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Functional Medicine

Back Clinic Functional Medicine Team. Functional medicine is an evolution in the practice of medicine that better addresses the healthcare needs of the 21st century. By shifting the traditional disease-centered focus of medical practice to a more patient-centered approach, functional medicine addresses the whole person, not just an isolated set of symptoms.

Practitioners spend time with their patients, listening to their histories and looking at the interactions among genetic, environmental, and lifestyle factors that can influence long-term health and complex, chronic disease. In this way, functional medicine supports the unique expression of health and vitality for each individual.

By changing the disease-centered focus of medical practice to this patient-centered approach, our physicians are able to support the healing process by viewing health and illness as part of a cycle in which all components of the human biological system interact dynamically with the environment. This process helps to seek and identify genetic, lifestyle, and environmental factors that may shift a person’s health from illness to well-being.

Safe Physiotherapy Interventions in Cervical Disc Herniations

Safe Physiotherapy Interventions in Cervical Disc Herniations

by | Chiropractic, Clinical Case Reports, Functional Medicine, Injury Care, Neck Pain

Recognizing clinical and experimental evidence, physiotherapy is a healthcare profession that helps restore and maintain function to individuals affected by injury, disease or disability by using mechanical force and movements, manual therapy, exercise and electrotherapy, as well as through patient education and advice. The terms physiotherapy and physical therapy are used interchangeably to describe the same healthcare profession. Physiotherapy is recommended for a variety of injuries and conditions, and it can help support overall health and wellness for people of all ages.

 

For further notice,�physiotherapy services may be offered alongside chiropractic care, to provide a cautious and gentle manipulation and/or mobilization of the cervical and thoracic spine in the instance of a large cervical disc herniation. Cervical disc herniations can cause pain and discomfort, numbness and weakness in the neck, shoulders, chest, arms and hands.

Abstract

 

A 34-year-old woman was seen in a physiotherapy department with signs and symptoms of cervical radiculopathy. Loss of cervical lordosis and a large paracentral to intraforaminal disc prolapse (8?mm) at C5�C6 level was reported on MRI. She was taking diclofenac sodium, tramadol HCl, diazepam and pregabalin for the preceding 2?months and no significant improvement, except temporary relief, was reported. She was referred to physiotherapy while awaiting a surgical opinion from a neurosurgeon. In physiotherapy she was treated with mobilisation of the upper thoracic spine from C7 to T6 level. A cervical extension exercise was performed with prior voluntary extension of the thoracic spine and elevated shoulders. She was advised to continue the same at home. General posture advice was given. Signs and symptoms resolved within the following four sessions of treatment over 3?weeks. Surgical intervention was subsequently deemed unnecessary.

 

Background

 

Surgical interventions are commonly recommended in large cervical prolapsed discs and the importance of non-aggressive physiotherapy interventions is less recognised and poorly understood. We present interventions that were associated with resolution of symptoms of radiculopathy resulting from a larger cervical herniated disc. These interventions, if applied correctly, may help to reduce the number of surgeries required for cervical prolapsed discs.

 

Case Presentation

 

The patient was a 34-year-old woman. She was seen in the physiotherapy department with a complaint of left-sided neck and shoulder pain. The pain was radiating to her left arm and there was associated numbness. The duration of symptoms was more than 2?months with no history of trauma. The pain was present on waking in the morning and gradually increased during the day. She was otherwise a healthy woman. Neck movements were aggravating the symptoms. She was seen in the acute hospital accident and emergency department (A&E) twice since onset and had been taking diclofenac sodium, tramadol HCl, diazepam and pregabalin. An MRI was planned and a request was sent for physiotherapy during the MRI waiting period. A neurosurgical review was requested by the A&E consultant upon receipt of the MRI report 7?weeks later.

 

Patient examination in the physiotherapy department revealed a normal gait pattern, her left arm held in front of her chest with the left shoulder slightly elevated. Her active range of neck motion was restricted and was painful on the left side. Flexion and rotation to the left were aggravating her arm and shoulder pain. Strength deficits were noted in the left elbow flexors and wrist extensors (4/5) when compared with the right side. There was paraesthesia along the radial border of the forearm and thumb regions. The brachioradialis reflex was diminished and biceps reflex was sluggish. Triceps and plantar reflexes were normal. Passive intervertebral movements were tender at C5�C6 level and were reproducing the pain. Sustained pressure at C7 and below was easing the pain and also improving the neck range of motion. The patient was deemed to have C6 radiculopathy. The MRI report, available 2?weeks after the commencement of physiotherapy, confirmed the diagnosis.

 

Investigations

 

The findings from the plain cervical x-ray were unremarkable. MRI showed (Figure 1) loss of cervical spine lordosis, a left paracentral to intraforaminal lesion with 8?mm hernia, which indented the cord and obstructed the left paracentral recess and neural foramen.

 

Figure 1 Loss of Cervical Spine Lordosis and Large Disc Herniation at C5 and C6 on MRI

Figure 1: Loss of cervical spine lordosis and large disc herniation at C5 and C6 on MRI.

 

Differential Diagnosis

 

  • Cervical myelopathy.

 

Treatment

 

The patient received pharmacological treatment for the initial two symptomatic months, which included diclofenic sodium, tramadol, diazepam and pregabalin (lyrica) tablet. Physiotherapy was started after 2?months. Physiotherapy intervention consisted of mobilisation of the thoracic spine, resisted cervical extension exercises, a home programme of exercises and advice regarding the posture.

 

Mobilisation of the thoracic spine was administered in the prone lying position from C7 toT6 level. Mild intensity oscillations (15?reps) in an anterosuperior direction were directly applied to each of the spinal segments, through the thumb over the spinous processes, during the first visit. The applied force was enough to appreciate intervertebral movement in each segment and without significant pain. High-intensity oscillations (10�20) were applied during the subsequent treatment sessions. The patient was asked for symptom feedback during treatment.

 

Cervical spine extension exercises were carried out in a sitting position. The patient was asked to extend her thoracic spine with lungs fully inflated and shoulders elevated followed by extension of her cervical spine. Head extension was moderately resisted by the therapist near the end range of extension for 5�10?s and brought back to neutral after each resisted movement. The resisted movement was repeated at least three times with intervals of 30?s. The patient was asked to perform the same exercise at home every hour during the day.

 

The patient was educated regarding the rationale of extension exercises, sitting and lying posture and their effects on the spine. The duration of each session was approximately 20�25?min.

 

Dr. Alex Jimenez’s Insight

Surgical interventions are generally recommended and widely considered for large cervical disc herniations. Although less recognized and often misunderstood, however, physiotherapy can be just as effective towards improving herniated discs in the cervical spine, excluding the need for surgery, according to the research study. Pharmacological treatments are also commonly used to help temporarily reduce symptoms alongside physiotherapy interventions. Cautious and gentle, spinal manipulation and mobilization of the cervical spine should be performed in the case of large cervical disc herniations to avoid aggravating the injury and/or condition. As recommended by a physiotherapist, or other healthcare professional experienced in physiotherapy, proper exercise can restore the function of the cervical spine and prevent regression of large prolapsed discs along the spine. Through appropriate physiotherapy intervention as well as through patient safety and compliance, the retraction of the cervical herniated discs is possible.

 

Outcome and Follow-Up

 

Pharmacological interventions were helpful to reduce the patient’s pain on a temporary basis. Symptoms were recurring and resolution was not sustainable. The symptoms started improving after the first physiotherapy session and continued to improve during the subsequent sessions. It fully resolved in four sessions extended over 3?weeks. The patient was reviewed 4?months after the resolution of symptoms and there was no recurrence of symptoms. She was reviewed by a neurosurgeon and the surgical option was withdrawn.

 

Discussion

 

Stiffness of the thoracic spine has been linked to the painful pathologies of the cervical spine, and manipulation of the thoracic spine has been shown to improve painful symptoms and mobility of the cervical spine. However, cervical disc herniations of greater than 4?mm are considered inappropriate for physiotherapy interventions such as traction and manipulation. Spinal manipulation refers to a passive movement thrust of high velocity and low amplitude, usually applied at the end range of movement and is beyond the patient’s control. Manipulation of the cervical spine is an aggressive procedure, which carries various risks and is often associated with worsening of symptoms. Manipulation was not considered in the treatment options for this patient because of the risks associated with it, and also because of patient’s anxiety and lack of MRI-confirmed diagnosis.

 

Active extension of the thoracic spine increases the range of motion of the cervical spine and, in these authors� clinical experience, relieves minor neck symptoms. Conversely, thoracic spine kyphosis, such as slouch sitting, restricts the mobility of the cervical spine and aggravates the painful symptoms. A good sitting posture is constituted by a slightly extended thoracic spine. Therefore, active extension of the thoracic spine prior to cervical extension may improve cervical movements and restore cervical curvature.

 

It is believed that excessive pressure during flexion on the anterior aspect of the intervertebral discs pushes the nucleus pulposus posteriorly and causes herniations. Conversely, cervical lordosis might have the reverse effect�that is, decreases pressure on the anterior aspect of the discs and may create a suction effect which retracts the herniated contents. Therefore, a combination of short duration and repeated movements at the end of extension may serve as a suction pump and possibly retract the extruded content of the disc. Active cervical extension exercises, with an extended thoracic spine posture, may have been the key element in a home exercise programme to restore lordosis of the cervical spine and relieve radiculopathy symptoms in the current case. This may possibly have been due to the retraction of the herniated discs.

 

Spinal mobilisation refers to a gentle, oscillatory, passive movement of a spinal segment. These are applied to a spinal segment to gently increase the passive range of motion. It allows the patient to report aggravation of pain and to resist any unwanted movements. No mobilisation treatment was administered at C5�C6 level as palpation at this level was aggravating the symptoms. Segments below this level were mobilised with emphasis at C7�T1 level. Any treatment at the affected segment was likely to irritate the nerve root and thereby increase the inflammatory process.

 

Various interventions are reported for the treatment of prolapsed discs. Saal et al reported the use of traction, specific physical therapy exercise, oral anti-inflammatory medication and patient education in the treatment of 26 patients with herniated cervical discs (<4?mm) and reported significant improvement in outcomes for 24 patients. They observed that surgery for disc herniations occurs when a patient has significant myotomal weakness, severe pain or pain that persists beyond an arbitrary conservative treatment period of 2�8?weeks.

 

Spontaneous regressions of cervical disc protrusions are reported in the literature. However, spontaneous regressions of herniated cervical discs are speculated to be rare. Various factors related to regression are hypothesised and theorised. Pan et al summarised the factors related to the resorption of herniated disc as: the age of the patients; dehydration of the expanded nucleus pulposus; resorption of haematoma; revascularisation; penetration of herniated cervical disc fragments through the posterior longitudinal ligament; size of disc herniations; and existence of cartilage and annulus fibrosus tissue in the herniated material. Some studies on spontaneous regressions of discs reported that the patients were receiving physiotherapy. Physiotherapy interventions are not defined in any of these studies, however. Therefore, it is possible that disc regressions in these studies may be due to similar physiotherapy interventions as described here, or the patients were practising techniques and adopting postures as reported in the current case.

 

Learning Points

 

  • Thoracic spine mobilisation improves cervical spine biomechanics and can be considered in conjunction with other interventions in all painful conditions of the cervical spine.
  • Active extension of the thoracic spine facilitates movements of the cervical spine and may help regression of large prolapsed discs.
  • There is a possibility of retraction of herniated cervical discs through appropriate physiotherapy intervention.
  • Patient education ensures safety and compliance to therapist advice.
  • Meticulous assessment and patient feedback guides the therapist in selection of intensity of mobilisation.

 

Footnotes

 

Competing interests: None.

 

Patient consent: Obtained.

 

In conclusion,�physiotherapy, or physical therapy, is used to treat various injuries, diseases and disabilities, through the use of mechanical force and movements, manual therapy, exercise, electrotherapy, and through patient education and advice to restore and maintain function. As in the case above, physiotherapy can be recommended and considered as treatment before referring to surgical interventions of large cervical disc herniations. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Sciatica

 

Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.

 

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IMPORTANT TOPIC: EXTRA EXTRA: Treating Sciatica Pain

 

 

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References
1.�Norlander S, Gustavsson BA, Lindell J, et al.�Reduced mobility in the cervico-thoracic motion segment�a risk factor for musculoskeletal neck-shoulder pain: a two-year prospective follow-up study.�Scand J Rehabil Med�1997;29:167�74.�[PubMed]
2.�Walser RF, Meserve BB, Boucher TR.�The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: a systematic review and meta-analysis of randomized clinical trials.�J Man Manipulative Ther�2009;17:237�46.�[PMC free article]�[PubMed]
3.�Krauss J, Creighton D, Ely JD, et al.�The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: a randomized clinical trial.�J Man Manipulative Ther2008;16:93�9.�[PMC free article]�[PubMed]
4.�Saal JS, Saal JA, Yurth EF.�Nonoperative management of herniated cervical intervertebral disc with radiculopathy.�Spine (Phila Pa 1976)�1996;21:1877�83.�[PubMed]
5.�Murphy DR, Beres JL.�Cervical myelopathy: a case report of a �near-miss� complication to cervical manipulation.�J Manipulative Physiol Ther�2008;31:553�7.�[PubMed]
6.�Leon-Sanchez A, Cuetter A, Ferrer G.�Cervical spine manipulation: an alternative medical procedure with potentially fatal complications.�South Med J�2007;100:201�3.�[PubMed]
7.�Scannell JP, McGill SM.�Disc prolapse: evidence of reversal with repeated extension.�Spine (Phila Pa 1976)�2009;34:344�50.�[PubMed]
8.�Gurkanlar D, Yucel E, Er U, et al.�Spontaneous regression of cervical disc herniations.�Minim Invasive Neurosurg�2006;49:179�83.�[PubMed]
9.�Mochida K, Komori H, Okawa A, et al.�Regression of cervical disc herniation observed on magnetic resonance images.�Spine (Phila Pa 1976)�1998;23:990�5; discussion 6�7.�[PubMed]
10.�Song JH, Park HK, Shin KM.�Spontaneous regression of a herniated cervical disc in a patient with myelopathy. Case report.�J Neurosurg�1999;90(1 Suppl):138�40.�[PubMed]
11.�Westmark RM, Westmark KD, Sonntag VK.�Disappearing cervical disc. Case report.�J Neurosurg1997;86:289�90.�[PubMed]
12.�Pan H, Xiao LW, Hu QF.�Spontaneous regression of herniated cervical disc fragments and its clinical significance.�Orthop Surg�2010;2:77�9.�[PubMed]
13.�Teplick JG, Haskin ME.�Spontaneous regression of herniated nucleus pulposus.�AJR Am J Roentgenol1985;145:371�5.�[PubMed]
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Traditional Chinese Medicine for Low Back Pain Due to Lumbar Disc Herniation

Traditional Chinese Medicine for Low Back Pain Due to Lumbar Disc Herniation

by | Chiropractic, Clinical Case Reports, Functional Medicine, Integrative Medicine, Lower Back Pain, Sciatica

Understanding the following, traditional Chinese medicine utilizes herbal medicines as well as various mind and body practices, such as acupuncture and tai chi, in order to treat or prevent numerous health issues. Traditional Chinese medicine, or TCM, originated in ancient China and has evolved over thousands of years. TCM has been primarily used as a complementary health approach along with other alternative treatment options like chiropractic care. Like TCM, chiropractic care is an alternative healthcare approach focused on the diagnosis, treatment and prevention of a variety of injuries and conditions of the musculoskeletal and nervous system, with an emphasis on manual manipulations and adjustments of the spine. As a doctor of chiropractic, or DC, TCM can also be offered to treat various types of injuries and conditions.

 

On a personal note, integrative TCM conservative therapies have been utilized to help treat symptoms of low back pain due to lumbar disc herniation, or LDH. Disc material from a ruptured or herniated disc in the lumbar spine can irritate or compress one or several of the nerves found in the lower spine. Pressure along the sciatic nerve can cause symptoms of sciatica, such as pain and discomfort, burning and tingling sensations, and numbness which may radiate from the buttocks into the leg and occasionally, down to the foot.�A randomized controlled trial was conducted in order to measure the outcomes of traditional Chinese medicine for low back pain due to LDH. The results have been recorded below.

 

Abstract

 

Low back pain due to lumbar disc herniation (LDH) is very common in clinic. This randomized controlled trial was designed to investigate the effects of integrative TCM conservative therapy for low back pain due to LDH. A total of 408 patients with low back pain due to LDH were randomly assigned to an experimental group with integrative TCM therapy and a control group with normal conservative treatment by the ratio of 3?:?1. The primary outcome was the pain by the visual analogue scale (VAS). The secondary outcome was the low back functional activities by Chinese Short Form Oswestry Disability Index (C-SFODI). Immediately after treatment, patients in the experimental group experienced significant improvements in VAS and C-SFODI compared with the control group (between-group difference in mean change from baseline, ?16.62 points, P < 0.001 in VAS; ?15.55 points, P < 0.001 in C-SFODI). The difference remained at one-month followup, but it is only significant in C-SFODI at six-month followup (?7.68 points, P < 0.001). No serious adverse events were observed. These findings suggest that integrative TCM therapy may be a beneficial complementary and alternative therapy for patients with low back pain due to LDH.

 

Introduction

 

Lumbar disc herniation (LDH) is a common disease and a major contributing factor of low back pain. Although many studies have confirmed that surgery is more effective for LDH, conservative therapies have also been recognized for their therapeutic efficacy. Considering the fact that 20% of patients still have pain after surgery, 7% to 15% of surgical patients may have failed back surgery syndrome, and some patients are scared of surgery, conservative treatment is still one of the primary means for LDH.

 

In China, TCM is one of the main conservative treatments for LDH. Previous studies have confirmed that some TCM therapies have certain effects on low back pain due to LDH. These include acupuncture, oral administration of Chinese medicine, external application of Chinese medicine, Chinese Tuina (massage), and TCM-characteristic functional exercise. Clinically, these therapeutic methods are not used alone but often in combination. Recently, the clinical pathway of treating LDH with integrative TCM therapy has attracted attention. The Shi’s Traumatology Medical Center of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine is well recognized for its long-term commitment to the research on conservative treatment for LDH, coupled with a package protocol for LDH. However, high-quality research evidence is needed to support the effectiveness of the protocol.

 

This clinical trial aims to study the efficacy and safety of integrative TCM therapy for LDH and thus confirm its clinical effect.

 

Materials and Methods

 

Design

 

We conducted a multicenter, randomized controlled trial to evaluate the effectiveness of integrative TCM conservative treatment for patients with low back pain due to LDH. Patients were randomly assigned to an experimental group and a control group by the ratio of 3?:?1 using computer-generated numbers. The randomized treatment assignments were sealed in opaque envelopes and opened individually for each patient who agreed to be in the study. The nurse, who had no role in the design and conduct of the study, prepared the envelopes. Patients in the experimental group were treated with integrative TCM therapy once a day, for two weeks, whereas patients in the control group were treated with a two-week normal conservative intervention. At baseline, immediately after treatment, one and six months after treatment, visual analogue scale (VAS) and the Chinese Short Form Oswestry Disability Index (C-SFODI) were used as outcome assessment. This trial is registered in Chinese Clinical Trial Registry (No. ChiCTR-TRC-11001343).

 

Subjects

 

Patients were recruited from Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University, and Yueyang Integrative Traditional Chinese and Western Medicine Hospital Affiliated to Shanghai University of Traditional Chinese Medicine between January 2011 and August 2012.

 

Inclusion criteria: (1) aging 20�60 years; (2) having low back pain due to LDH (MRI scan confirmed lumbar disk herniation) and ruling out other relevant ongoing pathologies such as fractures, lumbar spondylolisthesis, tumor, osteoporosis, or infection; (3) willing to participate in this study and signing the informed consent.

 

Exclusion criteria: (1) having other pain syndromes; (2) experiencing a history of spinal surgery; (3) having neurological disease; (4) having psychiatric disease; (5) having serious chronic diseases that could interfere with the outcomes (e.g., cardiovascular disease, rheumatoid arthritis, epilepsy, or other disqualifying conditions); (6) scared of acupuncture; (7) pregnant or planning to become pregnant during the study; (8) having other diseases that the researchers believe is not suitable for the study.

 

Treatment

 

Experimental Group

 

Patients in the experimental group receive a two-week integrative TCM treatment. They were further divided into three subgroups (according to the duration from initial low back pain to getting treatment) for different treatment methods: acute stage (0�14 days), subacute stage (15�30 days), and chronic stage (>30 days).

 

Acute stage: (1) Electroacupuncture + (2) Chinese herbal injection (Salvia miltiorrhiza injection) + (3) external plaster (Compound Redbud Injury-healing Cataplasms); Subacute stag: (1) Chinese Tuina (massage) + (2) hot compress using Chinese medicine + (3) external plaster (Compound Redbud Injury-healing Cataplasms); Chronic stage: (1) TCM functional exercise + (2) external plaster (Compound Redbud Injury-healing Cataplasms).

 

Treatment Parameters

 

Electroacupuncture. Points: bilateral Dachangshu (BL 25) and Baihuanshu (BL 30).

 

Method: Insert the needles (the sterile, disposable needles, 0.3 � 75?mm, manufactured by Suzhou Medical Supplies Factory Co., Ltd.) 2.5 to 2.8?cun. Upon De Qi (needling sensation), connect the needles with the electroacupuncture device (Model: G6805-II, manufactured by Guangzhou KangMai Medical Devices Co., Ltd.), using a continuous wave, an electrical stimulation pulse wave of approximately 0.6?ms and a frequency of 20?Hz. The treatment was conducted once every day, 30?min for each treatment.

 

External Plaster. Compound Redbud Injury-healing Cataplasms (Approval no. Z19991106, manufactured by Shanghai LEY’s Pharmaceutical Co., Ltd.).

 

Main ingredients: Zi Jing Pi (Cortex Cercis Chinensis), Huang Jing Zi (Negundo Chastetree Fruit), Da Huang (Radix et Rhizoma Rhei), Chuan Xiong (Rhizoma Chuanxiong), Tian Nan Xing (Rhizoma Arisaematis), and Ma Qian Zi (Semen Strychni).

 

Functions: Circulates blood, resolves stasis, eliminates swelling, and alleviates pain.

 

Method: Apply the cataplasms to the most painful area, one plaster each time, once a day.

 

Chinese Herbal Injection. Salvia miltiorrhiza injection (Approval no. Z51021303, manufactured by Sichuan ShengHe Pharmaceutical Co., Ltd.).

 

The main ingredient of the injection is Salvia root P.E. It acts to circulate blood and resolve stasis.

 

Method: Intravenous dripping of 20?mL salvia miltiorrhiza injection and 250 mL 5% glucose, once a day.

 

Hot Compress Using Chinese Medicine. Ingredients: 20?g of Cang Zhu (Rhizoma Atractylodis), Qin Jiao (Radix Gentianae Macrophyllae), Sang Zhi (Ramulus Mori), Mu Gua (Fructus Chaenomelis), Hong Hua (Flos Carthami), Chuan Xiong (Rhizoma Chuanxiong), Hai Feng Teng (Caulis Piperis Kadsurae) and Lei Gong Teng (Radix Tripterygii Wilfordii), respectively. All herbs were provided by Shanghai Hongqiao Pharmaceutical Co., Ltd. and have been tested and qualified.

 

Method: Place the previous medicinal into a gauze bag, decoct with water for 20?mins and take it out. After the temperature cooled to 40~45�C, apply the back to the affected low back area for 30�40 minutes, once a day. The hot compress can help circulate blood and resolve stasis.

 

TCM Functional Exercise. The exercise is known as �Fei Yan Shi� (literally meaning �the flying swallow style�) in Chinese.

 

Method: Ask the patient to take a prone position, extend both hands backwards, lift the chest and lower limbs off the bed using the abdomen as a pivot, and then relax. Conduct this exercise once a day and repeat 4-5 times each time.

 

Functions: Strengthens the power of back muscles, increases the stability of the spine, and thus prevents relapses.

 

Chinese Tuina (Massage). Ask the patient to take a prone position and find the tenderness spots on the low back. Then apply gun-rolling (10?min), Anrou-pressing and kneading (10?min), and Tanbo-plucking (5?min) manipulation to the tenderness spots and surrounding areas. Conclude with oblique pulling manipulation of the low back. Conduct the treatment once a day.

 

Functions: Relaxes spasm of the low back muscles and adjusts lumbar subluxation.

 

After one week TCM treatment, if the patient’s lower back pain without any relief or even aggravated, the prescription of pain medication was adjusted according to clinical guidelines, detailed records the type and dose of pain medication taken by patients, and the patient was identified as no effect.

 

Control Group

 

Patients in the control group receive a two-week normal conservative treatment. Intervention measures include three sections, (1) health education. The patients were invited to receive LDH health education twice a week in outpatient; the health education was designed exclusively to inform patients about the natural course of their illness and the expectation of successful recovery, irrespective of the initial intensity of their pain, educate patients to avoid some bad habits that aggravate the disease, such as a sitting position for a long time and carrying heavy loads, and encourage patients to participate in social activities. (2) Rest: in addition to the normal sleep, the patients need to rest in bed for at least 1-2 hours a day. (3) Pain medication or physical therapy: after one week health education, if the patient’s lower back pain without any relief or even aggravated, the prescription of pain medication was adjusted according to clinical guidelines, detailed records the type and dose of pain medication taken by patients. And if the patients do not want to take pain medication, then the patients were referred to a physiotherapist.

 

Measurements

 

All outcomes were assessed by observers unaware of the grouping, at baseline (M1), immediately after the last intervention (M2). The followup included the assessments at one month (M3) and six months (M4) after the last intervention.

 

The primary outcome measure was the change in pain by the visual analogue scale (VAS), scores range 0 to 100, and a higher score indicates a greater pain, 0 means no pain, and 100 means intolerable pain.

 

The secondary outcome measure was the change in the Chinese Short Form Oswestry Disability Index (C-SFODI), range 0 to 100%. The C-SFODI consists of nine questions, which come from Oswestry Disability Index (ODI); omit the sex life question in Section??8, because this question is always unacceptable by Chinese. The C-SFODI calculation formula is actual cumulative score/45 � 100%, with higher percentage indicating more severe functional disability. And the study has shown that the C-SFODI has good reliability and validity.

 

Statistical Analysis

 

Our pretrial power calculation indicated that 81 patients in experimental group were required to detect a difference in pain relief based on the preliminary experiment data at a significant level of 5% (a two-sided t-test) with 80% power. In anticipation of a 20% attrition rate, we sought 102 patients at least in experimental group. Taking into account the poor effect of control therapy, 102 patients were included in the control group.

 

Between-group difference at baseline was analyzed using independent-samples t-test or Chi-square test. Changes in continuous measures were analyzed by analysis of variance (ANOVA). Effects were evaluated on an intention-to-treat basis (ITT), and participants who did not complete the followup period were considered not having any changes in scores. A two-sided P value of less than 0.05 indicated statistical significance. Results are presented as mean and standard deviation (SD) at M1 and as between-group difference with 95% confidence intervals (CI) at M2, M3, and M4.

 

Quality Control

Before the beginning of the study, all researchers have to receive protocol training. A clinic research coordinator (CRC) was employed to assist researchers in each center. A monitor was also appointed to ensure the quality of the research.

 

Dr. Alex Jimenez’s Insight

The above clinical trial focused on investigating the safety and effectiveness of TCM, or traditional Chinese medicine, for low back pain due to lumbar disc herniation as well as to confirm its clinical result. The participants of the research study with low back pain due to LDH were divided into two groups: the experimental group, which was treated with integrative TCM conservative therapy; and the control group, which was treated normal conservative treatment. The experimental group was then further divided into three subgroups. The details of each TCM treatment method used in the subgroups, including the name, ingredients, method and function of each, are described above. The outcomes were measured accordingly by observers unaware of the specific group divisions. The statistic results were properly analyzed by researchers who received protocol training before the start of the study.

 

Results

 

Between January 2011 and August 2012, a total of 480 patients with low back pain due to LDH were recruited, 72 were rejected due to exclusion criterions, and 408 eligible patients were randomly assigned in accordance with the ratio of 3?:?1 to the experimental group and the control group, 306 in the experimental group and 102 in the control group. Patients in the experimental group all completed a two-week treatment. In the control group, at the second week one patient in the control group was unwilling to continue to participate and withdrew his informed consent, and two patients took Fenbid (500?mg for each dose, 2 doses a day) since the pain worsened during treatment (Figure 1).

 

Figure 1 Screening with Randomization and Completion Evaluations

Figure 1: Screening, randomization, and completion evaluations from the baseline to six-month followup, LDH = lumbar disc herniation.

 

Baseline Characteristics of the Patients

 

Table 1 shows the baseline data for the 408 participants. The mean age of all patients is 45 years, and 51% were women. In terms of disease staging, experimental group and control group were comparable. And the baseline outcome including VAS scores and C-SFODI were also reasonably well balanced between experimental group and control group.

 

Table 1 Baseline Characteristics of the Study Participants

Table 1: Baseline characteristics of the study participants.

 

Improvement in the Primary Outcome

 

The changes in the primary outcomes from baseline to six-month followup are shown in Table 2 and Figure 2. Immediately after the intervention, two groups showed significant decrease in VAS than the baseline. And the experimental group showed a more significant decrease than the control group (?16.62 points [95% confidence interval {CI}, ?20.25 to ?12.98]; P < 0.001).

 

Figure 2 Mean Changes of the Primary and Secondary Outcomes

Figure 2: Mean changes of the primary and secondary outcomes. The means of outcomes are shown for the experimental group (diamond) and the control group (squares). Measurements were obtained at baseline (M1), immediately after the last intervention (M2).

 

Table 2 Changes in Primary and Secondary Outcomes

Table 2: Changes in primary and secondary outcomes.

 

One month after intervention, two groups also had significantly greater reduction in VAS than the baseline. And again, the experimental group showed a more significant decrease than the control group (?6.37 points [95% CI, ?10.20 to ?2.54]; P = 0.001).

 

Six months after intervention, compared with the baseline, the changes in VAS remained significant in the experimental group and control group, but between-group difference was not significant (P = 0.091).

 

Improvement in the Secondary Outcome

 

Immediately after intervention, two groups had significant improvement in C-SFODI than the baseline, and the experimental group showed a more significant improvement than the control group (?15.55 points [95% CI, ?18.92 to ?12.18]; P < 0.001).

 

One month after intervention, two groups also had significant improvement in C-SFODI than the baseline. And again, the experimental group improved more (?11.37 points [95% CI, ?14.62 to ?8.11]; P < 0.001).

 

Six months after intervention, two groups also maintained significant improvement, and the experimental group showed superiority (?7.68 points [95% CI, ?11.42 to ?3.94]; P < 0.001).

 

Adverse Events

 

One patient in the experiment group had mild fainting during acupuncture, remission by bed rest, and then completed the remaining treatment. Two patients in the control group were given Fenbid orally due to aggravated low back pain. No other adverse events were noted in either experimental group or control group.

 

Discussion

 

Although the mechanism of low back pain caused by lumbar disc herniation (LDH) is still not very clear, the prevailing view is that low back pain due to LDH was found to occur not only in response to mechanical stimuli but also to chemical irritation around the nerve root sheath and sinuvertebral nerve.

 

Different TCM therapies have different advantages in the treatment of LDH. Pain is the main symptom in the acute stage of LDH; acupuncture has good analgesic effect on low back pain due to LDH. Lumbar dysfunction is the main symptom in the remission stage; Chinese massage has good effect on improving dysfunction. Oral Chinese herbal formulae, external use of Chinese medicine, and Chinese herbal injection also showed good effect in relieving pain and improving dysfunction caused by LDH. And one study also found that Salvia miltiorrhiza injection especially works better and faster for the acute stage when compared with mannitol. Although the mechanism of acupuncture, Chinese massage, and traditional Chinese herbs in the treatment of LDH remains unclear, it is generally agreed that these treatment methods play a role by increasing local blood circulation, relieving nerve root edema, and speeding up the metabolism of the local inflammatory mediators. In recovery stage of the disease, the major task is to strengthen the muscles of the waist and abdomen to prevent relapse, and TCM functional exercise has advantages in this regard and can subsequently increase the lumbar stability to prevent recurrence.

 

Treating LDH according to different stages has been more and more accepted. In China, LDH is mainly divided into three stages, including acute stage, subacute stage (or remission stage), and chronic stage (or recovery stage). Studies have proven that treating LDH according to different stages has obtained a good clinical effect. In addition, studies have also suggested that it can obtain a better effect than treatment without differentiating different stages.

 

The past 20 years of clinical practice have witnessed the safety of the treatment regimens used in this study. At the same time, its efficacy has been preliminarily confirmed; however, high quality research evidence is still needed. In the treatment regimens, different TCM therapies were selected according to the characteristics of different stages. Specifically, acupuncture and Chinese herbal injections were used in the acute stage for fast pain relief, Chinese Tuina (massage) and external application of Chinese medicine were used in the subacute stage for improvement of the lumbar functions, and low back muscle exercise was used in the chronic stage to increase the stability of the spine and prevent relapses.

 

In China, nonsurgical treatment of lumbar disc herniation mainly uses drugs, physical therapy, or TCM treatment. TCM treatment used in the experimental group has been used in clinical routine and is considered to have good clinical efficacy; the efficacy of conservative treatment used in the control group is considered very weak, usually as auxiliary treatment of other therapies. Ethics Committee considers that in order to maximize the protection of the interests of the patients, it is necessary to let the patients have more opportunity to receive TCM treatment, so in this research the sample size of the experimental group and the control group is 3?:?1.

 

The findings of this study have shown that immediately and one month after intervention, integrative TCM conservative treatment can significantly reduce the VAS scores and C-SFODI, and at six month after intervention, integrative TCM conservative treatment can also significantly reduce the C-SFODI, but two groups have no significant difference in reducing VAS score. VAS is an international general pain visual analog scale, and C-SFODI is the improved version of the ODI (Oswestry Disability Index), and it consists of 9 questions, a higher percentage indicating a more severe functional disability.

 

Regarding adverse events, one patient had mild fainting in the experiment group, two patients in the control group were given Fenbid oral due to low back pain aggravation, and no other adverse events were noted in either experimental group or control group. The mechanism of integrative TCM conservative treatment for LDH remains unclear, and it will be our future research orientation.

 

The main limitation of this study is the short followup time. As a result, we failed to conduct comprehensive evaluation regarding the long-term efficacy of integrative TCM conservative treatment for LDH.

 

Conclusions

 

This randomized controlled clinical trial provides reliable evidence regarding the effectiveness of integrative TCM conservative treatment for patients with low back pain due to lumbar disc herniation. A large sample of long-term followup is further needed for future research.

 

Conflict of Interests

 

No potential conflict of interests relevant to this study was reported.

 

Acknowledgments

 

This work is supported by the Key Discipline of TCM Orthopaedic and Traumatic of the Ministry of Education of the People’s Republic of China (100508); the Medical Key Project of Shanghai Science and Technology Commission (09411953400); the project of Shanghai Medical leading talent (041); the National Natural Science Foundation of China (81073114, 81001528); the National Key New Drugs Creation Project, innovative drug research and development technology platform (no. 2012ZX09303009-001); Shanghai University Innovation Team Construction Project of the Spine Disease of Traditional Chinese Medicine (2009-26).

 

In conclusion, with the measured outcomes and final results of the two groups of participants with low back pain due to lumbar disc herniation, the randomized controlled trial helped contribute valuable information regarding the safety and effectiveness, as well as the clinical effect of integrative TCM conservative therapy. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Sciatica

 

Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.

 

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IMPORTANT TOPIC: EXTRA EXTRA: Treating Sciatica Pain

 

 

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References
1.�Cypress BK. Characteristics of physician visits for back symptoms: a national perspective.�American Journal of Public Health.�1983;73(4):389�395.�[PMC free article]�[PubMed]
2.�Heliovaara M, Sievers K, Impivaara O, et al. Descriptive epidemiology and public health aspects of low back pain.�Annals of Medicine.�1989;21(5):327�333.�[PubMed]
3.�Peul WC, van Houwelingen HC, van Den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica.�New England Journal of Medicine.�2007;356(22):2245�2256.�[PubMed]
4.�Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the spine patient outcomes research trial.�Spine.�2010;35(14):1329�1338.[PMC free article]�[PubMed]
5.�Jacobs WCH, van Tulder M, Arts M, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review.�European Spine Journal.�2011;20(4):513�522.[PMC free article]�[PubMed]
6.�Kosteljanetz M, Espersen JO, Halaburt H, Miletic T. Predictive value of clinical and surgical findings in patients with lumbago-sciatica. A prospective study (Part I)�Acta Neurochirurgica.�1984;73(1-2):67�76.[PubMed]
7.�Markwalder TM, Battaglia M. Failed back surgery syndrome. Part II: surgical techniques, implant choice, and operative results in 171 patients with instability of the lumbar spine.�Acta Neurochirurgica.�1993;123(3-4):129�134.�[PubMed]
8.�Lee JH, Choi TY, Lee MS, et al. Acupuncture for acute low back pain: a systematic review.�The Clinical Journal of Pain.�2013;29(2):172�185.�[PubMed]
9.�Xu M, Yan S, Yin X, et al. Acupuncture for chronic low back pain in long-term follow-up: a meta-analysis of 13 randomized controlled trials.�The American Journal of Chinese Medicine.�2013;41(1):1�19.[PubMed]
10.�Li D, Dong XJ, Li SB. Clinical observation on lumbar disc Herniation using method of clearing away heat and toxin.�Liaoning Journal of Traditional Chinese Medicine.�2012;39(9):1750�1751.
11.�Zhao CW, Li JX, Leng XY, et al. Clinical analysis on the curative effect of external application of traditional Chinese medicine on lumbar disc herniation.�The Journal of Traditional Chinese Orthopedics and Traumatology.�2010;22(12):21�22.
12.�Kong LJ, Fang M, Zhan HS, et al. Tuina-focused integrative chinese medical therapies for inpatients with low back pain: a systematic review and meta-analysis.�Evidence-Based Complementary and Alternative Medicine.�2012;2012:17 pages.578305�[PMC free article]�[PubMed]
13.�Qiu JW, Wei RQ, Zhang FG. The function of low back muscle exercise in the evaluation of long-term curative effect of patients with lumbar disc herniation.�Chinese Journal of Gerontology.�2010;31(3):413�414.
14.�Li ZH, Liu LJ, Han YQ. Evaluation of clinical pathway Chinese medicine treatment of lumbar disc herniation.�Chinese Journal of Gerontology.�2010;31(2):322�323.
15.�Peul WC, van Houwelingen HC, van der Hout WB, et al. Prolonged conservative treatment or �early� surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial.�BMC Musculoskeletal Disorders.�2005;6(article 8)�[PMC free article]�[PubMed]
16.�Zheng GX, Zhao XO, Liu GL. Reliability of the modified oswestry disability index for evaluating patients with low back pain.�Chinese Journal of Spine and Spinal Cord.�2010;12(1):13�15.
17.�Anderson SR, Racz GB, Heavner J. Evolution of epidural lysis of adhesions.�Pain Physician.�2000;3(3):262�270.�[PubMed]
18.�Liu J, Fang L, Xu WD, et al. Effects of intravenous drip of compound Danshen injection on plasma NO and SOD levels in patients with lumbar intervertebral disc prolapse.�Chinese Journal of Clinical Health Care.�2004;7(4):272�274.
19.�Pan LH.�?-aescin sodium combined with Danshen injection in the treatment of lumbar disc herniation.�China Modern Doctor.�2010;48(23):117�121.
20.�Rhee HS, Kim YH, Sung PS. A randomized controlled trial to determine the effect of spinal stabilization exercise intervention based on pain level and standing balance differences in patients with low back pain.�Medical Science Monitor.�2012;18(3):CR174�CR181.�[PMC free article]�[PubMed]
21.�Wu K, Li YY, He YF, et al. Overview on clinical staging method of protrusion of lumbar intervertebral disc.�Journal of Liaoning University of Traditional Chinese Medicine.�2010;11(12):44�45.
22.�Li CH, Cai SH, Chen SQ, et al. The investigation of staging comprehensive program treatment for lumbar disc herniation.�Journal of Fujian University of Traditional Chinese Medicine.�2010;20(6):7�9.
23.�Li L, Zhan HS, Chen B, et al. Clinical observation of stage Treatment on 110 cases of lumbar disc herniation.�Chinese Journal of Traditional Medical Traumatology & Orthopedics.�2011;19(1):11�15.
24.�Li CH, Zheng QK, Zhang KM, et al. Phased comprehensive treatment for lumbar disc herniation in 60 cases.�Journal of Beijing University of Traditional Chinese Medicine(Clinical Medicine)�2011;18(6):10�12.
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Vertebral Artery Dissection Found During Chiropractic Examination

Vertebral Artery Dissection Found During Chiropractic Examination

by | Chiropractic, Clinical Case Reports, Clinical Case Series, Functional Medicine

Acknowledging the subsequent information below,�approximately more than 2 million people are injured in automobile accidents each year and among those incidents, the majority of the people involved are diagnosed with whiplash and/or neck injury by a healthcare professional. When the complex structure of the neck is subjected to trauma, tissue damage and other medical complications may occur. Vertebral artery dissection, or VAD, is characterized by a flap-like tear on the inner lining of the vertebral artery in charge of supplying blood to the brain. After the tear, blood can then enter the arterial wall and form a blood clot, thickening the artery wall and often impeding blood flow.

 

Through years of experience practicing chiropractic care,�VAD may often follow after trauma to the neck, such as that which occurs in an automobile accident, or whiplash injury. The symptoms of vertebral artery dissection include head and neck pain as well as intermittent or permanent stroke symptoms, such as difficulty speaking, impaired coordination and loss of vision. VAD, or vertebral artery dissection, is generally diagnosed with a contrast-enhanced CT or MRI scan.

 

Abstract

 

A 30-year-old woman presented to an emergency department with sudden onset of transient loss of left peripheral vision. Owing to a history of migraine headaches, she was released with a diagnosis of ocular migraine. Two days later, she sought chiropractic care for the chief symptom of severe neck pain. The chiropractor suspected the possibility of vertebral artery dissection (VAD). No manipulation was performed; instead, MR angiography (MRA) of the neck was obtained, which revealed an acute left VAD with early thrombus formation. The patient was placed on aspirin therapy. Repeat MRA of the neck 3?months later revealed resolution of the thrombus, without progression to stroke. This case illustrates the importance for all healthcare providers who see patients with neck pain and headache to be attentive to the symptomatic presentation of possible VAD in progress.

 

Background

 

Vertebral artery dissection (VAD) leading to stroke is an uncommon but potentially serious disorder. The incidence of stroke related to the vertebrobasilar system varies from 0.75 to 1.12/100?000 person-years. The pathological process in VAD typically involves dissection of the wall of the artery followed sometime later by thrombus formation, which may cause arterial occlusion or may lead to embolisation, causing occlusion of one or more of the distal branches off the vertebral artery, including the basilar artery, which can be catastrophic. VAD typically occurs in patients who have an inherent, transitory weakness in the arterial wall. In at least 80% of cases, the initial symptoms include neck pain with or without headache.

 

Many patients with VAD may in the early stages present to chiropractors seeking relief from neck pain and headache, without realising they are experiencing VAD. In many of these cases, the patient later develops a stroke. Until recently, it was assumed that the dissection (and subsequent stroke) was caused by cervical manipulative therapy (CMT). However, while early studies found an association between visits to a chiropractor and subsequent stroke related to VAD, recent data suggest that this relationship is not causal.

 

This case report is illustrative of the scenario in which a patient with an undiagnosed VAD in evolution consulted a chiropractor for neck pain and headache. After thorough history and examination, the chiropractor suspected VAD and did not perform CMT. Instead, the patient was referred for further evaluation, which detected a VAD in progress. Prompt diagnosis and anticoagulant treatment were thought to have averted progression to a stroke.

 

Case Presentation

 

A 30-year-old otherwise healthy woman consulted a chiropractor (DBF), reporting of right-sided neck pain in the suboccipital region. The patient reported that, 3?days previously, she had gone to the local hospital emergency department (ED) because of the sudden onset of loss of left peripheral vision. The visual symptoms interfered with her ability to see through her left eye; this was accompanied by �numbness� in her left eyelid. About 2?weeks prior to this ED visit, she had experienced an episode of acute left-sided neck pain with severe left-sided headache. She also related a history of migraine headache without prodrome. She was released from the ED with a tentative diagnosis of ocular migraine. She had never been previously diagnosed with ocular migraine, nor had she ever experienced any visual disturbances with her previous migraines.

 

Shortly after the left-sided ocular symptoms resolved, she suddenly developed right-sided neck pain without provocation, for which she sought chiropractic treatment. She also reported a transient episode of right-sided visual disturbance occurring that same day as well. This was described as sudden blurriness that was of short duration and resolved spontaneously earlier in the day of her presentation for chiropractic examination. When she presented for the initial chiropractic examination, she denied current visual disturbance. She said that she was not experiencing any numbness, paraesthesia or motor loss in the upper or lower extremities. She denied ataxia or difficulty with balance. Medical history was remarkable for childbirth 2� months prior to initial presentation. She stated that her migraine headaches were associated with her menstrual cycle. Family history was remarkable for a spontaneous ascending thoracic aortic aneurysm in her older sister, who was about 30?years of age when her aneurysm had occurred.

 

Investigations

 

Based on the history of sudden onset of severe upper cervical pain and headache with visual disturbance and ocular numbness, the DC was concerned about the possibility of early VAD. Urgent MR angiography (MRA) of the neck and head, along with MRI of the head, was ordered. No cervical spine examination or manipulation was performed because of the suspicion that the neck pain was related to VAD rather than to a �mechanical� cervical disorder.

 

MRA of the neck demonstrated that the left vertebral artery was small and irregular in calibre, extending from the C7 level cephalad to C2, consistent with dissection. There was a patent true lumen with a surrounding cuff of T1 hyper-intensity, consistent with dissection with subintimal thrombus within the false lumen (Figures 1 and ?2). MRI of the head with and without contrast, and MRA of the head without contrast, were both unremarkable. Specifically, there was no intracranial extension of dissection or evidence of infarction. MR perfusion of the brain revealed no focal perfusion abnormalities.

 

Figure 1 Axial Proton Density Image - Image 1

Figure 1: Axial proton density image demonstrates circumferential hyper-intensity surrounding the left cervical vertebral artery (representing the false lumen). Note decreased calibre of true lumen (black flow void) with respect to the right vertebral artery.

 

Figure 2 Axial Image from Three Dimensional Time of Flight MRA - Image 2

Figure 2: Axial image from three-dimensional time-of-flight MRA demonstrates T1 hypointense dissection flap separating the true lumen (lateral) from the false lumen (medial). MRA, MR angiography.

 

Differential Diagnosis

 

The ED released the patient with a tentative diagnosis of ocular migraine, due to her history of migraine headaches. However, the patient stated that the left-sided headache was atypical��like nothing I’ve ever experienced before.� Her previous migraines were associated with her menstrual cycle, but not with any vision changes. She had never been previously diagnosed with ocular migraine. MRA of the cervical region revealed that the patient actually had an acute dissection with thrombus formation in the left vertebral artery.

 

Treatment

 

Owing to the potential of impending stroke associated with an acute VAD with thrombus formation, the patient was admitted to the neurology stroke service for close neurological monitoring. During her admission, the patient did not experience any recurrence of neurological deficits and her headaches improved. She was discharged the following day with a diagnosis of left VAD and transient ischaemic attack. She was instructed to avoid vigorous exercise and trauma to the neck. Daily aspirin (325?mg) was prescribed, to be continued for 3�6?months after discharge.

 

Outcome and Follow-Up

 

After discharge from the stroke service, the patient had no recurrence of headache or visual disturbances, and her posterior neck pain symptoms resolved. Repeat imaging was performed 3?months after presentation, which demonstrated improved calibre of the cervical left vertebral artery with resolution of the thrombus within the false lumen (Figure 3). Imaging of the intracranial compartment remained normal, without evidence of interval infarction or perfusion asymmetry.

 

Figure 3 Maximum Intensity Projection MIP Images - Image 3

Figure 3: Maximum intensity projection (MIP) images from three-dimensional time-of-flight MRA (left image is at time of presentation and right image is at 3-month follow-up). The initial imaging demonstrates markedly diminutive calibre of the left vertebral artery

 

Discussion

 

The pathophysiological process of VAD is thought to start with degeneration of the tissues at the medial-adventitial border of the vertebral artery, leading to the development of microhaematomata within the wall of the artery and, eventually, arterial tear. This can lead to leakage of blood into the arterial wall, causing occlusion of the lumen with subsequent thrombus formation and embolisation, resulting in stroke related to one of the branches of the vertebral artery. This pathological process is similar to that of spontaneous carotid artery dissection, spontaneous thoracic aortic dissection and spontaneous coronary artery dissection. All these conditions tend to occur in younger adults and some have speculated that they may be part of a common inherited pathophysiological process. Notable in this case is the fact that the patient’s older sister had experienced a spontaneous thoracic aortic aneurysm (probably a dissection) at around the same age (30?years) as this patient was when she experienced her VAD.

 

While the dissection is often sudden, the luminal compromise and complications of VAD can develop gradually leading to variable symptoms and presentation, depending on the stage of the disease. The dissection itself, which develops some time before the onset of neural ischaemia, can cause stimulation of nociceptive receptors within the artery, producing pain that is most commonly felt in the upper cervical spine or head. Only after the pathophysiological process progresses to the point of complete arterial occlusion or thrombus formation with distal embolisation does the full manifestation of infarction occur. However, as illustrated in this case, neurological symptoms can develop early in the process, particularly in cases in which the true lumen demonstrates significant calibre decrease secondary to compression.

 

There are several interesting aspects to this case. First, it highlights the importance of spine clinicians being alert to the possibility that what may appear to be typical �mechanical� neck pain could be something potentially more sinister, such as VAD. The sudden onset of severe suboccipital pain, with or without headache, and accompanying brainstem related neurological symptoms, should alert the clinician to the possibility of VAD. As in the case reported here, patients with a history of migraine will typically describe the headache as different from their usual migraine. A careful neurological examination should be performed, looking for possible subtle neurological deficits, although the neurological examination will often be negative in the early stages of VAD.

 

Second, a triad of symptoms raised concern that the patient might be experiencing a VAD in progress. The symptom triad included: (1) spontaneous onset of severe upper cervical pain; (2) severe headache that was distinctly different from the patient’s usual migraine headaches; and (3) brainstem-related neurological symptoms (in the form of transient visual disturbance). Notably, careful neurological examination was negative. Nonetheless, the history was of sufficient concern to prompt immediate investigation.

 

When VAD is suspected but no frank signs of stroke are present, immediate vascular imaging is indicated. While the optimal imaging evaluation of VAD remains controversial, MRA or CTA are the diagnostic studies of choice given their excellent anatomic delineation and ability to evaluate for complications (including infarction and changes in brain perfusion). Some advocate the use of Doppler ultrasound; however, it has limited utility given the course of the vertebral artery in the neck and limited evaluation of the vertebral arteries cephalad to the origin. Additionally, ultrasound imaging is unlikely to allow visualisation of the dissection itself and thus can be negative in the absence of significant arterial occlusion.

 

Third, this case is interesting in light of the controversy about cervical manipulation as a potential �cause� of VAD. While case reports have presented patients who have experienced stroke related to VAD after cervical manipulation, and case�control studies have found a statistical association between visits to chiropractors and stroke related to VAD, further investigation has indicated that the association is not causal. Cassidy et al found that a patient who experiences stroke related to VAD is just as likely to have visited a primary care practitioner as to have visited a chiropractor prior to having the stroke. The authors suggested that the most likely explanation for the statistical association between visits to chiropractors and subsequent VAD is that a patient who experiences the initial symptoms of VAD (neck pain with or without headache) seeks medical attention for these symptoms (from a chiropractor, primary care practitioner, or another type of practitioner), then subsequently experiences the stroke, independent of any action taken by the practitioner.

 

It is important to note that, while there have been reported cases of carotid artery dissection after cervical manipulation, case�control studies have not found this association. The initial symptoms of carotid dissection (neurological symptoms, with neck and head pain less common than VAD), aortic dissection (sudden onset of severe, �tearing� pain) and coronary artery dissection (acute severe chest pain, ventricular fibrillation) are likely to cause the individual to immediately seek ED care, rather than seek chiropractic care. However, VAD has seemingly benign initial symptoms�neck pain and headache�which are symptoms that commonly cause patients to seek out chiropractic care. This may explain why only VAD is associated with visits to chiropractors, while these other types of dissections are not; patients with these other conditions, which have much more alarming symptoms, simply do not present to chiropractors.

 

This case is a good example of a patient with VAD in progress presenting to a chiropractor for the purpose of seeking relief from neck pain. Fortunately, the chiropractor was astute enough to ascertain that the patient’s symptoms were not suggestive of a �mechanical� cervical spine disorder, and appropriate diagnostic investigation was performed. However, if manipulation had been performed, the VAD that was already in progress from natural history may have been blamed on manipulation, after being detected on MRA imaging. Fortunately, in this case, the chiropractor was able to assist with early detection and treatment, and subsequently a stroke was likely averted.

 

Learning Points

 

  • A case is presented in which a patient saw a chiropractor, while seeking treatment for neck pain, and the history raised concern for possible vertebral artery dissection (VAD).
  • Rather than providing manipulative treatment, the chiropractor referred the patient for advanced imaging, which confirmed the diagnosis of VAD.
  • The case illustrates the importance of paying attention to subtle historical factors in patients with VAD.
  • It also serves as an example of a patient with a VAD in progress seeking the services of a chiropractor for the initial symptoms of the disorder.
  • In this case, early detection of the dissection occurred and the patient had a full recovery without any subsequent stroke.

 

Acknowledgments

 

The authors would like to acknowledge the assistance of Pierre Cote, DC, PhD, for his assistance with reviewing this manuscript.

 

Footnotes

 

Contributors: All the authors acknowledge that they have contributed the following to the submission of this manuscript: conception and design, drafting of the manuscript, critical revisions of the manuscript, literature review and references, and proof reading of the final manuscript.

 

Competing interests: None declared.

 

Patient consent: Obtained.

 

Provenance and peer review: Not commissioned; externally peer reviewed.

 

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 .

 

Cited by Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: Treating Sciatica Pain

 

 

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References
1.�Debette S, Leys D.�Cervical-artery dissections: predisposing factors, diagnosis, and outcome.�Lancet Neurol�2009;8:668�78.�doi:10.1016/S1474-4422(09)70084-5�[PubMed]
2.�Boyle E, Cote P, Grier AR et al.�Examining vertebrobasilar artery stroke in two Canadian provinces.�Spine�2008;33(4 Suppl):S170�5.�doi:10.1097/BRS.0b013e31816454e0�[PubMed]
3.�Lee VH, Brown RD Jr, Mandrekar JN et al.�Incidence and outcome of cervical artery dissection: a population-based study.�Neurology�2006;67:1809�12.�doi:10.1212/01.wnl.0000244486.30455.71[PubMed]
4.�Schievink WI.�Spontaneous dissection of the cartoid and vertebral arteries.�N Engl J Med�2001;344:898�906.�doi:10.1056/NEJM200103223441206�[PubMed]
5.�Volker W, Dittrich R, Grewe S et al.�The outer arterial wall layers are primarily affected in spontaneous cervical artery dissection.�Neurology�2011;76:1463�71.�doi:10.1212/WNL.0b013e318217e71c�[PubMed]
6.�Gottesman RF, Sharma P, Robinson KA et al.�Clinical characteristics of symptomatic vertebral artery dissection: a systematic review.�Neurologist�2012;18:245�54.�doi:10.1097/NRL.0b013e31826754e1[PMC free article]�[PubMed]
7.�Cassidy JD, Boyle E, Cote P et al.�Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.�Spine�2008;33(4�Suppl):S176�83.�doi:10.1097/BRS.0b013e3181644600�[PubMed]
8.�Rothwell DM, Bondy SJ, Williams JI.�Chiropractic manipulation and stroke: a population-based case-control study.�Stroke�2001;32:1054�60.�doi:10.1161/01.STR.32.5.1054�[PubMed]
9.�Smith WS, Johnston SC, Skalabrin EJ et al.�Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.�Neurology�2003;60:1424�8.�doi:10.1212/01.WNL.0000063305.61050.E6[PubMed]
10.�Volker W, Besselmann M, Dittrich R et al.�Generalized arteriopathy in patients with cervical artery dissection.�Neurology�2005;64:1508�13.�doi:10.1212/01.WNL.0000159739.24607.98�[PubMed]
11.�Evangelista A, Mukherjee D, Mehta RH et al.�Acute intramural hematoma of the aorta: a mystery in evolution.�Circulation�2005;111:1063�70.�doi:10.1161/01.CIR.0000156444.26393.80�[PubMed]
12.�Tweet MS, Hayes SN, Pitta SR et al.�Clinical features, management, and prognosis of spontaneous coronary artery dissection.�Circulation�2012;126:579�88.�doi:10.1161/CIRCULATIONAHA.112.105718[PubMed]
13.�Choi S, Boyle E, Cote P et al.�A population-based case-series of Ontario patients who develop a vertebrobasilar artery stroke after seeing a chiropractor.�J Manipulative Physiol Ther�2011;34:15�22.�doi:10.1016/j.jmpt.2010.11.001�[PubMed]
14.�Naggara O, Louillet F, Touze E et al.�Added value of high-resolution MR imaging in the diagnosis of vertebral artery dissection.�AJNR Am J Neuroradiol�2010;31:1707�12.�doi:10.3174/ajnr.A2165�[PubMed]
15.�Haynes MJ, Vincent K, Fischhoff C et al.�Assessing the risk of stroke from neck manipulation: a systematic review.�Int J Clin Pract�2012;66:940�7.�doi:10.1111/j.1742-1241.2012.03004.x[PMC free article]�[PubMed]
16.�Nebelsieck J, Sengelhoff C, Nassenstein I et al.�Sensitivity of neurovascular ultrasound for the detection of spontaneous cervical artery dissection.�J Clin Neurosci�2009;16:79�82.�doi:10.1016/j.jocn.2008.04.005�[PubMed]
17.�Bendick PJ, Jackson VP.�Evaluation of the vertebral arteries with duplex sonography.�J Vasc Surg1986;3:523�30.�doi:10.1016/0741-5214(86)90120-5�[PubMed]
18.�Murphy DR.�Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?�Chiropr Osteopat�2010;18:22�doi:10.1186/1746-1340-18-22[PMC free article]�[PubMed]
19.�Engelter ST, Grond-Ginsbach C, Metso TM et al.�Cervical artery dissection: trauma and other potential mechanical trigger events.�Neurology�2013;80:1950�7.�doi:10.1212/WNL.0b013e318293e2eb�[PubMed]
20.�Peters M, Bohl J, Th�mke F et al.�Dissection of the internal carotid artery after chiropractic manipulation of the neck.�Neurology�1995;45:2284�6.�doi:10.1212/WNL.45.12.2284�[PubMed]
21.�Nadgir RN, Loevner LA, Ahmed T et al.�Simultaneous bilateral internal carotid and vertebral artery dissection following chiropractic manipulation: case report and review of the literature.�Neuroradiology2003;45:311�14.�doi:10.1007/s00234-003-0944-x�[PubMed]
22.�Dittrich R, Rohsbach D, Heidbreder A et al.�Mild mechanical traumas are possible risk factors for cervical artery dissection.�Cerebrovasc Dis�2007;23:275�81.�doi:10.1159/000098327�[PubMed]
23.�Chung CL, Cote P, Stern P et al.�The association between cervical spine manipulation and carotid artery dissection: a systematic review of the literature.�J Manipulative Physiol Ther�2014; doi:10.1016/j.jmpt.2013.09.005�doi:10.1016/j.jmpt.2013.09.005�[PubMed]
24.�Thomas LC, Rivett DA, Attia JR et al.�Risk factors and clinical features of craniocervical arterial dissection.�Man Ther�2011;16:351�6.�doi:10.1016/j.math.2010.12.008�[PubMed]
25.�Klineberg E, Mazanec D, Orr D et al.�Masquerade: medical causes of back pain.�Cleve Clin J Med2007;74:905�13.�doi:10.3949/ccjm.74.12.905�[PubMed]
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What are Case Reports & Case Series?

What are Case Reports & Case Series?

by | Clinical Case Reports, Clinical Case Series, Functional Medicine

The diagnosis of a variety of diseases has been effectively determined through clinical and experimental data. Research studies provide valuable information on the pathogenesis of many conditions and are often the primary source of information regarding new diseases or conditions. Case reports and case series are first level research studies, offering the most initial insights on a particular health issue through the personal experience of one or more people with a disease or condition. The following article describes the purpose of case reports and case series, and how they provide clinical and experimental data.

 

Learning Objectives

 

1. Case reports and case series describe the experience of one or more people with a disease.
2. Case reports and case series are often the first data alerting to a new disease or condition.
3. Case reports and case series have specific limitations:

  • a. Lack of a denominator to calculate rates of disease
  • b. Lack of a comparison group
  • c. Selecting study populations
  • d. Sampling variation

 

Case Reports and Case Series

 

Case reports and case series represent the most basic type of study design, in which researchers describe the experience of a single person (case report) or a group of people (case series). Typically, case reports and case series describe individuals who develop a particular new disease or condition. Case reports and case series can provide compelling reading because they present a detailed account of the clinical experience of individual study subjects. In contrast, studies that evaluate large numbers of individuals typically summarize the data using statistical measures, such as means and proportions.

 

Example 3.1. A case series describes 15 young women who develop breast cancer; 9 of these women report at least once weekly ingestion of foods packaged with the estrogenic chemical bisphenol A (BPA). Urine testing confirms the presence of BPA among all nine case women.

 

It is tempting to surmise from these data that BPA might be causally related to breast cancer. However, case reports/case series have important limitations that preclude inference of a causal relationship.

First, case reports/case series lack denominator data that are necessary to calculate the rate of disease. The denominator refers to the population from which the diseased subjects arose. For example, to calculate the incidence proportion or incidence rate of breast cancer among women exposed to BPA, the total number of women who were exposed to BPA or the total number of person-years at risk is needed.

 

Table 1 - Incidence Proportion & Incidence Rate

 

Disease rates are needed for comparison with historically reported disease rates, or with rates from a selected comparison group. Unfortunately, obtaining the necessary denominator data may not be easy. In this example, additional data sources are needed to determine the total number of BPA-exposed women from whom the breast cancer cases arose. The case series data alone cannot be used to calculate the rate of breast cancer because they do not include the total number of women who were exposed to BPA.

 

A second problem with case report/case series report data is the lack of a comparison group. The 60% prevalence of BPA exposure among women with breast cancer seems unusually high, but what is prevalence of BPA exposure among women without breast cancer? This comparison is critical for addressing the hypothesis that BPA might be a cause of breast cancer.

 

A third limitation of case reports/case series is that these studies often describe highly select individuals who may not represent the general population. For example, it is possible that the 15 breast cancer cases originated from a single hospital in a community with high levels of air pollution or other potential carcinogens. Under these conditions, a fair estimate of breast cancer incidence among non-BPA exposed women from the same community would be required to make an inference that BPA causes breast cancer.

 

A fourth limitation of case reports/case series is sampling variation. This concept will be explored in detail later in this book. The basic idea is that there is tremendous natural variation in disease development in humans. The fact that 9 of 15 women with breast cancer reported BPA exposure is interesting; however, this number may be very different in the next case series of 15 women with breast cancer simply due to chance. A precise estimate of the rate of a disease, independent from chance, can be obtained only by increasing the number of diseased subjects.

 

Recall the list of factors that are used to judge whether a factor may be a cause of disease:

 

1. Randomized evidence
2. Strength of association
3. Temporal relationship between exposure and outcome
4. Dose-response association
5. Biological plausibility

 

In general, case reports/case series rely almost exclusively on biological plausibility to make their case for causation. For the BPA and breast cancer case series, there is no randomized evidence, no measure of the strength of association between BPA and breast cancer, no reported dose�response association, and no evidence that BPA exposure preceded the development of breast cancer. The inference for causation derives completely from previous biological knowledge regarding the estrogenic effects of BPA.

 

Despite limitations of case series data, they may be highly suggestive of an important new association, disease process, or unintended side effect of a medication or treatment.

 

Example 3.2. In 2007, a case series described three cases of male prepubertal gynecomastia. The report included detailed information on each subjects� age, body size, serum levels of endogenous steroids, and known exposures to exogenous hormones. It was discovered that all three otherwise healthy boys had been exposed to some product containing lavender oil (lotion, shampoo, soap), and that in each case, the gynecomastia resolved upon discontinuation of the product. Subsequent in vitro studies demonstrated endocrine-disrupting activity of lavender oil. This novel case series data may lead to further investigations to determine whether lavender oil, a common ingredient in commercially available products, may be a cause of gynecomastia.

 

Example 3.3. A vaccine designed to prevent rotavirus infection was found to cause weakening of the intestinal muscle layers in animals. Following release of the vaccine, a number of cases of intussusception (when one portion of the bowel slides into the next) were reported in children who received the vaccine, with some fatal cases. The strong biological plausibility underlying this initial association, and knowledge that intussusception is otherwise rare in infants, was highly suggestive of a causal relationship and the vaccine was removed from the market.

 

Information referenced from B. Kestenbaum, Epidemiology and Biostatistics: An Introduction to Clinical Research, DOI 10.1007/978-0-387-88433-2_3, � Springer Science+Business Media, LLC 2009. 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 .

 

Referenced by Dr. Alex Jimenez

 

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Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: Treating Sciatica Pain

 

 

Management of Sciatica: Nonsurgical & Surgical Therapies

Management of Sciatica: Nonsurgical & Surgical Therapies

by | Chiropractic, Chiropractic Examination, Clinical Case Reports, Clinical Case Series, Functional Medicine, Sciatica

Consider the following, sciatica is a medical term used to describe a collective group of symptoms resulting from the irritation or compression of the sciatic nerve, generally due to an injury or aggravated condition. Sciatica is commonly characterized by radiating pain along the sciatic nerve, which runs down one or both legs from the lower back. The following case vignette discusses Mr. Winston’s medical condition, a 50-year-old bus driver who reported experiencing chronic, lower back and leg pain associated with sciatica during a 4-week time period. Ramya Ramaswami, M.B., B.S., M.P.H., Zoher Ghogawala, M.D., and James N. Weinstein, D.O., provide a comprehensive analysis of the various treatment options available to treat sciatica, including undergoing lumbar disk surgery and receiving nonsurgical therapy.

 

On a personal note, as a practicing doctor of chiropractic, choosing the correct treatment care for any type of injury or condition can be a personal and difficult decision. If the circumstances are favorable, the patient may determine what is the best form of treatment for their type of medical issue. While nonsurgical therapies, such as chiropractic care, can often be utilized to improve symptoms of sciatica, more severe cases of sciatica may require surgical interventions to treat the source of the issue. In most cases, nonsurgical therapies should be considered first, before turning to surgical therapies for sciatica.

 

Case Vignette

 

A Man with Sciatica Who is Considering Lumbar Disk Surgery

 

Ramya Ramaswami, M.B., B.S., M.P.H.

 

Mr. Winston, a 50-year-old bus driver, presented to your office with a 4-week history of pain in his left leg and lower back. He described a combination of severe sharp and dull pain that originated in his left buttock and radiated to the dorsolateral aspect of his left thigh, as well as vague aching over the lower lumbar spine. On examination, passive raising of his left leg off the table to 45 degrees caused severe pain that simulated his main symptom, and the pain was so severe that you could not lift his leg further. There was no leg or foot weakness. His body-mass index (the weight in kilograms divided by the square of the height in meters) was 35, and he had mild chronic obstructive pulmonary disease as a result of smoking one pack of cigarettes every day for 22 years. Mr. Winston had taken a leave of absence from his work because of his symptoms. You prescribed 150 mg of pregabalin per day, which was gradually increased to 600 mg daily because the symptoms had not abated.

 

Now, 10 weeks after the initial onset of his symptoms, he returns for an evaluation. The medication has provided minimal alleviation of his sciatic pain. He has to return to work and is concerned about his ability to complete his duties at his job. He undergoes magnetic resonance imaging, which shows a herniated disk on the left side at the L4�L5 root. You discuss options for the next steps in managing his sciatica. He is uncertain about invasive procedures such as lumbar disk surgery but feels limited by his symptoms of pain.

 

Treatment Options

 

Which of the following would you recommend for Mr. Winston?

 

  1. Undergo lumbar disk surgery.
  2. Receive nonsurgical therapy.

 

To aid in your decision making, each of these approaches is defended in a short essay by an expert in the field. Given your knowledge of the patient and the points made by the experts, which option would you choose?

 

Option 1: Undergo Lumbar Disk Surgery
Option 2: Receive Nonsurgical Therapy

 

1. Undergo Lumbar Disk Surgery

 

Zoher Ghogawala, M.D.

 

Mr. Winston�s case represents a common scenario in the management of symptomatic lumbar disk herniation. In this particular case, the patient�s symptoms and the physical examination are consistent with nerve-root compression and inflammation directly from an L4�L5 herniated disk on his left side. The patient does not have weakness but has ongoing pain and has been unable to work for the past 10 weeks despite receiving pregabalin. Two questions emerge: first, does lumbar disk surgery (microdiskectomy) provide outcomes that are superior to those with continued nonoperative therapy in patients with more than 6 weeks of symptoms; and second, does lumbar microdiskectomy improve the likelihood of return to work in patients with these symptoms?

 

The highest quality data on the topic come from the Spine Patient Outcomes Research Trial (SPORT). The results of the randomized, controlled trial are difficult to interpret because adherence to the assigned treatment strategy was suboptimal. Only half the patients who were randomly assigned to the surgery group actually underwent surgery within 3 months after enrollment, and 30% of the patients assigned to nonoperative treatment chose to cross over to the surgical group. In this study, the patients who underwent surgery had greater improvements in validated patient-reported outcomes. The treatment effect of microdiskectomy was superior to that of nonoperative treatment at 3 months, 1 year, and 2 years. Moreover, in an as-treated analysis, the outcomes among patients who underwent surgery were superior to those among patients who received nonoperative therapy. Overall, the results of SPORT support the use of microdiskectomy in this case.

 

Results of clinical trials are based on a comparison of treatment options in study populations and may or may not apply to individual patients. SPORT did not specify what type of nonoperative therapy was to be used. Physical therapy was used in 73% of the patients, epidural injections in 50%, and medical therapies (e.g., nonsteroidal antiinflammatory drugs) in more than 50%. In the case of Mr. Winston, pregabalin has been tried, but physical therapy and epidural glucocorticoid injections have not been attempted. Despite widespread use of physical therapy for the treatment of lumbar disk herniation, the evidence supporting its effectiveness is inconclusive, according to published guidelines of the North American Spine Society. On the other hand, there is evidence that transforaminal epidural glucocorticoid injection provides short-term relief (30 days) in patients with nerve-root symptoms directly related to a herniated disk. Overall, there is evidence, from SPORT and from a randomized trial from the Netherlands published in the Journal, that early surgery between 6 and 12 weeks after the onset of symptoms provides greater alleviation of leg pain and better overall pain relief than prolonged conservative therapy.

 

The ability to return to work has not been formally studied in comparisons of operative with nonoperative treatments for lumbar disk herniation. Registry data from the NeuroPoint-SD study showed that more than 80% of the patients who were working before disk herniation returned to work after surgery. The ability to return to work may be dependent on the type of vocation, since patients who are manual laborers may need more time to recover to reduce the risk of reherniation.

 

It is well recognized that many patients who have a symptomatic lumbar disk herniation will have improvement spontaneously over several months. Surgery can alleviate symptoms more quickly by immediately removing the offending disk herniation from the affected nerve root. The risk�benefit equation will vary among individual patients. In the case of Mr. Winston, obesity and mild pulmonary disease might increase the risk of complications from surgery, although in SPORT, 95% of surgical patients did not have any operative or postoperative complication. For Mr. Winston, a patient with pain that has persisted for more than 6 weeks, microdiskectomy is a rational option that is supported by high-quality evidence.

 

2. Receive Nonsurgical Therapy

 

James N. Weinstein, D.O.

 

This case involves a common presentation of low back pain radiating to the buttock and posterolateral thigh that might represent either referred mechanical pain or radiculopathy. Classic radiculopathy resulting from compression of a lower lumbar nerve root (L4, L5, or S1) results in pain that radiates distal to the knee and is often accompanied by weakness or numbness in the respective myotome or dermatome. In this case, the pain is proximal to the knee and is not associated with weakness or numbness. In SPORT, surgery resulted in faster recovery and a greater degree of improvement than nonoperative treatment in patients with pain that radiated distal to the knee and was accompanied by neurologic signs or symptoms. However, since Mr. Winston would not have met the inclusion criteria for SPORT, the results of diskectomy in this case would be somewhat unpredictable. He does not have radiculopathy that radiates below the knee, and he does not have weakness or numbness; nonoperative treatment should be exhausted before any consideration of a surgical procedure that in most cases has not been shown to be effective in patients with this type of presentation. In this issue of the Journal, Mathieson and colleagues report the results of a randomized, controlled trial that showed that pregabalin did not significantly alleviate pain related to sciatica. Mr. Winston has been treated only with pregabalin; therefore, other conservative options should be explored.

 

Saal and Saal reported that more than 80% of patients with radiculopathy associated with a lumbar disk herniation had improvement in a matter of months with exercise-based physical therapy. In the nonoperative SPORT cohort, patients had significant improvement from baseline, and approximately 60% of those with classic radiculopathy who initially received nonoperative treatment avoided surgery. Mr. Winston has had minimal treatment and has had symptoms for only 10 weeks. He should undergo a course of exercise-based physical therapy and a trial of a nonsteroidal antiinflammatory medication and may consider a lumbar epidural glucocorticoid injection. Although there is little evidence of the effectiveness of these nonoperative options alone, the combination of these treatments and the benign natural history of the patient�s condition could result in alleviation or resolution of symptoms. If these interventions � and time � do not resolve his symptoms, surgery could be considered as a final option, but it may not have long-term effectiveness and could in and of itself cause the possibility of more harm than good. Mr. Winston has risk factors, such as obesity and a history of smoking, that have been shown to contribute to poor surgical outcomes of certain spinal procedures.

 

Mr. Winston has symptoms of back pain that interfere with his quality of life. He would need to understand, through shared decision making, that a nonsurgical approach is likely to be more effective than surgery over time.

 

Information referenced from the National Center for Biotechnology Information (NCBI) and the New England Journal of Medicine (NEJM). 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 .

 

Cited by Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: Treating Sciatica Pain

 

 

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References

 

  • 1. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 2006;296:2441–2450

  • 2. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451–2459

  • 3. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014;14:180–191

  • 4. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 2010;11:1149–1168

  • 5. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245–2256

  • 6. Ghogawala Z, Shaffrey CI, Asher AL, et al. The efficacy of lumbar discectomy and single-level fusion for spondylolisthesis: results from the NeuroPoint-SD registry: clinical article. J Neurosurg Spine 2013;19:555–563

  • 7. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363–370

  • 8. Lurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976) 2014;39:3–16

  • 9. Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med 2017;376:1111–1120

  • 10. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine (Phila Pa 1976) 1989;14:431–437

  • 11. Pinto RZ, Maher CG, Ferreira ML, et al. Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ 2012;344:e497–e497

  • 12. Pearson A, Lurie J, Tosteson T, et al. Who should have surgery for an intervertebral disc herniation? Comparative effectiveness evidence from the Spine Patient Outcomes Research Trial. Spine 2012;37:140–149

  • 13. Weeks WB, Weinstein JN. Patient-reported data can help people make better health care choices. Harvard Business Review. September 21, 2015

 

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Assessment and Treatment of Upper Trapezius

Assessment and Treatment of Upper Trapezius

by | Chiropractic, Functional Medicine, Injury Care

These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).

 

Clinical Application of Neuromuscular Techniques: Upper Trapezius

 

Lewit (1999) simplifies the need to assess for shortness by stating, �The upper trapezius should be treated if tender and taut.� Since this is an almost universal state in modern life, it seems that everyone requires MET application to this muscle. Lewit also notes that a characteristic mounding of the muscle can often be observed when it is very short, producing the effect of �Gothic shoulders�, similar to the architectural supports of a Gothic church tower (see Fig. 2.13).

 

Assessment for Shortness of Upper Trapezius (13) (Fig. 4.30)

 

Figure 4 30 Assessment of the Relative Shortness of the Right Side Upper Trapezius Image 1

 

Figure 4.30 Assessment of the relative shortness of the right side upper trapezius. One side is compared with the other (for both the range of unforced motion and the nature of the end-feel of motion) to ascertain the side most in need of MET attention.

 

Test for upper trapezius for shortness (a) See scapulohumeral rhythm test (Ch. 5) which helps identify excessive activity or inappropriate tone in levator scapula and upper trapezius, which, because they are postural muscles, indicates shortness (Fig 5.13A, B). Greenman (1996) describes a functional �firing sequence� assessment which identifies general imbalance and dysfunction involving the upper and lower fixators of the shoulder (Fig. 4.31).

 

Figure 4 31 Palpation Assessment for Upper and Lower Fixators of the Shoulder Image 2

 

Figure 4.31 Palpation assessment for upper and lower fixators of the shoulder, including upper trapezius (Greenman 1996).

 

The patient is seated and the practitioner stands behind. The practitioner rests his right hand over the right shoulder area to assess firing sequence of muscles. The other hand can be placed either on the mid-thoracic region, mainly on the side being assessed, or spanning the lower back to palpate quadratus firing. The assessment should be performed at least twice so that various hand positions are used for different muscles (as in Fig. 4.31).

 

Greenman bases his description on Janda (1983), who notes the �correct� sequence for shoulder abduction, when seated, as involving: supraspinatus, deltoid, infraspinatus, middle and lower trapezius and finally contralateral quadratus. In dysfunctional states the most common substitutions are said to involve: shoulder elevation by levator scapulae and upper trapezius, as well as early firing by quadratus lumborum, ipsilateral and contralateral.

 

Inappropriate activity of the upper fixators results in shortness, and of the lower fixators in weakness and possible lengthening (see Ch. 2 for discussion of postural/phasic, etc. muscle characteristics).

 

Test for upper trapezius for shortness (b) The patient is seated and the practitioner stands behind with one hand resting on the shoulder of the side to be tested and stabilising it. The other hand is placed on the ipsilateral side of the head and the head/neck is taken into contralateral sidebending without force while the shoulder is stabilised (see Fig. 4.30).

 

The same procedure is performed on the other side with the opposite shoulder stabilised. A comparison is made as to which sidebending manoeuvre produced the greater range and whether the neck can easily reach 45� of side-flexion in each direction, which it should. If neither side can achieve this degree of sidebend, then both trapezius muscles may be short. The relative shortness of one, compared with the other, is evaluated.

 

Test for upper trapezius for shortness (c) The patient is seated and the practitioner stands behind with a hand resting over the muscle on the side to be assessed. The patient is asked to extend the arm at the shoulder joint, bringing the flexed arm/elbow backwards. If the upper trapezius is stressed on that side it will inappropriately activate during this movement. Since it is a postural muscle, shortness in it can then be assumed (see discussion of postural muscle characteristics in Ch. 3).

 

Test of upper trapezius for shortness (d) The patient is supine with the neck fully (but not forcefully) sidebent contralaterally (away from the side being assessed). The practitioner is standing at the head of the table and uses a cupped hand contact on the ipsilateral shoulder (i.e. on the side being tested) to assess the ease with which it can be depressed (moved caudally) (Fig. 4.32).

 

Figure 4 32 MET Treatment of Right Side Upper Trapezius Muscle Image 3

 

Figure 4.32 MET treatment of right side upper trapezius muscle. A Posterior fibres, B middle fibres, C anterior fibres. Note that stretching in this (or any of the alternative positions which access the middle and posterior fibres) is achieved following the isometric contraction by means of an easing of the shoulder away from the stabilised head, with no force being applied to the neck and head itself.

 

There should be an easy �springing� sensation as the practitioner pushes the shoulder towards the feet, with a soft end-feel to the movement. If depression of the shoulder is difficult or if there is a harsh, sudden end-point, upper trapezius shortness is confirmed.

 

This same assessment (always with full lateral flexion) should be performed with the head fully rotated away from the side being treated, half turned away from the side being treated, and slightly turned towards the side being treated, in order to respectively assess the relative shortness and functional efficiency of posterior, middle and anterior subdivisions of the upper portion of trapezius.

 

MET Treatment of Chronically Shortened Upper Trapezius

 

MET treatment of upper trapezius, method (a) (Fig. 4.32) In order to treat all the fibres of upper trapezius, MET needs to be applied sequentially. The upper trapezius is subdivided here into anterior, middle and posterior fibres. The neck should be placed into different positions of rotation, coupled with the sidebending as described in the assessment description above, for precise treatment of the various fibres.

 

The patient lies supine, arm on the side to be treated lying alongside the trunk, head/neck sidebent away from the side being treated to just short of the restriction barrier, while the practitioner stabilises the shoulder with one hand and cups the ear/mastoid area of the same side of the head with the other:

 

  • With the neck fully sidebent and fully rotated contralaterally, the posterior fibres of upper trapezius are involved in the contraction (see below). This will facilitate subsequent stretching of this aspect of the muscle.
  • With the neck fully sidebent and half rotated, the middle fibres are involved in the contraction.
  • With the neck fully sidebent and slightly rotated towards the side being treated the anterior fibres of upper trapezius are being treated.

 

The various contractions and subsequent stretches can be performed with practitioner�s arms crossed, hands stabilising the mastoid area and shoulder.

 

The patient introduces a light resisted effort (20% of available strength) to take the stabilised shoulder towards the ear (a shrug movement) and the ear towards the shoulder. The double movement (or effort towards movement) is important in order to introduce a contraction of the muscle from both ends simultaneously. The degree of effort should be mild and no pain should be felt. The contraction is sustained for 10 seconds (or so) and, upon complete relaxation of effort, the practitioner gently eases the head/neck into an increased degree of sidebending and rotation, where it is stabilised, as the shoulder is stretched caudally.

 

When stretching is introduced the patient can usefully assist in this phase of the treatment by initiating, on instruction, the stretch of the muscle (�as you breathe out please slide your hand towards your feet�). This reduces the chances of a stretch reflex being initiated. Once the muscle is being stretched, the patient relaxes and the stretch is held for 10�30 seconds.

 

CAUTION: No stretch should be introduced from the cranial end of the muscle as this could stress the neck. The head is stabilised at its side-flexion and rotation barrier.

 

Disagreement

 

There is some disagreement as to the head/neck rotation position as described in the treatment method above, which calls (for posterior and middle fibres) for sidebending and rotation away from the affected side.

 

Liebenson (1996), suggests that the patient �lies supine with the head supported in anteflexion and laterally flexed away and rotated towards the side of involvement�.

 

Lewit (1985b) suggests: �The patient is supine � the therapist fixes the shoulder from above with one hand, sidebending the head and neck with the other hand so as to take up the slack. He then asks the patient to look towards the side away from which the head is bent, resisting the patient�s automatic tendency to move towards the side of the lesion.� (This method is described below.)

 

The author has used the methods described above with good effect and urges readers to try these approaches as well as those of Liebenson and Lewit, and to evaluate results for themselves.

 

MET treatment of acutely shortened upper trapezius, method (b) Lewit suggests the use of eye movements to facilitate initiation of PIR before stretching, an ideal method for acute problems in this region.

 

The patient is supine, while the practitioner fixes the shoulder and the sidebent (away from the treated side) head and neck at the restriction barrier and asks the patient to look, with the eyes only (i.e. not to turn the head), towards the side away from which the neck is bent.

 

This eye movement is maintained, as is a held breath, while the practitioner resists the slight isometric contraction that these two factors (eye movement and breath) will have created.

 

On exhalation and complete relaxation, the head/neck is taken to a new barrier and the process repeated. If the shoulder is brought into the equation, this is firmly held as it attempts to lightly push into a shrug. After this 10 second contraction the muscle will have released somewhat and slack can again be taken out as the head is repositioned before a repetition of the procedure commences.

 

Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

By Dr. Alex Jimenez

 

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Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

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WELLNESS TOPIC: EXTRA EXTRA: Managing Workplace Stress

 

 

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References
1.�Ballou SK, Keefer L. Multicultural considerations in the diagnosis and management of irritable bowel syndrome: a selective summary.�Eur J Gastroenterol Hepatol.�2013;25:1127�1133.�[PubMed]
2.�Gonzales Gamarra RG, Ruiz S�nchez JG, Le�n Jim�nez F, Cubas Benavides F, D�az V�lez C. [Prevalence of irritable bowel syndrome in the adult population of the city of Chiclayo in 2011]�Rev Gastroenterol Peru.�2012;32:381�386.�[PubMed]
3.�Gwee KA, Lu CL, Ghoshal UC. Epidemiology of irritable bowel syndrome in Asia: something old, something new, something borrowed.�J Gastroenterol Hepatol.�2009;24:1601�1607.�[PubMed]
4.�Krogsgaard LR, Engsbro AL, Bytzer P. The epidemiology of irritable bowel syndrome in Denmark. A population-based survey in adults ? 50 years of age.�Scand J Gastroenterol.�2013;48:523�529.�[PubMed]
5.�Ibrahim NK, Battarjee WF, Almehmadi SA. Prevalence and predictors of irritable bowel syndrome among medical students and interns in King Abdulaziz University, Jeddah.�Libyan J Med.�2013;8:21287.[PMC free article]�[PubMed]
6.�Lee YY, Waid A, Tan HJ, Chua AS, Whitehead WE. Rome III survey of irritable bowel syndrome among ethnic Malays.�World J Gastroenterol.�2012;18:6475�6480; discussion p. 6479.�[PMC free article][PubMed]
7.�Ghoshal UC, Abraham P, Bhatt C, Choudhuri G, Bhatia SJ, Shenoy KT, Banka NH, Bose K, Bohidar NP, Chakravartty K, et al. Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force.�Indian J Gastroenterol.�2008;27:22�28.�[PubMed]
8.�Bures J, Cyrany J, Kohoutova D, F�rstl M, Rejchrt S, Kvetina J, Vorisek V, Kopacova M. Small intestinal bacterial overgrowth syndrome.�World J Gastroenterol.�2010;16:2978�2990.�[PMC free article][PubMed]
9.�Dibaise JK, Young RJ, Vanderhoof JA. Enteric microbial flora, bacterial overgrowth, and short-bowel syndrome.�Clin Gastroenterol Hepatol.�2006;4:11�20.�[PubMed]
10.�Bouhnik Y, Alain S, Attar A, Flouri� B, Raskine L, Sanson-Le Pors MJ, Rambaud JC. Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome.�Am J Gastroenterol.�1999;94:1327�1331.�[PubMed]
11.�Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review.�Gastroenterol Hepatol (N Y)�2007;3:112�122.�[PMC free article]�[PubMed]
12.�Posserud I, Stotzer PO, Bj�rnsson ES, Abrahamsson H, Simr�n M. Small intestinal bacterial overgrowth in patients with irritable bowel syndrome.�Gut.�2007;56:802�808.�[PMC free article]�[PubMed]
13.�Ghoshal U, Ghoshal UC, Ranjan P, Naik SR, Ayyagari A. Spectrum and antibiotic sensitivity of bacteria contaminating the upper gut in patients with malabsorption syndrome from the tropics.�BMC Gastroenterol.�2003;3:9.�[PMC free article]�[PubMed]
14.�Carrara M, Desideri S, Azzurro M, Bulighin GM, Di Piramo D, Lomonaco L, Adamo S. Small intestine bacterial overgrowth in patients with irritable bowel syndrome.�Eur Rev Med Pharmacol Sci.�2008;12:197�202.�[PubMed]
15.�Ghoshal UC, Ghoshal U, Das K, Misra A. Utility of hydrogen breath tests in diagnosis of small intestinal bacterial overgrowth in malabsorption syndrome and its relationship with oro-cecal transit time.�Indian J Gastroenterol.�2006;25:6�10.�[PubMed]
16.�Ghoshal UC, Kumar S, Mehrotra M, Lakshmi C, Misra A. Frequency of small intestinal bacterial overgrowth in patients with irritable bowel syndrome and chronic non-specific diarrhea.�J Neurogastroenterol Motil.�2010;16:40�46.�[PMC free article]�[PubMed]
17.�Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome.�Am J Gastroenterol.�2000;95:3503�3506.�[PubMed]
18.�Sachdeva S, Rawat AK, Reddy RS, Puri AS. Small intestinal bacterial overgrowth (SIBO) in irritable bowel syndrome: frequency and predictors.�J Gastroenterol Hepatol.�2011;26 Suppl 3:135�138.�[PubMed]
19.�Park H. The role of small intestinal bacterial overgrowth in the pathophysiology of irritable bowel syndrome.�J Neurogastroenterol Motil.�2010;16:3�4.�[PMC free article]�[PubMed]
20.�Ghoshal UC, Shukla R, Ghoshal U, Gwee KA, Ng SC, Quigley EM. The gut microbiota and irritable bowel syndrome: friend or foe?�Int J Inflam.�2012;2012:151085.�[PMC free article]�[PubMed]
21.�Brown AC. Ulcerative colitis, Crohn�s disease and irritable bowel syndrome patients need fecal transplant research and treatment.�J Crohns Colitis.�2014;8:179.�[PubMed]
22.�Sampath K, Levy LC, Gardner TB. Fecal transplantation: beyond the aesthetic.�Gastroenterology.�2013;145:1151�1153.�[PubMed]
23.�Grace E, Shaw C, Whelan K, Andreyev HJ. Review article: small intestinal bacterial overgrowth–prevalence, clinical features, current and developing diagnostic tests, and treatment.�Aliment Pharmacol Ther.�2013;38:674�688.�[PubMed]
24.�Yakoob J, Abbas Z, Khan R, Hamid S, Awan S, Jafri W. Small intestinal bacterial overgrowth and lactose intolerance contribute to irritable bowel syndrome symptomatology in Pakistan.�Saudi J Gastroenterol.�2011;17:371�375.�[PMC free article]�[PubMed]
25.�Gwee KA, Bak YT, Ghoshal UC, Gonlachanvit S, Lee OY, Fock KM, Chua AS, Lu CL, Goh KL, Kositchaiwat C, et al. Asian consensus on irritable bowel syndrome.�J Gastroenterol Hepatol.�2010;25:1189�1205.�[PubMed]
26.�Lacy BE, Gabbard SL, Crowell MD. Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air?�Gastroenterol Hepatol (N Y)�2011;7:729�739.�[PMC free article]�[PubMed]
27.�Harder H, Serra J, Azpiroz F, Passos MC, Aguad� S, Malagelada JR. Intestinal gas distribution determines abdominal symptoms.�Gut.�2003;52:1708�1713.�[PMC free article]�[PubMed]
28.�Kumar S, Misra A, Ghoshal UC. Patients with irritable bowel syndrome exhale more hydrogen than healthy subjects in fasting state.�J Neurogastroenterol Motil.�2010;16:299�305.�[PMC free article][PubMed]
29.�Hungin AP, Mulligan C, Pot B, Whorwell P, Agr�us L, Fracasso P, Lionis C, Mendive J, Philippart de Foy JM, Rubin G, Winchester C, de Wit N. Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice — an evidence-based international guide.�Aliment Pharmacol Ther.�2013;38:864�886.�[PMC free article]�[PubMed]
30.�Attar A, Flouri� B, Rambaud JC, Franchisseur C, Ruszniewski P, Bouhnik Y. Antibiotic efficacy in small intestinal bacterial overgrowth-related chronic diarrhea: a crossover, randomized trial.�Gastroenterology.�1999;117:794�797.�[PubMed]
31.�Marcelino RT, Fagundes-Neto U. [Hydrogen test (H2) in the air expired for the diagnosis of small bowel bacterial overgrowth]�Arq Gastroenterol.�1995;32:191�198.�[PubMed]
32.�Santavirta J. Lactulose hydrogen and [14C]xylose breath tests in patients with ileoanal anastomosis.�Int J Colorectal Dis.�1991;6:208�211.�[PubMed]
33.�Ghoshal UC. How to interpret hydrogen breath tests.�J Neurogastroenterol Motil.�2011;17:312�317.[PMC free article]�[PubMed]
34.�Yang CY, Chang CS, Chen GH. Small-intestinal bacterial overgrowth in patients with liver cirrhosis, diagnosed with glucose H2 or CH4 breath tests.�Scand J Gastroenterol.�1998;33:867�871.�[PubMed]
35.�Ghoshal UC, Ghoshal U, Ayyagari A, Ranjan P, Krishnani N, Misra A, Aggarwal R, Naik S, Naik SR. Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time.�J Gastroenterol Hepatol.�2003;18:540�547.�[PubMed]
36.�Lu CL, Chen CY, Chang FY, Lee SD. Characteristics of small bowel motility in patients with irritable bowel syndrome and normal humans: an Oriental study.�Clin Sci (Lond)�1998;95:165�169.�[PubMed]
37.�Sciarretta G, Furno A, Mazzoni M, Garagnani B, Malaguti P. Lactulose hydrogen breath test in orocecal transit assessment. Critical evaluation by means of scintigraphic method.�Dig Dis Sci.�1994;39:1505�1510.�[PubMed]
38.�Rao SS, Camilleri M, Hasler WL, Maurer AH, Parkman HP, Saad R, Scott MS, Simren M, Soffer E, Szarka L. Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies.�Neurogastroenterol Motil.�2011;23:8�23.[PubMed]
39.�Yu D, Cheeseman F, Vanner S. Combined oro-caecal scintigraphy and lactulose hydrogen breath testing demonstrate that breath testing detects oro-caecal transit, not small intestinal bacterial overgrowth in patients with IBS.�Gut.�2011;60:334�340.�[PubMed]
40.�Rana SV, Sharma S, Sinha SK, Kaur H, Sikander A, Singh K. Incidence of predominant methanogenic flora in irritable bowel syndrome patients and apparently healthy controls from North India.�Dig Dis Sci.�2009;54:132�135.�[PubMed]
41.�Dridi B, Henry M, El Kh�chine A, Raoult D, Drancourt M. High prevalence of Methanobrevibacter smithii and Methanosphaera stadtmanae detected in the human gut using an improved DNA detection protocol.�PLoS One.�2009;4:e7063.�[PMC free article]�[PubMed]
42.�Chatterjee S, Park S, Low K, Kong Y, Pimentel M. The degree of breath methane production in IBS correlates with the severity of constipation.�Am J Gastroenterol.�2007;102:837�841.�[PubMed]
43.�Lunia MK, Sharma BC, Sachdeva S. Small intestinal bacterial overgrowth and delayed orocecal transit time in patients with cirrhosis and low-grade hepatic encephalopathy.�Hepatol Int.�2013;7:268�273.[PubMed]
44.�Resmini E, Parodi A, Savarino V, Greco A, Rebora A, Minuto F, Ferone D. Evidence of prolonged orocecal transit time and small intestinal bacterial overgrowth in acromegalic patients.�J Clin Endocrinol Metab.�2007;92:2119�2124.�[PubMed]
45.�Hamilton I, Worsley BW, Cobden I, Cooke EM, Shoesmith JG, Axon AT. Simultaneous culture of saliva and jejunal aspirate in the investigation of small bowel bacterial overgrowth.�Gut.�1982;23:847�853.[PMC free article]�[PubMed]
46.�Corazza GR, Sorge M, Strocchi A, Benati G, Di Sario A, Treggiari EA, Brusco G, Gasbarrini G. Non-absorbable antibiotics and small bowel bacterial overgrowth.�Ital J Gastroenterol.�1992;24:4�9.�[PubMed]
47.�Kuwahara T, Ogura Y, Oshima K, Kurokawa K, Ooka T, Hirakawa H, Itoh T, Nakayama-Imaohji H, Ichimura M, Itoh K, et al. The lifestyle of the segmented filamentous bacterium: a non-culturable gut-associated immunostimulating microbe inferred by whole-genome sequencing.�DNA Res.�2011;18:291�303.�[PMC free article]�[PubMed]
48.�Beumer RR, de Vries J, Rombouts FM. Campylobacter jejuni non-culturable coccoid cells.�Int J Food Microbiol.�1992;15:153�163.�[PubMed]
49.�Fromm H, Sarva RP, Ravitch MM, McJunkin B, Farivar S, Amin P. Effects of jejunoileal bypass on the enterohepatic circulation of bile acids, bacterial flora in the upper small intestine, and absorption of vitamin B12.�Metabolism.�1983;32:1133�1141.�[PubMed]
50.�Yoshida T, McCormick WC, Swell L, Vlahcevic ZR. Bile acid metabolism in cirrhosis. IV. Characterization of the abnormality in deoxycholic acid metabolism.�Gastroenterology.�1975;68:335�341.[PubMed]
51.�Bj�rneklett A, Fausa O, Midtvedt T. Bacterial overgrowth in jejunal and ileal disease.�Scand J Gastroenterol.�1983;18:289�298.�[PubMed]
52.�Vanner S. The small intestinal bacterial overgrowth. Irritable bowel syndrome hypothesis: implications for treatment.�Gut.�2008;57:1315�1321.�[PubMed]
53.�Kinross JM, von Roon AC, Holmes E, Darzi A, Nicholson JK. The human gut microbiome: implications for future health care.�Curr Gastroenterol Rep.�2008;10:396�403.�[PubMed]
54.�Clauw DJ. Fibromyalgia: an overview.�Am J Med.�2009;122:S3�S13.�[PubMed]
55.�Pimentel M, Wallace D, Hallegua D, Chow E, Kong Y, Park S, Lin HC. A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing.�Ann Rheum Dis.�2004;63:450�452.�[PMC free article]�[PubMed]
56.�Simr�n M, Stotzer PO. Use and abuse of hydrogen breath tests.�Gut.�2006;55:297�303.[PMC free article]�[PubMed]
57.�Gasbarrini A, Lauritano EC, Gabrielli M, Scarpellini E, Lupascu A, Ojetti V, Gasbarrini G. Small intestinal bacterial overgrowth: diagnosis and treatment.�Dig Dis.�2007;25:237�240.�[PubMed]
58.�Ghoshal UC, Srivastava D, Verma A, Misra A. Slow transit constipation associated with excess methane production and its improvement following rifaximin therapy: a case report.�J Neurogastroenterol Motil.�2011;17:185�188.�[PMC free article]�[PubMed]
59.�Bala L, Ghoshal UC, Ghoshal U, Tripathi P, Misra A, Gowda GA, Khetrapal CL. Malabsorption syndrome with and without small intestinal bacterial overgrowth: a study on upper-gut aspirate using 1H NMR spectroscopy.�Magn Reson Med.�2006;56:738�744.�[PubMed]
60.�Haboubi NY, Lee GS, Montgomery RD. Duodenal mucosal morphometry of elderly patients with small intestinal bacterial overgrowth: response to antibiotic treatment.�Age Ageing.�1991;20:29�32.�[PubMed]
61.�Shindo K, Machida M, Koide K, Fukumura M, Yamazaki R. Deconjugation ability of bacteria isolated from the jejunal fluid of patients with progressive systemic sclerosis and its gastric pH.�Hepatogastroenterology.�1998;45:1643�1650.�[PubMed]
62.�Wanitschke R, Ammon HV. Effects of dihydroxy bile acids and hydroxy fatty acids on the absorption of oleic acid in the human jejunum.�J Clin Invest.�1978;61:178�186.�[PMC free article]�[PubMed]
63.�Shanab AA, Scully P, Crosbie O, Buckley M, O�Mahony L, Shanahan F, Gazareen S, Murphy E, Quigley EM. Small intestinal bacterial overgrowth in nonalcoholic steatohepatitis: association with toll-like receptor 4 expression and plasma levels of interleukin 8.�Dig Dis Sci.�2011;56:1524�1534.�[PubMed]
64.�Ghoshal UC, Park H, Gwee KA. Bugs and irritable bowel syndrome: The good, the bad and the ugly.�J Gastroenterol Hepatol.�2010;25:244�251.�[PubMed]
65.�Barbara G, Stanghellini V, Brandi G, Cremon C, Di Nardo G, De Giorgio R, Corinaldesi R. Interactions between commensal bacteria and gut sensorimotor function in health and disease.�Am J Gastroenterol.�2005;100:2560�2568.�[PubMed]
66.�Cherbut C, Aub� AC, Blotti�re HM, Galmiche JP. Effects of short-chain fatty acids on gastrointestinal motility.�Scand J Gastroenterol Suppl.�1997;222:58�61.�[PubMed]
67.�Ramakrishna BS, Roediger WE. Bacterial short chain fatty acids: their role in gastrointestinal disease.�Dig Dis.�1990;8:337�345.�[PubMed]
68.�Dumoulin V, Moro F, Barcelo A, Dakka T, Cuber JC. Peptide YY, glucagon-like peptide-1, and neurotensin responses to luminal factors in the isolated vascularly perfused rat ileum.�Endocrinology.�1998;139:3780�3786.�[PubMed]
69.�Balsari A, Ceccarelli A, Dubini F, Fesce E, Poli G. The fecal microbial population in the irritable bowel syndrome.�Microbiologica.�1982;5:185�194.�[PubMed]
70.�Nobaek S, Johansson ML, Molin G, Ahrn� S, Jeppsson B. Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome.�Am J Gastroenterol.�2000;95:1231�1238.�[PubMed]
71.�Cummings JH, Macfarlane GT. The control and consequences of bacterial fermentation in the human colon.�J Appl Bacteriol.�1991;70:443�459.�[PubMed]
72.�Camilleri M. Probiotics and irritable bowel syndrome: rationale, mechanisms, and efficacy.�J Clin Gastroenterol.�2008;42 Suppl 3 Pt 1:S123�S125.�[PubMed]
73.�Spiller R. Probiotics: an ideal anti-inflammatory treatment for IBS?�Gastroenterology.�2005;128:783�785.�[PubMed]
74.�Ford AC, Spiegel BM, Talley NJ, Moayyedi P. Small intestinal bacterial overgrowth in irritable bowel syndrome: systematic review and meta-analysis.�Clin Gastroenterol Hepatol.�2009;7:1279�1286.�[PubMed]
75.�Cuoco L, Salvagnini M. Small intestine bacterial overgrowth in irritable bowel syndrome: a retrospective study with rifaximin.�Minerva Gastroenterol Dietol.�2006;52:89�95.�[PubMed]
76.�Di Stefano M, Corazza GR. Treatment of small intestine bacterial overgrowth and related symptoms by rifaximin.�Chemotherapy.�2005;51 Suppl 1:103�109.�[PubMed]
77.�Pimentel M, Lembo A, Chey WD, Zakko S, Ringel Y, Yu J, Mareya SM, Shaw AL, Bortey E, Forbes WP. Rifaximin therapy for patients with irritable bowel syndrome without constipation.�N Engl J Med.�2011;364:22�32.�[PubMed]
78.�Hwang L, Low K, Khoshini R, Melmed G, Sahakian A, Makhani M, Pokkunuri V, Pimentel M. Evaluating breath methane as a diagnostic test for constipation-predominant IBS.�Dig Dis Sci.�2010;55:398�403.�[PubMed]
79.�Low K, Hwang L, Hua J, Zhu A, Morales W, Pimentel M. A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test.�J Clin Gastroenterol.�2010;44:547�550.�[PubMed]
80.�Bengmark S. Colonic food: pre- and probiotics.�Am J Gastroenterol.�2000;95:S5�S7.�[PubMed]
81.�Quigley EM, Quera R. Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics.�Gastroenterology.�2006;130:S78�S90.�[PubMed]
82.�Xiao SD, Zhang DZ, Lu H, Jiang SH, Liu HY, Wang GS, Xu GM, Zhang ZB, Lin GJ, Wang GL. Multicenter, randomized, controlled trial of heat-killed Lactobacillus acidophilus LB in patients with chronic diarrhea.�Adv Ther.�2003;20:253�260.�[PubMed]
83.�O’Mahony L, McCarthy J, Kelly P, Hurley G, Luo F, Chen K, O�Sullivan GC, Kiely B, Collins JK, Shanahan F, et al. Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles.�Gastroenterology.�2005;128:541�551.�[PubMed]
84.�Tsuchiya J, Barreto R, Okura R, Kawakita S, Fesce E, Marotta F. Single-blind follow-up study on the effectiveness of a symbiotic preparation in irritable bowel syndrome.�Chin J Dig Dis.�2004;5:169�174.[PubMed]
85.�Kim YG, Moon JT, Lee KM, Chon NR, Park H. [The effects of probiotics on symptoms of irritable bowel syndrome]�Korean J Gastroenterol.�2006;47:413�419.�[PubMed]
86.�Park JS, Yu JH, Lim HC, Kim JH, Yoon YH, Park HJ, Lee SI. [Usefulness of lactulose breath test for the prediction of small intestinal bacterial overgrowth in irritable bowel syndrome]�Korean J Gastroenterol.�2010;56:242�248.�[PubMed]
87.�Mann NS, Limoges-Gonzales M. The prevalence of small intestinal bacterial vergrowth in irritable bowel syndrome.�Hepatogastroenterology.�2009;56:718�721.�[PubMed]
88.�Scarpellini E, Giorgio V, Gabrielli M, Lauritano EC, Pantanella A, Fundar� C, Gasbarrini A. Prevalence of small intestinal bacterial overgrowth in children with irritable bowel syndrome: a case-control study.�J Pediatr.�2009;155:416�420.�[PubMed]
89.�Nucera G, Gabrielli M, Lupascu A, Lauritano EC, Santoliquido A, Cremonini F, Cammarota G, Tondi P, Pola P, Gasbarrini G, et al. Abnormal breath tests to lactose, fructose and sorbitol in irritable bowel syndrome may be explained by small intestinal bacterial overgrowth.�Aliment Pharmacol Ther.�2005;21:1391�1395.�[PubMed]
90.�Reddymasu SC, Sostarich S, McCallum RW. Small intestinal bacterial overgrowth in irritable bowel syndrome: are there any predictors?�BMC Gastroenterol.�2010;10:23.�[PMC free article]�[PubMed]
91.�Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy.�Clin Gastroenterol Hepatol.�2010;8:504�508.�[PubMed]
92.�Parodi A, Dulbecco P, Savarino E, Giannini EG, Bodini G, Corbo M, Isola L, De Conca S, Marabotto E, Savarino V. Positive glucose breath testing is more prevalent in patients with IBS-like symptoms compared with controls of similar age and gender distribution.�J Clin Gastroenterol.�2009;43:962�966.[PubMed]
93.�Rana SV, Sinha SK, Sikander A, Bhasin DK, Singh K. Study of small intestinal bacterial overgrowth in North Indian patients with irritable bowel syndrome: a case control study.�Trop Gastroenterol.�2008;29:23�25.�[PubMed]
94.�Majewski M, McCallum RW. Results of small intestinal bacterial overgrowth testing in irritable bowel syndrome patients: clinical profiles and effects of antibiotic trial.�Adv Med Sci.�2007;52:139�142.[PubMed]
95.�Lupascu A, Gabrielli M, Lauritano EC, Scarpellini E, Santoliquido A, Cammarota G, Flore R, Tondi P, Pola P, Gasbarrini G, et al. Hydrogen glucose breath test to detect small intestinal bacterial overgrowth: a prevalence case-control study in irritable bowel syndrome.�Aliment Pharmacol Ther.�2005;22:1157�1160.[PubMed]
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Research Studies on SIBO in Irritable Bowel Syndrome

Research Studies on SIBO in Irritable Bowel Syndrome

by | Chiropractic, Functional Medicine

Irritable bowel syndrome, or IBS, is a prevalent condition characterized by abdominal pain or discomfort, bloating, connected to altered stool form (such as diarrhea and constipation) as well as passage. Approximately 4 percent to 30 percent of individuals world-wide suffer from IBS. Small intestinal bacterial overgrowth, or SIBO, which was clinically demonstrated in patients with structural abnormalities in the gut, such as ileo-transverse anastomosis, stricture, fistula, slow motility and reduced gut defense, may also be characterized by abdominal pain or discomfort, bloating, flatulence and loose motion. It’s been recognized that SIBO may occur in the absence of structural abnormalities. These patients may be incorrectly diagnosed with IBS, or irritable bowel syndrome.

 

How common is SIBO diagnosed in IBS?

 

Small intestinal bacterial overgrowth has been described as the excessive presence of bacteria, forming 105 units per milliliter on culture of their intestine aspirate. As this is an invasive test, lots of noninvasive techniques like lactulose and glucose hydrogen breath tests (LHBT and GHBT) are broadly used to diagnose SIBO. This issue has been recognized among people with IBS. In a variety of research studies, frequency of SIBO among patients presenting IBS varied from 4 percent to 78 percent, according to Table ?1, more so among patients with diarrhea-predominant IBS. Not only quantitative increase (SIBO) but qualitative change from the gut bacteria (dysbiosis) was reported among patients with IBS. Research studies utilizing antibiotics and probiotics have caused disagreement to care for this disease with lately transplantation which led to a paradigm shift. Nonetheless, it’s essential to understand the wide-variability in frequency of SIBO among people with IBS. A wide-variability in frequency may indicate it is vital to evaluate the evidence carefully to determine whether the association between IBS and SIBO is under-projected in previous research studies.

 

Table 1 Summary of Prevalence of SIBO in IBS Image 1

 

The research studies are examined by people on discordance with the connection between IBS and SIBO as well as their strength and weakness, such as evidence on exploitation of gut flora on indications of IBS and other issues.

 

Assessment of Studies on SIBO in IBS

 

Table ?1 summarizes the outcomes among patients with IBS from research studies on individuals with SIBO. As can be noted in the table, the frequency of people with IBS and SIBO varied from 4 percent to 78 percent and from 1 percent and 40 percent among controls. Frequency of individuals with SIBO and IBS was greater than among controls. It might be concluded that SIBO is correlated with IBS. It’s essential to assess the explanations in various research studies.

 

Critical Evaluation of Studies on SIBO in IBS

 

Can IBS phenotype determine frequency of SIBO?

 

IBS is a state that’s heterogeneous. The sub-types may be diarrhea or constipation-predominant or may be alternating. Patients with diarrhea-predominant IBS have organic cause including SIBO compared to other types of IBS. In a study on 129 patients with non-diarrheal IBS, 73 with long-term diarrhea, for example diarrhea-predominant IBS, and 51 healthy controls, frequency of SIBO with GHBT was 11 (8.5 percent), 16 (22 percent) and 1 (2%), respectively. Similar findings are reported in various studies. Diarrheal IBS needs to be evaluated in comparison to other sorts of IBS for SIBO. Research studies that contained percentage of individuals are extremely likely to reveal frequency of SIBO.

 

Bloating is a symptom commonly reported among patients with IBS. Frequency of bloating has been reported to vary from Asia by 26 percent to 83 percent in research studies on IBS. The pathogenesis of bloating may be correlated with increased quantity of gas in the gut, its abnormal source and improved gut sense in response to distension of the gut. Patients with SIBO may have increased amount of gas inside the gut, so it’s plausible to believe IBS patients with bloating that is noticeable are expected to have SIBO. There is limited data with this specific circumstance. Evidence also demonstrated that both fasting along with post-substrate (e.g., sugar, lactulose) breath hydrogen is considerably higher compared to individuals with IBS compared to controls. Probiotics and antibiotics, which are demonstrated to reduce gas, are demonstrated to ease bloating. It has been noted that treatment can revert hydrogen breath tests back to normal. Patients with IBS, flatulence and bloating should be evaluated for SIBO. More data is involved with this issue.

 

Can techniques used to diagnose SIBO determine its frequency?

 

Several techniques are used to diagnose SIBO; including GHBT LHBT,14C breath test, and culture of aspirate. The principle of hydrogen breath tests is summarized in Figure 1. Dietary carbohydrates produce hydrogen in the gut. In patients with SIBO, the bacteria in the small bowel ferment these carbohydrates, producing hydrogen, which gets absorbed and is exhaled in the breath.

 

Figure 1 Outline of Principle of Method and Interpretation of Glucose and Lactulose Hydrogen Breath Tests Image 2

Figure 1

 

Hydrogen breath test involves giving patients a load of carbohydrate (generally in the sort of glucose and lactulose) and measuring expired hydrogen concentrations in a period of time. Identification of SIBO using hydrogen breath test depends upon the bodily principle of patients with SIBO, glucose may be fermented by bacteria in the intestine resulting in production of hydrogen gas that is consumed and exhaled in expired air (Figure ?1, A1). By contrast, lactulose, which may function as a non-absorbable disaccharide, will produce an early summit due to fermentation in the small intestine (normally within 90-min) or two summit (as a consequence of small intestine fermentation and minute from colon), if SIBO is present (Figure ?1, B2 and B3). There are limits in hydrogen breath test for identification of SIBO. There may be similarities in patients with problems and SIBO employing rapid transit making differentiation difficult. An ancient summit can be positive in people with gut transit time. By way of instance, in a study from India, median oro-cecal transit interval was 65 minutes (variety 40-110 moments) in healthy subjects. In another study from Taiwan, mean transit interval was 85 min. It’s been substantiated in Western individuals recently by simultaneously using LHBT and radio-nuclide method to gauge gut transport. Double summit standards for evaluation of SIBO using LHBT is quite insensitive. Sensitivity of GHBT to diagnose SIBO is 44 percent contemplating the culture of gut aspirate as a regular standard. As a result, it’s estimated that the researchers who used a historic summit standards in LHBT could discover a greater frequency of SIBO among people with IBS along with controls. In contrast, those who would use either GHBT or double summit benchmark in LHBT might locate a minimum frequency of SIBO alike in patients with IBS and controls. It is well worth noting from Table ?1 that the frequency of SIBO among people with IBS and controls on LHBT (early summit standards) varied from 34.5 percent to 78 percent and 7 percent to 40 percent, respectively; in contrast with the frequency GHBT varied from 8.5 percent to 46 percent and 2 percent to 18percent.

 

Fifteen percent of people might have methanogenic flora in the gut. Methanobrevibacter smithii, Methanobrevibacter stadmanae and perhaps several of those coliform bacteria are methanogens. In these areas, only hydrogen breath tests may not diagnose SIBO, estimation of methane may also be demanded (Figure ?1). Table ?1 shows that 8.5 percent to 26 percent of IBS sufferers and 0 percent to 25 percent of controls exhaled methane inside their breath. Whether methane was not expected in them, SIBO could not have been diagnosed. Methane was not estimated, which could have resulted in underestimation of frequency of SIBO as outlined in a proportion of the research study. Methane production in excess is connected to constipation. Consequently, methane estimation in breath, which is inaccessible in several commercially available hydrogen breath test machines, is particularly vital in patients employing constipation-predominant IBS. Some could have slow transit through the small intestine making prolonged testing as a lot of hours required and many people may not want to undergo such testing. However, a period of testing for them may overlook SIBO’s identification.

 

The jejunal aspirate culture has traditionally been used as the gold standard to diagnose SIBO, according to Figure ?2. On the other hand, the limitations of this test include invasiveness in addition to the challenges posed by attempting to civilization all strains and species. In fact, usage of air during endoscopy might lead to a false negative impact as anaerobes do not rise when these are exposed to oxygen. Furthermore, a massive percentage of germs are not cultured. By contrast, single lumen catheter passed through the nose or through the biopsy channel of endoscope, may lead to contamination with oro-pharyngeal flora supplying false positive result. Therefore, we left a double-lumen catheter to prevent these oro-pharyngeal contamination (Figure ?2). Studies on SIBO one of patients with IBS using qualitative civilization of small bowel aspirate are scanty (Table ?1). A study by Posserud et al reported that a frequency of SIBO of 4 percent among people with IBS. Taking the result of study using GHBT, the sensitivity of 44 percent to diagnose the intestine aspirate appears to have the incidence of SIBO . More studies are essential on this issue.

 

Figure 2 Outline of Method of Culturing Bacteria and Counting the Colonies Image 3

Figure 2

 

Figure 3 Bile Acid Breath Test Involving Bile Acid and Glycocholic Acid Image 4

Figure 3

 

13C and�14C based tests have also been developed based on the bacterial metabolism of D-xylose (Figure ?3). Of acids containing13C and�14C may be used to diagnose SIBO. The glycocholic acid breath test contains the managing of the bile acid14C glycocholic acid, as well as the discovery of14CO2, which may be increased in SIBO (Figure 3), according to the clinical and experimental data from the various research studies on SIBO associated with IBS. While evidence may appear conclusive, further research studies may be required to properly determine the results.

 

Information referenced from the National Center for Biotechnology Information (NCBI) and the National University of Health Sciences. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

By Dr. Alex Jimenez

 

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Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

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WELLNESS TOPIC: EXTRA EXTRA: Managing Workplace Stress

 

 

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References
1.�Ballou SK, Keefer L. Multicultural considerations in the diagnosis and management of irritable bowel syndrome: a selective summary.�Eur J Gastroenterol Hepatol.�2013;25:1127�1133.�[PubMed]
2.�Gonzales Gamarra RG, Ruiz S�nchez JG, Le�n Jim�nez F, Cubas Benavides F, D�az V�lez C. [Prevalence of irritable bowel syndrome in the adult population of the city of Chiclayo in 2011]�Rev Gastroenterol Peru.�2012;32:381�386.�[PubMed]
3.�Gwee KA, Lu CL, Ghoshal UC. Epidemiology of irritable bowel syndrome in Asia: something old, something new, something borrowed.�J Gastroenterol Hepatol.�2009;24:1601�1607.�[PubMed]
4.�Krogsgaard LR, Engsbro AL, Bytzer P. The epidemiology of irritable bowel syndrome in Denmark. A population-based survey in adults ? 50 years of age.�Scand J Gastroenterol.�2013;48:523�529.�[PubMed]
5.�Ibrahim NK, Battarjee WF, Almehmadi SA. Prevalence and predictors of irritable bowel syndrome among medical students and interns in King Abdulaziz University, Jeddah.�Libyan J Med.�2013;8:21287.[PMC free article]�[PubMed]
6.�Lee YY, Waid A, Tan HJ, Chua AS, Whitehead WE. Rome III survey of irritable bowel syndrome among ethnic Malays.�World J Gastroenterol.�2012;18:6475�6480; discussion p. 6479.�[PMC free article][PubMed]
7.�Ghoshal UC, Abraham P, Bhatt C, Choudhuri G, Bhatia SJ, Shenoy KT, Banka NH, Bose K, Bohidar NP, Chakravartty K, et al. Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force.�Indian J Gastroenterol.�2008;27:22�28.�[PubMed]
8.�Bures J, Cyrany J, Kohoutova D, F�rstl M, Rejchrt S, Kvetina J, Vorisek V, Kopacova M. Small intestinal bacterial overgrowth syndrome.�World J Gastroenterol.�2010;16:2978�2990.�[PMC free article][PubMed]
9.�Dibaise JK, Young RJ, Vanderhoof JA. Enteric microbial flora, bacterial overgrowth, and short-bowel syndrome.�Clin Gastroenterol Hepatol.�2006;4:11�20.�[PubMed]
10.�Bouhnik Y, Alain S, Attar A, Flouri� B, Raskine L, Sanson-Le Pors MJ, Rambaud JC. Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome.�Am J Gastroenterol.�1999;94:1327�1331.�[PubMed]
11.�Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review.�Gastroenterol Hepatol (N Y)�2007;3:112�122.�[PMC free article]�[PubMed]
12.�Posserud I, Stotzer PO, Bj�rnsson ES, Abrahamsson H, Simr�n M. Small intestinal bacterial overgrowth in patients with irritable bowel syndrome.�Gut.�2007;56:802�808.�[PMC free article]�[PubMed]
13.�Ghoshal U, Ghoshal UC, Ranjan P, Naik SR, Ayyagari A. Spectrum and antibiotic sensitivity of bacteria contaminating the upper gut in patients with malabsorption syndrome from the tropics.�BMC Gastroenterol.�2003;3:9.�[PMC free article]�[PubMed]
14.�Carrara M, Desideri S, Azzurro M, Bulighin GM, Di Piramo D, Lomonaco L, Adamo S. Small intestine bacterial overgrowth in patients with irritable bowel syndrome.�Eur Rev Med Pharmacol Sci.�2008;12:197�202.�[PubMed]
15.�Ghoshal UC, Ghoshal U, Das K, Misra A. Utility of hydrogen breath tests in diagnosis of small intestinal bacterial overgrowth in malabsorption syndrome and its relationship with oro-cecal transit time.�Indian J Gastroenterol.�2006;25:6�10.�[PubMed]
16.�Ghoshal UC, Kumar S, Mehrotra M, Lakshmi C, Misra A. Frequency of small intestinal bacterial overgrowth in patients with irritable bowel syndrome and chronic non-specific diarrhea.�J Neurogastroenterol Motil.�2010;16:40�46.�[PMC free article]�[PubMed]
17.�Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome.�Am J Gastroenterol.�2000;95:3503�3506.�[PubMed]
18.�Sachdeva S, Rawat AK, Reddy RS, Puri AS. Small intestinal bacterial overgrowth (SIBO) in irritable bowel syndrome: frequency and predictors.�J Gastroenterol Hepatol.�2011;26 Suppl 3:135�138.�[PubMed]
19.�Park H. The role of small intestinal bacterial overgrowth in the pathophysiology of irritable bowel syndrome.�J Neurogastroenterol Motil.�2010;16:3�4.�[PMC free article]�[PubMed]
20.�Ghoshal UC, Shukla R, Ghoshal U, Gwee KA, Ng SC, Quigley EM. The gut microbiota and irritable bowel syndrome: friend or foe?�Int J Inflam.�2012;2012:151085.�[PMC free article]�[PubMed]
21.�Brown AC. Ulcerative colitis, Crohn�s disease and irritable bowel syndrome patients need fecal transplant research and treatment.�J Crohns Colitis.�2014;8:179.�[PubMed]
22.�Sampath K, Levy LC, Gardner TB. Fecal transplantation: beyond the aesthetic.�Gastroenterology.�2013;145:1151�1153.�[PubMed]
23.�Grace E, Shaw C, Whelan K, Andreyev HJ. Review article: small intestinal bacterial overgrowth–prevalence, clinical features, current and developing diagnostic tests, and treatment.�Aliment Pharmacol Ther.�2013;38:674�688.�[PubMed]
24.�Yakoob J, Abbas Z, Khan R, Hamid S, Awan S, Jafri W. Small intestinal bacterial overgrowth and lactose intolerance contribute to irritable bowel syndrome symptomatology in Pakistan.�Saudi J Gastroenterol.�2011;17:371�375.�[PMC free article]�[PubMed]
25.�Gwee KA, Bak YT, Ghoshal UC, Gonlachanvit S, Lee OY, Fock KM, Chua AS, Lu CL, Goh KL, Kositchaiwat C, et al. Asian consensus on irritable bowel syndrome.�J Gastroenterol Hepatol.�2010;25:1189�1205.�[PubMed]
26.�Lacy BE, Gabbard SL, Crowell MD. Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air?�Gastroenterol Hepatol (N Y)�2011;7:729�739.�[PMC free article]�[PubMed]
27.�Harder H, Serra J, Azpiroz F, Passos MC, Aguad� S, Malagelada JR. Intestinal gas distribution determines abdominal symptoms.�Gut.�2003;52:1708�1713.�[PMC free article]�[PubMed]
28.�Kumar S, Misra A, Ghoshal UC. Patients with irritable bowel syndrome exhale more hydrogen than healthy subjects in fasting state.�J Neurogastroenterol Motil.�2010;16:299�305.�[PMC free article][PubMed]
29.�Hungin AP, Mulligan C, Pot B, Whorwell P, Agr�us L, Fracasso P, Lionis C, Mendive J, Philippart de Foy JM, Rubin G, Winchester C, de Wit N. Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice — an evidence-based international guide.�Aliment Pharmacol Ther.�2013;38:864�886.�[PMC free article]�[PubMed]
30.�Attar A, Flouri� B, Rambaud JC, Franchisseur C, Ruszniewski P, Bouhnik Y. Antibiotic efficacy in small intestinal bacterial overgrowth-related chronic diarrhea: a crossover, randomized trial.�Gastroenterology.�1999;117:794�797.�[PubMed]
31.�Marcelino RT, Fagundes-Neto U. [Hydrogen test (H2) in the air expired for the diagnosis of small bowel bacterial overgrowth]�Arq Gastroenterol.�1995;32:191�198.�[PubMed]
32.�Santavirta J. Lactulose hydrogen and [14C]xylose breath tests in patients with ileoanal anastomosis.�Int J Colorectal Dis.�1991;6:208�211.�[PubMed]
33.�Ghoshal UC. How to interpret hydrogen breath tests.�J Neurogastroenterol Motil.�2011;17:312�317.[PMC free article]�[PubMed]
34.�Yang CY, Chang CS, Chen GH. Small-intestinal bacterial overgrowth in patients with liver cirrhosis, diagnosed with glucose H2 or CH4 breath tests.�Scand J Gastroenterol.�1998;33:867�871.�[PubMed]
35.�Ghoshal UC, Ghoshal U, Ayyagari A, Ranjan P, Krishnani N, Misra A, Aggarwal R, Naik S, Naik SR. Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time.�J Gastroenterol Hepatol.�2003;18:540�547.�[PubMed]
36.�Lu CL, Chen CY, Chang FY, Lee SD. Characteristics of small bowel motility in patients with irritable bowel syndrome and normal humans: an Oriental study.�Clin Sci (Lond)�1998;95:165�169.�[PubMed]
37.�Sciarretta G, Furno A, Mazzoni M, Garagnani B, Malaguti P. Lactulose hydrogen breath test in orocecal transit assessment. Critical evaluation by means of scintigraphic method.�Dig Dis Sci.�1994;39:1505�1510.�[PubMed]
38.�Rao SS, Camilleri M, Hasler WL, Maurer AH, Parkman HP, Saad R, Scott MS, Simren M, Soffer E, Szarka L. Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies.�Neurogastroenterol Motil.�2011;23:8�23.[PubMed]
39.�Yu D, Cheeseman F, Vanner S. Combined oro-caecal scintigraphy and lactulose hydrogen breath testing demonstrate that breath testing detects oro-caecal transit, not small intestinal bacterial overgrowth in patients with IBS.�Gut.�2011;60:334�340.�[PubMed]
40.�Rana SV, Sharma S, Sinha SK, Kaur H, Sikander A, Singh K. Incidence of predominant methanogenic flora in irritable bowel syndrome patients and apparently healthy controls from North India.�Dig Dis Sci.�2009;54:132�135.�[PubMed]
41.�Dridi B, Henry M, El Kh�chine A, Raoult D, Drancourt M. High prevalence of Methanobrevibacter smithii and Methanosphaera stadtmanae detected in the human gut using an improved DNA detection protocol.�PLoS One.�2009;4:e7063.�[PMC free article]�[PubMed]
42.�Chatterjee S, Park S, Low K, Kong Y, Pimentel M. The degree of breath methane production in IBS correlates with the severity of constipation.�Am J Gastroenterol.�2007;102:837�841.�[PubMed]
43.�Lunia MK, Sharma BC, Sachdeva S. Small intestinal bacterial overgrowth and delayed orocecal transit time in patients with cirrhosis and low-grade hepatic encephalopathy.�Hepatol Int.�2013;7:268�273.[PubMed]
44.�Resmini E, Parodi A, Savarino V, Greco A, Rebora A, Minuto F, Ferone D. Evidence of prolonged orocecal transit time and small intestinal bacterial overgrowth in acromegalic patients.�J Clin Endocrinol Metab.�2007;92:2119�2124.�[PubMed]
45.�Hamilton I, Worsley BW, Cobden I, Cooke EM, Shoesmith JG, Axon AT. Simultaneous culture of saliva and jejunal aspirate in the investigation of small bowel bacterial overgrowth.�Gut.�1982;23:847�853.[PMC free article]�[PubMed]
46.�Corazza GR, Sorge M, Strocchi A, Benati G, Di Sario A, Treggiari EA, Brusco G, Gasbarrini G. Non-absorbable antibiotics and small bowel bacterial overgrowth.�Ital J Gastroenterol.�1992;24:4�9.�[PubMed]
47.�Kuwahara T, Ogura Y, Oshima K, Kurokawa K, Ooka T, Hirakawa H, Itoh T, Nakayama-Imaohji H, Ichimura M, Itoh K, et al. The lifestyle of the segmented filamentous bacterium: a non-culturable gut-associated immunostimulating microbe inferred by whole-genome sequencing.�DNA Res.�2011;18:291�303.�[PMC free article]�[PubMed]
48.�Beumer RR, de Vries J, Rombouts FM. Campylobacter jejuni non-culturable coccoid cells.�Int J Food Microbiol.�1992;15:153�163.�[PubMed]
49.�Fromm H, Sarva RP, Ravitch MM, McJunkin B, Farivar S, Amin P. Effects of jejunoileal bypass on the enterohepatic circulation of bile acids, bacterial flora in the upper small intestine, and absorption of vitamin B12.�Metabolism.�1983;32:1133�1141.�[PubMed]
50.�Yoshida T, McCormick WC, Swell L, Vlahcevic ZR. Bile acid metabolism in cirrhosis. IV. Characterization of the abnormality in deoxycholic acid metabolism.�Gastroenterology.�1975;68:335�341.[PubMed]
51.�Bj�rneklett A, Fausa O, Midtvedt T. Bacterial overgrowth in jejunal and ileal disease.�Scand J Gastroenterol.�1983;18:289�298.�[PubMed]
52.�Vanner S. The small intestinal bacterial overgrowth. Irritable bowel syndrome hypothesis: implications for treatment.�Gut.�2008;57:1315�1321.�[PubMed]
53.�Kinross JM, von Roon AC, Holmes E, Darzi A, Nicholson JK. The human gut microbiome: implications for future health care.�Curr Gastroenterol Rep.�2008;10:396�403.�[PubMed]
54.�Clauw DJ. Fibromyalgia: an overview.�Am J Med.�2009;122:S3�S13.�[PubMed]
55.�Pimentel M, Wallace D, Hallegua D, Chow E, Kong Y, Park S, Lin HC. A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing.�Ann Rheum Dis.�2004;63:450�452.�[PMC free article]�[PubMed]
56.�Simr�n M, Stotzer PO. Use and abuse of hydrogen breath tests.�Gut.�2006;55:297�303.[PMC free article]�[PubMed]
57.�Gasbarrini A, Lauritano EC, Gabrielli M, Scarpellini E, Lupascu A, Ojetti V, Gasbarrini G. Small intestinal bacterial overgrowth: diagnosis and treatment.�Dig Dis.�2007;25:237�240.�[PubMed]
58.�Ghoshal UC, Srivastava D, Verma A, Misra A. Slow transit constipation associated with excess methane production and its improvement following rifaximin therapy: a case report.�J Neurogastroenterol Motil.�2011;17:185�188.�[PMC free article]�[PubMed]
59.�Bala L, Ghoshal UC, Ghoshal U, Tripathi P, Misra A, Gowda GA, Khetrapal CL. Malabsorption syndrome with and without small intestinal bacterial overgrowth: a study on upper-gut aspirate using 1H NMR spectroscopy.�Magn Reson Med.�2006;56:738�744.�[PubMed]
60.�Haboubi NY, Lee GS, Montgomery RD. Duodenal mucosal morphometry of elderly patients with small intestinal bacterial overgrowth: response to antibiotic treatment.�Age Ageing.�1991;20:29�32.�[PubMed]
61.�Shindo K, Machida M, Koide K, Fukumura M, Yamazaki R. Deconjugation ability of bacteria isolated from the jejunal fluid of patients with progressive systemic sclerosis and its gastric pH.�Hepatogastroenterology.�1998;45:1643�1650.�[PubMed]
62.�Wanitschke R, Ammon HV. Effects of dihydroxy bile acids and hydroxy fatty acids on the absorption of oleic acid in the human jejunum.�J Clin Invest.�1978;61:178�186.�[PMC free article]�[PubMed]
63.�Shanab AA, Scully P, Crosbie O, Buckley M, O�Mahony L, Shanahan F, Gazareen S, Murphy E, Quigley EM. Small intestinal bacterial overgrowth in nonalcoholic steatohepatitis: association with toll-like receptor 4 expression and plasma levels of interleukin 8.�Dig Dis Sci.�2011;56:1524�1534.�[PubMed]
64.�Ghoshal UC, Park H, Gwee KA. Bugs and irritable bowel syndrome: The good, the bad and the ugly.�J Gastroenterol Hepatol.�2010;25:244�251.�[PubMed]
65.�Barbara G, Stanghellini V, Brandi G, Cremon C, Di Nardo G, De Giorgio R, Corinaldesi R. Interactions between commensal bacteria and gut sensorimotor function in health and disease.�Am J Gastroenterol.�2005;100:2560�2568.�[PubMed]
66.�Cherbut C, Aub� AC, Blotti�re HM, Galmiche JP. Effects of short-chain fatty acids on gastrointestinal motility.�Scand J Gastroenterol Suppl.�1997;222:58�61.�[PubMed]
67.�Ramakrishna BS, Roediger WE. Bacterial short chain fatty acids: their role in gastrointestinal disease.�Dig Dis.�1990;8:337�345.�[PubMed]
68.�Dumoulin V, Moro F, Barcelo A, Dakka T, Cuber JC. Peptide YY, glucagon-like peptide-1, and neurotensin responses to luminal factors in the isolated vascularly perfused rat ileum.�Endocrinology.�1998;139:3780�3786.�[PubMed]
69.�Balsari A, Ceccarelli A, Dubini F, Fesce E, Poli G. The fecal microbial population in the irritable bowel syndrome.�Microbiologica.�1982;5:185�194.�[PubMed]
70.�Nobaek S, Johansson ML, Molin G, Ahrn� S, Jeppsson B. Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome.�Am J Gastroenterol.�2000;95:1231�1238.�[PubMed]
71.�Cummings JH, Macfarlane GT. The control and consequences of bacterial fermentation in the human colon.�J Appl Bacteriol.�1991;70:443�459.�[PubMed]
72.�Camilleri M. Probiotics and irritable bowel syndrome: rationale, mechanisms, and efficacy.�J Clin Gastroenterol.�2008;42 Suppl 3 Pt 1:S123�S125.�[PubMed]
73.�Spiller R. Probiotics: an ideal anti-inflammatory treatment for IBS?�Gastroenterology.�2005;128:783�785.�[PubMed]
74.�Ford AC, Spiegel BM, Talley NJ, Moayyedi P. Small intestinal bacterial overgrowth in irritable bowel syndrome: systematic review and meta-analysis.�Clin Gastroenterol Hepatol.�2009;7:1279�1286.�[PubMed]
75.�Cuoco L, Salvagnini M. Small intestine bacterial overgrowth in irritable bowel syndrome: a retrospective study with rifaximin.�Minerva Gastroenterol Dietol.�2006;52:89�95.�[PubMed]
76.�Di Stefano M, Corazza GR. Treatment of small intestine bacterial overgrowth and related symptoms by rifaximin.�Chemotherapy.�2005;51 Suppl 1:103�109.�[PubMed]
77.�Pimentel M, Lembo A, Chey WD, Zakko S, Ringel Y, Yu J, Mareya SM, Shaw AL, Bortey E, Forbes WP. Rifaximin therapy for patients with irritable bowel syndrome without constipation.�N Engl J Med.�2011;364:22�32.�[PubMed]
78.�Hwang L, Low K, Khoshini R, Melmed G, Sahakian A, Makhani M, Pokkunuri V, Pimentel M. Evaluating breath methane as a diagnostic test for constipation-predominant IBS.�Dig Dis Sci.�2010;55:398�403.�[PubMed]
79.�Low K, Hwang L, Hua J, Zhu A, Morales W, Pimentel M. A combination of rifaximin and neomycin is most effective in treating irritable bowel syndrome patients with methane on lactulose breath test.�J Clin Gastroenterol.�2010;44:547�550.�[PubMed]
80.�Bengmark S. Colonic food: pre- and probiotics.�Am J Gastroenterol.�2000;95:S5�S7.�[PubMed]
81.�Quigley EM, Quera R. Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics.�Gastroenterology.�2006;130:S78�S90.�[PubMed]
82.�Xiao SD, Zhang DZ, Lu H, Jiang SH, Liu HY, Wang GS, Xu GM, Zhang ZB, Lin GJ, Wang GL. Multicenter, randomized, controlled trial of heat-killed Lactobacillus acidophilus LB in patients with chronic diarrhea.�Adv Ther.�2003;20:253�260.�[PubMed]
83.�O’Mahony L, McCarthy J, Kelly P, Hurley G, Luo F, Chen K, O�Sullivan GC, Kiely B, Collins JK, Shanahan F, et al. Lactobacillus and bifidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles.�Gastroenterology.�2005;128:541�551.�[PubMed]
84.�Tsuchiya J, Barreto R, Okura R, Kawakita S, Fesce E, Marotta F. Single-blind follow-up study on the effectiveness of a symbiotic preparation in irritable bowel syndrome.�Chin J Dig Dis.�2004;5:169�174.[PubMed]
85.�Kim YG, Moon JT, Lee KM, Chon NR, Park H. [The effects of probiotics on symptoms of irritable bowel syndrome]�Korean J Gastroenterol.�2006;47:413�419.�[PubMed]
86.�Park JS, Yu JH, Lim HC, Kim JH, Yoon YH, Park HJ, Lee SI. [Usefulness of lactulose breath test for the prediction of small intestinal bacterial overgrowth in irritable bowel syndrome]�Korean J Gastroenterol.�2010;56:242�248.�[PubMed]
87.�Mann NS, Limoges-Gonzales M. The prevalence of small intestinal bacterial vergrowth in irritable bowel syndrome.�Hepatogastroenterology.�2009;56:718�721.�[PubMed]
88.�Scarpellini E, Giorgio V, Gabrielli M, Lauritano EC, Pantanella A, Fundar� C, Gasbarrini A. Prevalence of small intestinal bacterial overgrowth in children with irritable bowel syndrome: a case-control study.�J Pediatr.�2009;155:416�420.�[PubMed]
89.�Nucera G, Gabrielli M, Lupascu A, Lauritano EC, Santoliquido A, Cremonini F, Cammarota G, Tondi P, Pola P, Gasbarrini G, et al. Abnormal breath tests to lactose, fructose and sorbitol in irritable bowel syndrome may be explained by small intestinal bacterial overgrowth.�Aliment Pharmacol Ther.�2005;21:1391�1395.�[PubMed]
90.�Reddymasu SC, Sostarich S, McCallum RW. Small intestinal bacterial overgrowth in irritable bowel syndrome: are there any predictors?�BMC Gastroenterol.�2010;10:23.�[PMC free article]�[PubMed]
91.�Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy.�Clin Gastroenterol Hepatol.�2010;8:504�508.�[PubMed]
92.�Parodi A, Dulbecco P, Savarino E, Giannini EG, Bodini G, Corbo M, Isola L, De Conca S, Marabotto E, Savarino V. Positive glucose breath testing is more prevalent in patients with IBS-like symptoms compared with controls of similar age and gender distribution.�J Clin Gastroenterol.�2009;43:962�966.[PubMed]
93.�Rana SV, Sinha SK, Sikander A, Bhasin DK, Singh K. Study of small intestinal bacterial overgrowth in North Indian patients with irritable bowel syndrome: a case control study.�Trop Gastroenterol.�2008;29:23�25.�[PubMed]
94.�Majewski M, McCallum RW. Results of small intestinal bacterial overgrowth testing in irritable bowel syndrome patients: clinical profiles and effects of antibiotic trial.�Adv Med Sci.�2007;52:139�142.[PubMed]
95.�Lupascu A, Gabrielli M, Lauritano EC, Scarpellini E, Santoliquido A, Cammarota G, Flore R, Tondi P, Pola P, Gasbarrini G, et al. Hydrogen glucose breath test to detect small intestinal bacterial overgrowth: a prevalence case-control study in irritable bowel syndrome.�Aliment Pharmacol Ther.�2005;22:1157�1160.[PubMed]
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