in the table, the frequency of episodes and the use of medication were substantially reduced for the four cases. However, one cannot conclude that this could be the case for other migraine sufferers due to the small number of cases presented.

Acknowledgement

The author greatly appreciates the contribution of Dr Dave Mealing in the preparation of the paper.

A Randomized Controlled Trial of Chiropractic Spinal Manipulative Therapy for Migraine.

Abstract

Objective: To assess the efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine.
Design: A randomized controlled trial of 6 months’ duration. The trial consisted of 3 stages: 2 months of data collection (before treatment), 2 months of treatment, and a further 2 months of data collection (after treatment). Comparison of outcomes to the initial baseline factors was made at the end of the 6 months for both an SMT group and a control group.
Setting: Chiropractic Research Center of Macquarie University.
Participants: One hundred twenty-seven volunteers between the ages of 10 and 70 years were recruited through media advertising. The diagnosis of migraine was made on the basis of the International Headache Society standard, with a minimum of at least one migraine per month.
Interventions: Two months of chiropractic SMT (diversified technique) at vertebral fixations determined by the practitioner (maximum of 16 treatments).
Main Outcome Measures: Participants completed standard headache diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms, and use of medication for each migraine episode.
Results: The average response of the treatment group (n = 83) showed statistically significant improvement in migraine frequency (P < .005), duration (P < .01), disability (P < .05), and medication use (P< .001) when compared with the control group (n = 40). Four persons failed to complete the trial because of a variety of causes, including change in residence, a motor vehicle accident, and increased migraine frequency. Expressed in other terms, 22% of participants reported more than a 90% reduction of migraines as a consequence of the 2 months of SMT. Approximately 50% more participants reported significant improvement in the morbidity of each episode.
Conclusion: The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.

Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-Type Headaches: a Randomized Clinical Trial

Abstract

Objective: To compare the effectiveness of spinal manipulation and pharmaceutical treatment (amitriptyline) for chronic tension-type headache.
Design: Randomized controlled trial using two parallel groups. The study consisted of a 2-wk baseline period, a 6-wk treatment period and a 4-wk posttreatment, follow-up period.
Setting: Chiropractic college outpatient clinic.
Patients: One hundred and fifty patients between the ages of 18 and 70 with a diagnosis of tension-type headaches of at least 3 months’ duration at a frequency of at least once per wk.
Interventions: 6 wk of spinal manipulative therapy provided by chiropractors or 6 wk of amitriptyline treatment managed by a medical physician.
Main Outcome Measures: Change in patient-reported daily headache intensity, weekly headache frequency, over-the-counter medication usage and functional health status (SF-36).
Results: A total of 448 people responded to the recruitment advertisements; 298 were excluded during the screening process. Of the 150 patients who were enrolled in the study, 24 (16%) dropped out: 5 (6.6%) from the spinal manipulative therapy and 19 (27.1%) from the amitriptyline therapy group. During the treatment period, both groups improved at very similar rates in all primary outcomes. In relation to baseline values at 4 wk after cessation of treatment, the spinal manipulation group showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and an improvement of 16% in functional health status. By comparison, the amitriptyline therapy group showed no improvement or a slight worsening from baseline values in the same four major outcome measures. Controlling for baseline differences, all group differences at 4 wk after cessation of therapy were considered to be clinically important and were statistically significant. Of the patients who finished the study, 46 (82.1%) in the amitriptyline therapy group reported side effects that included drowsiness, dry mouth and weight gain. Three patients (4.3%) in the spinal manipulation group reported neck soreness and stiffness.
Conclusions: The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline therapy was slightly more effective in reducing pain at the end of the treatment period but was associated with more side effects. Four weeks after the cessation of treatment, however, the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast to the patients that received amitriptyline therapy, who reverted to baseline values. The sustained therapeutic benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare spinal manipulative therapy to an appropriate placebo such as sham manipulation in future clinical trials.

In conclusion,�the following research studies demonstrated the effectiveness of chiropractic spinal manipulative therapy while one research study compared it with the use of amitriptyline for migraine. The article concludes that both chiropractic migraine pain treatment as well as medication were significantly effective in the improvement of migraine headache, however, amitriptyline is reported to present various side effects. Finally, patients may choose the best possible treatment for their migraine pain, as recommended by a healthcare professional. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Neck Pain

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References

1. Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology 1993; 43(Suppl 3): S6-10.
2. Stewart WF, Lipton RB, Celentous DD, et al. Prevalence of migraine headache in the United States. JAMA 1992; 267: 64-9.
3. King J. Migraine in the Workplace. Brainwaves. Australian Brain Foundation 1995. Hawthorn, Victoria.
4. Wolff�s Headache and other head pain. Revised by Dalessio DJ. 3rd Ed 1972 Oxford University Press, New York.
5. Linet OS, Stewart WF, Celentous DD, et al. An epidemiological study of headaches among adolescents and young adults. JAMA 1989; 261: 221-6.
6. Anthony M. Migraine and its Management, Australian Family Physician 1986; 15(5): 643-9.
7. Sjasstad O, Fredricksen TA, Sand T. The localisation of the initial pain of attack: a comparison between classic migraine and cervicogenic headache. Functional Neurology 1989; 4: 73-8
8. Tuchin PJ, Bonello R. Classic migraine or not classic migraine, that is the question. Aust Chiro & Osteo 1996; 5: 66-74.
9. Tuchin PJ. The Efficacy Of Chiropractic Spinal Manipulative Therapy (SMT) In The Treatment Of Migraine – A Pilot Study. Aust Chiro & Osteo 1997; 6: 41-7.
10. Parker GB, Tupling H, Pryor DS. A Controlled Trial of Cervical Manipulation for Migraine, Aust NZ J Med 1978; 8: 585-93.
11. Hasselburg PD. Commission of Inquiry Into Chiropractic. Chiropractic in New Zealand. 1979 Government Printing Office New Zealand.
12. Parker GB, Tupling H, Pryor DS. Why Does Migraine Improve During a Clinical Trial? Further Results from a Trial of Cervical Manipulation for Migraine. Aust NZ J Med 1980; 10: 192-8.
13. Vernon H, Dhami MSI. Vertebrogenic Migraine, J Canadian Chiropractic Assoc 1985; 29(1): 20-4.
14. Wight JS. Migraine: A Statistical Analysis of Chiropractic Treatment. J Am Chiro Assoc 1978; 12: 363-7.
15. Vernon H, Steiman I, Hagino C. Cervicogenic Dysfunction in muscle contraction headache and migraine: a descriptive study. J Manipulative Physiol Ther 1992; 15: 418-29.
16. Whittingham W, Ellis WS, Molyneux TP. The effect of manipulation (Toggle recoil technique) for headaches with upper cervical joint dysfunction: a case study. J Manipulative Physiol Ther. 1994; 17(6): 369-75.
17. Lenhart LJ. Chiropractic Management of Migraine without Aura: A case study. JNMS 1995; 3: 20-6.
18. Tuchin PJ, Scwafer T, Brookes M. A Case Study of Chronic Headaches. Aust Chiro Osteo 1996; 5: 47- 53.
19. Nelson CF. The tension headache, migraine continuum: A hypothesis. J Manipulative Physiol Ther 1994; 17(3): 157-67.
20. Kidd R, Nelson C. Musculoskeletal dysfunction of the neck in migraine and tension headache. Headache 1993; 33: 566-9.
21. Milne E. The Mechanism and treatment of migraine and other disorders of cervical and postural dysfunction. Cephalgia 1989; 9(Suppl 10): 381-2.
22. Young K, Dharmi M. The Efficacy Of cervical manipulation as opposed to pharmacological therapeutics in the treatment of migraine patients. Transactions of the Consortium for Chiropractic Research. 1987.
23. Marcus DA. Migraine and tension type headaches: the questionable validity of current classification systems. Pain 1992; 8: 28-36.
24. Headache Classification Committee of the International Headache, Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalgia 1988; 9(Suppl 7): 1-93.
25. Rasmussen BK, Jensen R, Schroll M, Olsen J. Interactions between migraine and tension type headaches in the general population. Arch Neurol 1992; 49: 914-8.
26. Vernon H. Upper Cervical Syndrome: Cervical Diagnosis and Treatment. In Vernon H. (Ed): Differential Diagnosis of Headache. 1988 Baltimore, Williams and Wilkins.
27. Vernon HT. Spinal manipulation and headache of cervical origin. J Manipulative Physiol Ther 1989; 12: 455-68.

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Migraine Headache Chiropractic Treatment | El Paso, TX Chiropractor

by spinedoctors | Chiropractic, Functional Medicine, Migraine

A migraine is commonly identified by a moderate to severe throbbing pain or a pulsing sensation, usually on one side of the head, often accompanied by nausea, vomiting and extreme sensitivity to light and sound. Migraine headache pain can last for hours to even days and the symptoms can become so severe they may be disabling. Many doctors can treat varying intensities of head pain, however, the use of drugs and/or medications may only temporarily relieve the painful symptoms. Evidence-based research studies like the one described below, have determined that chiropractic spinal manipulative therapy may effectively improve migraine headaches. The purpose of the article is to educate patients on migraine headache chiropractic treatment.

A Twelve Month Clinical Trial of Chiropractic Spinal Manipulative Therapy for Migraine

Abstract

Objective: To assess the efficacy of Chiropractic spinal manipulative therapy (SMT) in the treatment of migraine.
Design: A prospective clinical trial of twelve months duration. The trial consisted of 3 stages: two month pre- treatment, two month treatment, and two months post treatment. Comparison of outcomes to the initial baseline factors was made and also 6 months after the cessation of the study.
Setting: Chiropractic Research Centre of Macquarie University
Participants: Thirty two volunteers, between the ages of 20 to 65 were recruited through media advertising. The diagnosis of migraine was based on a self reported detailed questionnaire, with minimum of one migraine per month.
Interventions: Two months of chiropractic SMT at vertebral fixations determined by the practitioner, through orthopedic and chiropractic testing.
Main Outcome Measures: Participants completed diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms and use of medication for each migraine episode.
Results: The initial 32 participants showed statistically significant (p < 0.05) improvement in migraine frequency, VAS, disability, and medication use, when compared to initial baseline levels. A further assessment of outcomes after a six month follow up (based on 24 participants), continued to show statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), disability (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels. In addition, information was collected regarding any changes in neck pain following chiropractic SMT. The results indicated that 14 participants (58%) reported no increase in neck pain as a consequence of the two months of SMT. Five participants (21%) reported a slight increase, three participants (13%) reported mild pain, and two participants (8%) reported moderate pain.
Conclusion: The results of this study support the hypothesis that Chiropractic SMT is an effective treatment for migraine, in some people. However, a larger controlled study is required.
Key Indexing Terms (MeSH): Migraine; chiropractic; spinal manipulation; prospective trial; neck.

Introduction

The cervical spine as a cause of headache has been well described in the literature (1,2). The Headache Classification Committee of the International Headaches Society, has defined cervicogenic headache, in addition to the other types of headaches, including migraine and tension type headache (3).

However, the role of spinal conditions (especially the cervical spine) and their associated treatment for migraine does not have a well established causal relationship or clear aetiological pathway (4-7). In addition, migraine often has uncertain or overlapping diagnostic criteria thus making the role of the cervical spine as an aetiological factor even more uncertain (8,9).

Migraine Headache Chiropractic Treatment | El Paso, TX Chiropractor

Migraines are a common and debilitating conditions yet because of this uncertain aetiology, the most appropriate long term treatment has not been established (9,10). Most aetiological models relate to vascular causes of migraine, where episodes seem to be initiated by a decreased blood flow to the cerebrum followed by extracranial vasodilatation during the headache phase (11,12). However, other aetiological models seem connected with vascular changes related to neurological causes and associated serotonergic disturbances (10). Therefore, previous treatments have focused on pharmacological modification of blood flow or serotonin antagonist block (11).

This paper will evaluate the efficacy of chiropractic spinal manipulative treatment during a prospective clinical trial of twelve months duration.

Chiropractic Treatment

Chiropractic SMT is defined as a passive manual manoeuvre during which the three joint complex is carried beyond the normal physiological range of movement without exceeding the boundaries of anatomical integrity (4). SMT requires a dynamic force in a specific direction, usually with a short amplitude to correct a problem of reduced vertebral motion or positional fault. Treatment usually consists of short amplitude, high velocity spinal manipulative thrusts (diversified technique), on areas of vertebral fixation determined by a clinical history and physical examinations.

Dr Jimenez works on wrestler's neck_preview | El Paso, TX Chiropractor

The most commonly used factors to locate vertebral fixation (denoted vertebral subluxation complex by�chiropractors) are a clinical history relating to mechanical pain patterns and medical details to excluded possible non- mechanical causes (4). These findings would then be confirmed by a thorough physical examination, by assessing which tests/signs (orthopaedic and chiropractic) were able to reproduce the presenting symptom (7).

Studies in effectiveness and cost-effectiveness of treatment for back pain have found significant benefit for chiropractic spinal manipulative therapy (SMT). These studies have been detailed in a previous publication by this author on chiropractic in the workers compensation system (13). In addition, numerous studies have identified improvement in neck pain and headache following chiropractic SMT (4,7,14-17).

This paper will test an hypothesis that spinal conditions appear to contribute to the aetiology and morbidity of migraine.

Methodology

The study was twelve month prospective clinical trial which involved 32 subjects who received a two month course of chiropractic SMT. Treatment consisted of short amplitude, high velocity spinal manipulative thrusts (chiropractic adjustive technique), on areas of vertebral subluxation determined by the physical examination.

Participants were recruited via the radio and newspapers in the Sydney region. Applicants completed a previously reported questionnaires, and were selected according to responses in the following symptoms. The participants needed to a minimum of 5 of the following IHS indicators: reaction to pain requiring cessation of activities, the need to seek a quiet dark area, unilateral pain located parieto- temporal, pain described as pulsating/throbbing, associated symptoms of nausea &/or vomiting, photophobia &/or phonophobia, migraine aggravated by head or neck movements, and a family history of migraine (3).

Inclusion was also based on participants experiencing at least one migraine a month. Exclusion was based on non- migraine indicators of a daily migraine or the initiating factor being trauma. Participants were also excluded from the study if there were contra-indications to SMT, such as meningitis or cerebral aneurysm. In addition, participants with temporal arteritis, benign intracranial hypertension or space occupying lesions were also excluded due to safety aspects.

Participants completed diaries during the initial six month trial noting the frequency, VAS, duration, disability, associated symptoms and use of medication for each migraine episode. Participants were instructed how to complete the diary which contained a table and an�instruction sheet. Participants had to note the date of the migraine, an intensity score based on a visual analogue scale, the hours the migraine lasted and the time before they could return to normal activities. In addition, participants noted associated symptoms using a letter abbreviation and they noted the type and strength of medication for each migraine episode.

Patient’s blinding was achieved by participants being informed that they may be randomly assigned to a control group which would receive a placebo (non effective) treatment. Concurrently, the practitioners were “blinded” to previous treatment results, assignment of control procedures and other outcome measures.

The first aspect of the trial was conducted over six months, and consisted of 3 stages: two months pre-treatment, two months treatment, and two months post treatment. Participants were contacted by the author a further six months after the initial trial and asked to complete another questionnaire regarding their current migraine episodes for comparison to baseline data. The follow up questionnaire sought information on the same outcome measures, as detailed in the diaries described above.

Comparison was made to initial baseline outcome measurements of migraine preceding commencement of SMT, data at the end of the two months post SMT, and to the six month follow up data. Statistical analysis involved comparing the changes of the different outcome measurements of frequency, VAS, duration, disability, and medication use throughout the trial. Statistical tests employed were a paired t test to test for significant difference between each group and a one way analysis of variance (ANOVA) to test for changes for all groups.

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

“How can chiropractic spinal manipulative therapy help manage my migraine headache pain?”�Although researchers today don’t know the definitive cause behind these complex headaches, many healthcare professionals believe migraines are often the result of an underlying issue along the cervical spine, or neck. If you suffer from migraine headache pain, chiropractic treatment can help correct spinal misalignments, or subluxations, in the cervical spine to improve the severity of the headache and decrease their frequency. It’s not necessary to rely on drugs and/or medications to relieve the painful symptoms, however, these may be used if properly directed by a healthcare professional. Rather than focusing on the head pain alone, a doctor of chiropractic will target the source of the issue and help improve your overall health and wellness.

Results

Thirty two participants, between the ages of 23 to 60, joined the study with there being 14 males and 18 females. Table 1 gives the comparative descriptive statistics for the group. The length of time the person had migraines ranged between 5 to 36 years for the group, with the average being 18.1 years. The duration of a typical migraine episode ranged between 0.75 to 108 hours for the group, with the average being 23.3 hours. The disability (length of time before the person could return to normal activities) of a typical migraine ranged between 0 to 108 hours for the group, with the average being 25.0 hours.

Table 1 Comparative Statistics for Group Prior to Commencement of Study | Dr. Alex Jimenez | El Paso, TX Chiropractor

The percentage response for each of the diagnostic criteria of the IHS guidelines is detailed in table 2 (Table 2). The highest responses were for photophobia (91%), nausea (88%), reaction to pain requiring the person to seek a quiet dark area (84%), phonophobia (72%), throbbing pain characteristic (69%), parieto-temporal pain location (69%), inability to continue normal activities (66%), and family history (63%).

Table 2 IHS Criteria Questionnaire Responses for Group Prior to Commencement of Study | Dr. Alex Jimenez | El Paso, TX Chiropractor

The IHS diagnostic criteria with the lowest responses were aura (31%), migraines aggravated by head or neck movement (53%), and vomiting (56%). A moderate number (44%) of people did not indicate aura as a feature, however, they described either homonymous visual changes or parasthesias. Therefore, the number of people experiencing migraine with aura (MA) for this group was twenty four (75%) of a total group of thirty two.

The group showed statistically significant improvement (p < 0.05) in migraine frequency, VAS, duration and disability, when compared to initial baseline levels. The frequency rates reduced by 46% for the group, severity reduced by 12%, duration reduced by 20%, disability reduced by 14% only one participant (3.1 %) reported that their migraine episodes were worse after the two months of SMT, but this was not sustained at the two month post treatment follow up period. Table 3 demonstrates variate scores in each of the six diary categories for the three phases of the trial.

Table 3 Comparative Results for Group Prior to Commencement of Study | Dr. Alex Jimenez | El Paso, TX Chiropractor

From the initial thirty two participants who entered the study, four participants failed to complete the entire trial, one due to alteration in work situation, one due to a fractured ankle, one due to soreness after SMT, and one ACO�following a perceived worsening of their migraine due to chiropractic SMT. In addition, four people failed to return their six month follow up data, and were excluded from the assessment. Therefore the assessment of changes in migraine at the twelve month period was based on 24 participants. Table 4 gives the comparative statistics for this group at the end of the 12 month period.

Table 4 Changes in Outcome Measures for Group Baseline Levels Compared to the 12 Month Follow Up | Dr. Alex Jimenez | El Paso, TX Chiropractor

The average response at twelve months (n=24) showed statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), duration (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels (Figure ????). The greatest area for improvement was with the frequency of episodes (60% reduction), and the associated severity of each migraine (14% reduction). In addition, the duration of the migraine (20% reduction) and the use of medication, reduced significantly following the SMT intervention (36% reduction). Table 3 shows mean variate scores for the three phases of the trial and statistical significance by analysis of variance (ANOVA).

Another additional result related to associated neck pain. Fourteen participants (58%) reported no increase in neck pain as a consequence of the two months of SMT. Five participants (21%) reported slight pain, three participants (13%) reported mild pain, and two participants (8%) reported moderate pain.

Discussion

The majority of participants were chronic migraine sufferers, on average they had experienced migraines for 18.1 years. However, the results have demonstrated a significant (p< 0.005) reduction in their migraine episodes and their associated disability. The mean number of migraines per month reduced from 7.6 to 2.6 episodes.

A twelve month study gives the results substantial significance because a criticism of early studies were that the length of the trial was too short to allow for the cyclical nature of migraines (18). However, the study was limited in the sample size and the fact that the trial was a pragmatic study which did not consider what aspects of chiropractic SNIT had contributed to the improvement in the migraines.

In addition, the study was limited due to the lack of a control group. However, it could be argued that participants acted as their own form of control, due to the�baseline two months data collection, especially given the fact that this group were chronic migraine sufferers.

A further limitation of this study, as with other studies of migraine or headaches was that there is substantial overlap in diagnosis and classification of migraines. The questionnaire used in this study proved to have good reliability, however, there is strong suggestion that many headache sufferers may have more than one type of headache (6-9). An advantage with the design of this study is that regardless of the exact “diagnosis” of the migraine, self reported improvement of outcome measures allow assessment of the validity of the therapy in question (4).

This study appears to confirm that there are a number of precipitating or aggravating factors involved in migraine episodes and therefore a single treatment regime may prove ineffective in the long term (4,5,9,15).

Practitioners need to be aware of the various treatment strategies and their relative advantages or limitations.

Importantly, many of the associated symptoms suffered by participants on the trial were reported to be decreased following the SMT. The associated symptoms which decreased following the trial included nausea (41% of participants felt reduction), photophobia (31 % felt reduction), vomiting (25% felt reduction), and phonophobia (25% felt reduction). Commonly reported side effects which often increase following pharmaceutical trials include nausea, vomiting, fatigue, chest pain, paraesthesia, somnolence, syncope, vertigo and less commonly atrial fibrillation. In addition, recent evidence has identified sumatriptan to be a potential cause of birth defects and myocardial infarction (19,20).

Dr Jimenez works on back treatment at Push crossfit competition | El Paso, TX Chiropractor

Whilst not a factor noted by the IHS, stress as either an aggravating or precipitating factor was cited by 73% of participants. In addition, 66% of people reported neck pain at the time of the migraine, with a further 31 % of people reporting upper back pain (some people noted both simultaneously).

Interestingly, five people at the end of the 12 months followup had no migraines and had decreased need for medication by 100% following chiropractic SMT. No patients reported that their migraines had increased as a result of the SMT trial.

Conclusion

The results of this study support the hypothesis that Chiropractic SMT is an effective treatment for migraine, in some people. However, due to the multifactorial nature of migraine, and the finding that episodes usually reduce following any intervention, further larger controlled study is required.

A prospective randomised controlled trial utilising detuned EPT (interferential), a sham manipulation group and an SMT group is nearing conclusion. It is anticipated this trial will provide further information of the efficacy of Chiropractic SMT in the treatment of migraine with aura.

In conclusion,�because migraine headache pain can be significantly debilitating, it’s essential for patients who suffer from this complex type of head pain to understand the effectiveness of chiropractic spinal manipulative therapy. According to the results of the research study above, migraine headache chiropractic treatment can be effectively used to as migraine treatment. Regardless of the results of the twelve month clinical trial, further research studies are still required. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Neck Pain

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

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References

1. Bogduk N. Cervical causes of headache and dizziness. In: Greive GP (ed) Modern manual therapy of the vertebral column. 2nd ed 1994. Churchill Livingstone, Edinburgh. p3l7-31.
2. Jull GA. Cervical Headache: a review. In: Greive GP (ed) Modem manual therapy of the vertebral column. 2nd ed 1994. Churchill Livingstone, Edinburgh. p 333-34,6
3. Headache Classification Committee of the International Headache, Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalgia 1988, 9. Suppl. 7: 1-93.
4. Tuchin PJ. The efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine – a pilot study. Aust Chiro & Osteo 1997; 6: 41-7.
5. Milne E. The mechanism and treatment of migraine and other disorders of cervical and postural dysfunction. Cephaigia 1989; 9, Suppi 10: 381-2.
6. Kidd R, Nelson C. Musculoskeletal dysfunction of the neck in migraine and tension headache. Headache 1993; 33: 566-9.
7. Tuchin PJ, Bonello R. Classic migraine or not classic migraine, that is the question. Aust Chiro & Osteo 1996; 5: 66-74.
8. Marcus DA. Migraine and tension type headaches: the questionable validity of current classification systems. 1992; Pain 8: 28-36.
9. Rasmussen BK, Jensen R, Schroll M, Olsen J. Interactions between migraine and tension type headaches in the general population. Arch Neurol 1992; 49: 914-8.
10. Lance JW. A concept of migraine and the search for the ideal headache drug. Headache 1990; 1: 17-23.
11. Dalassio D. The pathology of migraine. Clin J Pain 1990 6: 235-9.
12. Moskowitz MA. Basic mechanisms in vascular headache. Neurol Clin 1990; 16: 157-68
13. Tuchin PJ, Bonello R. Preliminary Findings of Analysis of Chiropractic Utilisation and Cost in the Workers Compensation System of New South Wales. J Manipulative Physiol Ther 1995; lg: 503-11.
14. Tuchin PJ, Scwafer T, Brookes M. A Case Study of Chronic Headaches. Aust Chiro & Osteo 1996; 5: 47-53.
15. Parker GB, Tupling H, Pryor DS. A Controlled Trial of Cervical Manipulation for Migraine. Aust NZ J Med 1978; 8: 585-93.
16. Young K, Dharmi M. The efficacy of cervical manipulation as opposed to pharmacological therapeutics in the treatment of migraine patients. Transactions of the Consortium for Chiropractic Research. 1987.
17. Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study. J Manipulative Physiol Ther 1992; 15: 418-29
18. Parker GB, Tupling H, Pryor DS. Why does migraine improve during a clinical trial? Further results from a trial of cervical manipulation for migraine. Aust NZ J Med 1980; 10: 192-8.
19. Ottervanger JP, Stricker BH. Cardiovascular adverse reactions to sumatriptan: cause for concern? CNS Drugs 1995; 3: 90-8.
20. Simmons VE, Blakeborough P. The safety profile of sumatriptan. Rev Contemp Pharmacother 1994; 5: 319-28.

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Migraine Pain Treatment | Dr. Alex Jimenez

by spinedoctors | Chiropractic, Functional Medicine, Migraine

A migraine is characterized as a moderate to severe headache, often accompanied by nausea and sensitivity to light and sound. Nearly 1 in 4 United States households include someone who suffers from migraine. As a matter of fact, migraine is considered to be the 3rd most prevalent condition in the world. Researchers haven’t identified a definitive cause for migraines, however, several factors are believed to trigger the complex headache pain, including a misalignment in the cervical spine. Chiropractic care is a well-known alternative treatment option used to help treat migraine headaches and improve the symptoms. The purpose of the following case study is to demonstrate the effects of chiropractic care on migraine pain management.

A Case of Chronic Migraine Remission After Chiropractic Care

Abstract

Objective: To present a case study of migraine sufferer who had a dramatic improvement after chiropractic spinal manipulative therapy (CSMT).
Clinical features: The case presented is a 72-year�old woman with a 60-year history of migraine headaches, which included nausea, vomiting, photophobia, and phonophobia.
Intervention and outcome: The average frequency of migraine episodes before treatment was 1 to 2 per week, including nausea, vomiting, photophobia, and phonophobia; and the average duration of each episode was 1 to 3 days. The patient was treated with CSMT. She reported all episodes being eliminated after CSMT. The patient was certain there had been no other lifestyle changes that could have contributed to her improvement. She also noted that the use of her medication was reduced by 100%. A 7-year follow-up revealed that the person had still not had a single migraine episode in this period.
Conclusion: This case highlights that a subgroup of migraine patients may respond favorably to CSMT. While a case study does not represent significant scientific evidence, in context with other studies conducted, this study suggests that a trial of CSMT should be considered for chronic, nonresponsive migraine headache, especially if migraine patients are nonresponsive to pharmaceuticals or prefer to use other treatment methods.
Key indexing terms: Migraine, Chiropractic, Spinal manipulative therapy

Introduction

Migraine remains a common and debilitating condition.[1, 2] It has an estimated incidence of 6% in males and 18% in females.[2] A study in Australia found the cost to industry to be an estimated $750 million.[3] Lipton et al found that migraine is one of the most frequent reasons for consultations with general practitioners, affecting between 12 million and 18 million people each year in the United States.[4] The estimated cost in the United States is $25 billion in lost productivity due to 156 million full-time work days being lost each year.[5] Recent information has suggested that these older figures above are still current, but also underestimated, because of many sufferers not stating their problem because of a perceived poor social stigma.[6]

The Brain Foundation in Australia notes that 23% of households contain at least one migraine sufferer. Nearly all migraine sufferers and 60% of those with tension-type headache experience reductions in social activities and work capacity. The direct and indirect costs of migraine alone would be about $1 billion per annum.[3]

The Headache Classification Committee of the International Headache Society (IHS) defines migraines as having the following: unilateral location, pulsating quality, moderate or severe intensity, and aggravated by routine physical activity. During the headache, the person must also experience nausea and/or vomiting, photophobia, and/or phonophobia.[7] In addition, there is no suggestion either by history or by physical or neurologic examination that the person has a headache listed in groups 5 to 11 of their classification system.[7] Groups 5 to 11 of the classification system include headache associated with head trauma, vascular disorder, nonvascular intracranial disorder, substances or their withdrawal, noncephalic infection, or metabolic disorder, or with disorders of cranium, neck, eyes, nose, sinuses, teeth, mouth, or other facial or cranial structures.

Some confusion relates to the �aura� feature that distinguishes migraine with aura (MA) and migraine without aura (MW). An aura usually consists of homonymous visual disturbances, unilateral paresthesias and/or numbness, unilateral weakness, aphasia, or unclassifiable speech difficulty.[7] Some migraineurs describe the aura as an opaque object, or a zigzag line around a cloud; even cases of tactile hallucinations have been recorded.[8] The new terms MA and MW replace the old terms classic migraine and common migraine, respectively.

The IHS diagnostic criteria for MA (category 1.2) is at least 3 of the following:

One or more fully reversible aura symptoms indicating focal cerebral cortex and/or brain stem dysfunction.
At least 1 aura symptom develops gradually over more than 4 minutes or 2 or more symptoms occurring in succession.
No aura symptom lasts more than 60 minutes.
Headache follows aura with a free interval of less than 60 minutes.

Migraine is often still nonresponsive to treatment.[9] However, several studies have demonstrated statistically significant reduction in migraines after chiropractic spinal manipulative therapy (CSMT).[10-15]

This article will discuss a patient presenting with MW and her response after CSMT. The discussion will also outline specific diagnostic criteria for migraine and other headaches relevant to chiropractors, osteopaths, or other health practitioners.

Case Report

A 72-year�old 61-kg white woman presented with migraine headaches that had commenced in early childhood (approximately 12 years old). The patient could not relate anything to the commencement of her migraines, although she believed there was a family history (father) of the condition. During the history, the patient stated that she suffered regular migraine headaches (1-2 per week) with which she also experienced nausea, vomiting, vertigo, and photophobia. She needed to cease activities to alleviate the symptoms, and she often required acetaminophen and codeine medication (25 mg) or sumatriptan succinate for pain relief. The patient was also taking verapamil (calcium ion antagonist, for essential hypertension), calcitriol (calcium uptake, for osteoporosis), pnuemenium on a daily basis, and carbamazipine (antiepileptic, neurotropic medication) twice daily.

The patient reported that an average episode lasted 1 to 3 days and that she could not perform activities of daily living for a minimum of 12 hours. In addition, a visual analogue scale score for an average episode was 8.5 out of a possible maximum score of 10, corresponding to a description of �terrible� pain. The patient noted that stress or tension would precipitate a migraine and that light and noise aggravated her condition. She described the migraine as a throbbing head pain located in the parietotemporal region and was always left-sided.

The patient had a previous history of a pulmonary embolism (2 years before treatment) and had a partial hysterectomy 4 years before treatment. She also stated she had hypertension that was controlled. She was a widow with 2 children, and she had never smoked. The patient had tried acupuncture, physiotherapy, substantial dental treatment, and numerous other medications; but nothing had changed her migraine pattern. She stated that she had never had previous chiropractic treatment. The patient also stated that she had been treated by a neurologist for �migraines� over many years.

On examination, she was found to have very sensitive suboccipital and upper cervical musculature and decreased range of motion at the joint between the occiput and first cervical vertebra (Occ-C1), coupled with pain on flexion and extension of the cervical spine. She also had significant reduction in thoracic spine motion and a marked increase in her thoracic kyphosis.

Blood pressure testing revealed she was hypertensive (178/94), which the patient reported was an average result (stage 2 hypertension using the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 guidelines).

Based on the IHS Headache Classification Committee classification and diagnostic criteria, the patient had an MW�category 1.1, previously called common migraine (Table 1). This appeared secondary to moderate cervical segmental dysfunction with mild to moderate suboccipital and cervical paraspinal myofibrosis.

Table 1: Headache classifications (IHS Headache Classification Committee)

The patient received CSMT (diversified chiropractic �adjustments�) to her Occ-C1 joint, upper thoracic spine (T2 through T7), and the affected hypertonic musculature. Hypertonic muscles were released through gentle massage and stretching. An initial course of 8 treatments was conducted at a frequency of twice a week for 4 weeks. The treatment program also included recording several features for every migraine episode. This included frequency, visual analogue scores, episode duration, medication, and time before they could return to normal activities.

The patient reported a dramatic improvement after her first treatment and noticed a reduction in the intensity of her head and neck pain. This continued with the patient reporting having no migraines in the initial month course of treatment. Further treatment was recommended to increase her range of motion, increase muscle tone, and reduce suboccipital muscle tension. In addition, monitoring of her migraine symptoms was continued. A program of treatment at a frequency of once a week for a further 8 weeks was instigated. After the next phase of treatment, the patient noted much less neck tension, better movement, and no migraine. In addition, she no longer used pain-relieving medication (acetaminophen, codeine, and sumatriptan succinate) and noted that she did not experience nausea, vomiting, photophobia, or phonophobia (Table 2). The patient continued treatment at 2-weekly intervals and stated that, after 6 months, her migraine episodes had disappeared completely. In addition, she was no longer experiencing neck pain. Examination revealed no pain on active neck movement; however, a passive motion restriction at the C1-2 motion segment was still present.

Table 2: Category 1: migraine (IHS Headache Classification Committee)

The patient is currently having treatment every 4 weeks, and she still reports no return of her migraine episodes or neck pain. The patient has now not experienced any migraines for a period of more than 7 years since her last episode, which was immediately before her having her first chiropractic treatment.

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Migraine pain is a debilitating symptom which can be effectively managed with chiropractic care. Chiropractic treatment provides a wide selection of services which can help patients with a variety of injuries and/or conditions, including symptoms of chronic pain, limited range of motion and many other health issues. Chiropractic care can also help control stress associated with migraine. Our staff is determined to treat patients by focusing on the source of the issue rather than temporarily relieving the symptoms using drugs and/or medications. The purpose of the article is to demonstrate evidence-based results on the improvement of migraine using chiropractic care and to educate patients on the best type of treatment for their specific health issues. Chiropractic treatment offers relief from migraine pain as well as overall health and wellness.

Discussion

Case studies do not form high levels of scientific data. However, some cases do present significant findings. For example, cases with long (chronic) and/or severe symptomatology can highlight alternative treatment options. With case studies such as this, there is always a possibility that the symptoms spontaneously resolved, with no effective from the treatment. The case presented highlights a potential alternative treatment option. A 7-year follow-up revealed that the person had still not had a single migraine episode in this period. The patient was certain that there had been no other lifestyle changes that could have contributed to her improvement. She also noted that the migraines had stopped after her first treatment.

The average frequency of her migraines before treatment was 1 to 2 per week, with episodes that always included nausea, vomiting, photophobia, and phonophobia. In addition, the average duration of each episode was 1 to 3 days before her receiving CSMT. The person also noted that the use of her pain-relieving medication was also reduced by 100% (Table 3).

Table 3: Summary of key changes for this case

Migraines are a common and debilitating condition; yet because they have an uncertain etiology, the most appropriate treatment regime is often unclear.[16] Previous etiological models described vascular causes of migraine, where episodes seem to be initiated by a decreased blood flow to the cerebrum followed by extracranial vasodilation during the headache phase.[8] However, other etiological models seem connected with vascular changes related to neurologic changes and associated serotonergic disturbances.[9] Therefore, previous treatments have focused on pharmacological modification of blood flow or serotonin antagonist block.[17]

Studies examining the role of the cervical spine to headache (ie, �cervicogenic headache�) have been well described in the literature.[18-30] However, the relation of the cervical spine to migraine is less well documented.[10-15] Previous studies by this author have demonstrated an apparent reduction in migraines after CSMT.[10, 11] In addition, other studies have suggested that CSMT may be an effective intervention for migraine.[14, 15] Although, previous studies have some limitations (inaccurate diagnosis, overlapping symptoms, inadequate control groups), the level of evidence gives support for CSMT in migraine treatment.[11] However, practitioners need to be critically aware of potential overlap of diagnoses when reviewing migraine research or case studies on effectiveness of their treatment.[18-22] This is especially important in comparison of migraine patients who may be suitable for chiropractic manipulative therapy.[23-28]

Between 40% and 66% of patients with migraine, particularly those with severe or frequent migraine attacks, do not seek help from a physician.[29] Among those who do, many do not continue regular physician visits.[30] This may be due to patients’ perceived lack of empathy from the physician and a belief that physicians cannot effectively treat migraine. In a 1999 British survey, 17% of 9770 migraineurs had not consulted a physician because they believed their condition would not be taken seriously; and 8% had not seen a physician because they believed existing migraine medications were ineffective.[30] The most common reason for not seeking a physician’s advice (cited by 76% of patients) was the patients’ belief that they did not need a physician’s opinion to treat their migraine attacks.

The case was presented to assist practitioners making a more informed decision on the treatment of choice for migraines. The outcome of this case is also relevant in relation to other research that concludes that CSMT is a very effective treatment for some people. Practitioners could consider CSMT for migraine based on the following:

Limitation of passive neck movements.
Changes in neck muscle contour, texture, or response to active and passive stretching and contraction.
Abnormal tenderness of the suboccipital area.
Neck pain before or at the onset of the migraine.
Initial response to CSMT.

As with all case reports, results are limited in application to larger populations. Careful clinical decision making should be used when applying these results to other patients and clinical situations.

Conclusion

This case demonstrates that some migraine sufferers may respond well with manual therapies, which includes CSMT. Therefore, migraine patients who have not received a trial of CSMT should be encouraged to consider this treatment and assess any potential response. Where there are no contraindications to CSMT, an initial trial of treatment may be warranted. Following evidence-based medicine guidelines, medical practitioners should discuss CSMT with migraine patients as an option for treatment.[31, 32] Subsequent studies should address this issue and the role that CSMT has in migraine management.

In conclusion, migraine pain is a common condition which affects a large number of the population. Although the cause of migraines is not fully understood, treatment for the complex head pain can ultimately help manage the symptoms. Chiropractic spinal manipulative therapy, or CSMT, may improve migraine in patients and may be a valuable treatment option to consider. However, further research studies are required to demonstrate further results. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Neck Pain

blog picture of cartoon paperboy big news

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

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

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References

1. Bigal M.E., Lipton R.B., Stewart W.F. The epidemiology and impact of migraine. Curr Neurol Neurosci Rep. 2004;4(2):98�104. [PubMed]

2. Lipton R.B., Stewart W.F., Diamond M.L., Diamond S., Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study 11. Headache. 2001;41:646�657. [PubMed]

3. Alexander L. Migraine in the workplace. Brainwaves. Australian Brain Foundation; Hawthorn, Victoria: 2003. pp. 1�4.

4. Lipton R.B., Bigal M.E. The epidemiology of migraine. Am J Med. 2005;118(Suppl 1):3S�10S. [PubMed]

5. Lipton R.B., Bigal M.E. Migraine: epidemiology, impact, and risk factors for progression. Headache. 2005;45(Suppl 1):S3�S13. [PubMed]

6. Stewart W.F., Lipton R.B. Migraine headache: epidemiology and health care utilization. Cephalalgia. 1993;13(suppl 12):41�46. [PubMed]

7. Headache Classification Committee of the International Headache, Society Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalgia. 2004;24(Suppl. 1):1�151. [PubMed]

8. Goadsby P.J., Lipton R.B., Ferrari M.D. Migraine�current understanding and treatment. N Engl J Med. 2002;346:257�263. [PMID 11807151] [PubMed]

9. Goadsby P.J. The scientific basis of medication choice in symptomatic migraine treatment. Can J Neurol Sci. 1999;26(suppl 3):S20�S26. [PubMed]

10. Tuchin P.J., Pollard H., Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther. 2000;23:91�95. [PubMed]

11. Tuchin P.J. The efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine�a pilot study. Aust Chiropr Osteopath. 1997;6:41�47. [PMC free article] [PubMed]

12. Tuchin P.J., Bonello R. Classic migraine or not classic migraine, that is the question. Aust Chiropr Osteopath. 1996;5:66�74. [PMC free article] [PubMed]

13. Tuchin P.J., Scwafer T., Brookes M. A case study of chronic headaches. Aust Chiropr Osteopath. 1996;5:47�53. [PMC free article] [PubMed]

14. Nelson C.F., Bronfort G., Evans R., Boline P., Goldsmith C., Anderson A.V. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther. 1998;21:511�519. [PubMed]

15. Parker G.B., Tupling H., Pryor D.S. A controlled trial of cervical manipulation for migraine. Aust NZ J Med. 1978;8:585�593. [PubMed]

16. Dowson A.J., Lipscome S., Sender J. New guidelines for the management of migraine in primary care. Curr Med Res Opin. 2002;18:414�439. [PubMed]

17. Ferrari M.D., Roon K.I., Lipton R.B. Oral triptans (serotonin 5-HT1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet. 2001;358:1668�1675. [PubMed]

18. Sjasstad O., Saunte C., Hovdahl H., Breivek H., Gronback E. Cervical headache: an hypothesis. Cephalgia. 1983;3:249�256.

19. Vernon H.T. Spinal manipulation and headache of cervical origin. J Manipulative Physiol Ther. 1989;12:455�468. [PubMed]

20. Sjasstad O., Fredricksen T.A., Stolt-Nielsen A. Cervicogenic headache, C2 rhizopathy, and occipital neuralgia: a connection. Cephalgia. 1986;6:189�195. [PubMed]

21. Bogduk N. Cervical causes of headache and dizziness. In: Greive G.P., editor. Modern manual therapy of the vertebral column. 2nd ed. Edinburgh; Churchill Livingstone: 1994. pp. 317�331.

22. Jull G.A. Cervical headache: a review. In: Greive GP, editor. Modern manual therapy of the vertebral column. 2nd ed. Edinburgh; Churchill Livingstone: 1994. pp. 333�346.

23. Boline P.D., Kassak K., Bronfort G. Spinal manipulations vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. 1995;18:148�154. [PubMed]

24. Vernon H., Steiman I., Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study. J Manipulative Physiol Ther. 1992;15:418�429. [PubMed]

25. Kidd R., Nelson C. Musculoskeletal dysfunction of the neck in migraine and tension headache. Headache. 1993;33:566�569. [PubMed]

26. Whittingham W., Ellis W.S., Molyneux T.P. The effect of manipulation (Toggle recoil technique) for headaches with upper cervical joint dysfunction: a case study. J Manipulative Physiol Ther. 1994;17:369�375. [PubMed]

27. Jull G., Trott P., Potter H., Zito G., Shirley D., Richardson C. A randomized controlled trial of exercise and spinal manipulation for cervicogenic headache. Spine. 2002;27:1835�1843. [PubMed]

28. Bronfort G, Nilsson N, Assendelft WJJ, Bouter L, Goldsmith C, Evans R, et al. Non-invasive physical treatments for chronic headache (a Cochrane review). In: The Cochrane Library Issue 2 2003. Oxford: Update Software.

29. Dowson A., Jagger S. The UK migraine patient survey: quality of life and treatment. Curr Med Res Opin. 1999;15:241�253. [PubMed]

30. Solomon G.D., Price K.L. Burden of migraine: a review of its socioeconomic impact. Pharmacoeconomics. 1997;11(Suppl 1):1�10. [PubMed]

31. Bronfort G., Assendelft W.J.J., Evans R., Haas M., Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001;24:457�466. [PubMed]

32. Vernon H.T. Spinal manipulation in the management of tension-type migraine and cervicogenic headaches: the state of the evidence. Top Clin Chiropr. 2002;9:14�21.

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The Role of Psychological Interventions in the Management of Patients with Chronic Pain

Abstract

Dr. Alex Jimenez’s Insight

Introduction

Pain Management

Psychophysiological Techniques

Biofeedback

Behavioral Approaches

Relaxation Training

Operant Behavior Therapy

Cognitive-Behavioral Approaches

Acceptance-Based Approaches

Expectations

Emotional Concomitants of Pain

Conclusion

Footnotes

Additional Topics: Back Pain

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References

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A Critical Review of Manual Therapy Use for Headache Disorders: Prevalence, Profiles, Motivations, Communication and Self-Reported Effectiveness

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Design

Search Outcomes, Analyses and Quality Appraisal

Results

Prevalence of MT Use

Profile and Motivations for MT Use

Concurrent Use and Order of Use of Headache Providers and Related Communication of MT Users

Self-Reported Effectiveness of MT Treatment Outcomes

Discussion

Future Research

Limitations

Conclusion

Acknowledgements

Funding

Availability of Data and Materials

Authors’ Contributions

Competing Interests

Consent for Publication

Ethics Approval and Consent to Participate

Publisher�s Note

Abbreviations

Contributor Information

Dr. Alex Jimenez’s Insight

Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT)

Abstract

Study Design

Objective

Summary of Background Data

Methods

Results

Conclusion

Introduction

Methods

Study Design

Patient Population

Study Interventions

Study Measures

Statistical Considerations

Results

Patient Characteristics

Surgical Treatment and Complications

Cross-Over

Main Treatment Effects

Loss-to-Follow-Up

Discussion

Comparisons to Other Studies

Limitations

Conclusions

Acknowledgments

Footnotes