Spinal Manipulation vs. Mobilization for Cervicogenic Headache in El Paso, TX

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Neck Pain, Randomized Controlled Trial

A primary headache is characterized as head pain caused by a headache disorder itself. The three types of primary headache disorders include, migraine, tension-type headaches and cluster headaches. Head pain is a painful and debilitating symptom that can also occur as a result of another underlying cause. A secondary headache is characterized as head pain which occurs due to an injury and/or condition. A spinal misalignment, or subluxation, along the cervical spine, or neck, is commonly associated with a variety of headache symptoms.

Cervicogenic headache is a secondary headache caused by an injury and/or condition affecting the surrounding structures of the cervical spine, or neck. Many healthcare professionals will recommend the use of drugs/medications to help improve headache, however, several alternative treatment options can be safely and effectively used to treat secondary headaches. The purpose of the following article is to demonstrate the impact of upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache.

Contents

Upper Cervical and Upper Thoracic Manipulation Versus Mobilization and Exercise in Patients with Cervicogenic Headache: a Multi-Center Randomized Clinical Trial

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Abstract

Background: Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH.
Methods: One hundred and ten participants (n?=?110) with CH were randomized to receive both cervical and thoracic manipulation (n?=?58) or mobilization and exercise (n?=?52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable.
Results: The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p?<?0.001) and disability (p?<?0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p?<?0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p?<?0.001).
Conclusions: Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.
Trial registration: NCT01580280 April 16, 2012.
Keywords: Cervicogenic headache, Spinal manipulation, Mobilization, High velocity low amplitude thrust

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

In comparison to primary headache, such as migraine, cluster headache and tension-type headache, secondary headache is characterized as head pain caused by another illness or physical issue. In the case of cervicogenic headache, the cause of head pain is due to an injury and/or condition along the cervical spine and its surrounding structures, including the vertebrae, intervertebral discs and soft tissues. In addition, many healthcare professionals believe that primary headache can be associated with health issues in the cervical spine, or neck. Cervicogenic headache treatment should target the source of the symptoms and it can vary depending on the patient. Chiropractic care utilizes spinal adjustments and manual manipulations to carefully restore the original structure and function of the spine, helping to reduce stress and pressure in order to improve cervicogenic headache symptoms, among other type of headache. Chiropractic care can also be utilized to help treat primary headaches, such as migraines.

Background

The International Classification of Headache Disorders defines cervicogenic headache (CH) as, �headache caused by a disorder of the cervical spine and its component bony, disc, and/or soft tissue elements, usually but not invariably accompanied by neck pain.� [1] (p.760) The prevalence of CH has been reported to be between 0.4 and 20 % of the headache population [2, 3], and as high as 53 % in patients with headache after whiplash injury [4]. The dominant features of CH usually include: unilaterality of head pain without side-shift, elicitation of pain with external pressure over the ipsilateral upper neck, limited cervical range of motion, and the triggering of attacks by various awkward or sustained neck movements [4, 5].

Individuals with CH are frequently treated with spinal manipulative therapy including both mobilization and manipulation [6]. Spinal mobilization consists of slow, rhythmical, oscillating techniques whereas manipulation consists of high-velocity low-amplitude thrust techniques. [7] In a recent systematic review, Bronfort and colleagues reported that spinal manipulative therapy (both mobilization and manipulation) were effective in the management of adults with CH [8]. However, they did not report if manipulation resulted in superior outcomes compared to mobilization for the management of this population.

Several studies have investigated the effect of spinal manipulation in the management of CH [9�13]. Haas et al. [10] investigated the effectiveness of cervical manipulation in subjects with CH. Jull et al. [11] demonstrated treatment efficacy for manipulative therapy and/or exercise in the management of CH. However the manipulative therapy group included manipulation and mobilization therefore it cannot be determined if the beneficial effect was a result of the manipulation, mobilization or the combination.

A few studies have examined the benefits of manipulation versus mobilization for the management of mechanical neck pain with or without exercise [14�16]. However, no studies have directly compared the effects of manipulation versus mobilization and exercise in patients with CH. Considering the purported risks of manipulation [17], it is essential to determine if manipulation results in improved outcomes compared to mobilization for the management of patients with CH. Therefore, the purpose of this randomized clinical trial was to compare the effects of manipulation versus mobilization and exercise in patients with CH. We hypothesized that patients receiving manipulation over a 4-week treatment period would experience greater reductions in headache intensity, headache frequency, headache duration, disability, and medication intake at a 3-month follow-up than patients receiving cervical and thoracic mobilization combined with exercise.

Methods

Participants

In this multi-center randomized clinical trial, consecutive patients with CH presenting to 1 of 8 outpatient physical therapy clinics from a variety of geographical locations (Arizona, Georgia, New York, Ohio, Pennsylvania, South Carolina) were recruited over a 29-month period (from April 2012 to August 2014). For patients to be eligible, they had to present with a diagnosis of CH according to the revised diagnostic criteria [5] developed by the Cervicogenic Headache International Study Group (CHISG) [5, 18, 19]. CH was classified according to the �major criteria� (not including confirmatory evidence by diagnostic anesthetic blockades) and �head pain characteristics� of the CHISG. Therefore, in order to be included in the study, patients had to exhibit all of the following criteria: (1) unilaterality of the head pain without sideshift, starting in the upper posterior neck or occipital region, eventually spreading to the oculofrontotemporal area on the symptomatic side, (2) pain triggered by neck movement and/or sustained awkward positions, (3) reduced range of motion in the cervical spine [20] (i.e., less than or equal to 32 � of right or left passive rotation on the Flexion-Rotation Test [21�23], (4) pain elicited by external pressure over at least one of the upper cervical joints (C0-3), and (5) moderate to severe, non-throbbing and non-lancinating pain. In addition, participants had to have a headache frequency of at least 1 per week for a minimum of 3 months, a minimum headache intensity pain score of two points (0�10 on the NPRS scale), a minimum disability score of 20 % or greater (i.e., 10 points or greater on the 0�50 NDI scale), and be between 18 and 65 years of age.

Patients were excluded if they exhibited other primary headaches (i.e., migraine, TTH), suffered from bilateral headaches, or exhibited any red flags (i.e., tumor, fracture, metabolic diseases, rheumatoid arthritis, osteoporosis, resting blood pressure greater than 140/90 mmHg, prolonged history of steroid use, etc.), presented with two or more positive neurologic signs consistent with nerve root compression (muscle weakness involving a major muscle group of the upper extremity, diminished upper extremity deep tendon reflex, or diminished or absent sensation to pinprick in any upper extremity dermatome), presented with a diagnosis of cervical spinal stenosis, exhibited bilateral upper extremity symptoms, had evidence of central nervous system involvement (hyperreflexia, sensory disturbances in the hand, intrinsic muscle wasting of the hands, unsteadiness during walking, nystagmus, loss of visual acuity, impaired sensation of the face, altered taste, the presence of pathological reflexes), had a history of whiplash injury within the previous 6 weeks, had prior surgery to the head or neck, had received treatment for head or neck pain from any practitioner within the previous month, had received physical therapy or chiropractic treatment for head or neck pain within the previous 3 months, or had pending legal action regarding their head or neck pain.

The most recent literature suggests that pre-manipulative cervical artery testing is unable to identify those individuals at risk of vascular complications from cervical manipulation [24, 25], and any symptoms detected during pre-manipulative testing may be unrelated to changes in blood flow in the vertebral artery [26, 27]. Hence, pre-manipulative cervical artery testing was not performed in this study; however, screening questions for cervical artery disease had to be negative [24, 28, 29]. This study was approved by the Institutional Review Board at Long Island University, Brooklyn, NY. The study was registered at www.clinicaltrials.gov with trial identifier NCT01580280. All patients were informed that they would receive either manipulation or mobilization and exercise and then provided informed consent before their enrollment in the study.

Treating Therapists

Twelve physical therapists (mean age 36.6 years, SD 5.62) participated in the delivery of treatment for patients in this study. They had an average of 10.3 (SD 5.66, range 3�20 years) years of clinical experience, and all had completed a 60 h post-graduate certification program that included practical training in manual techniques including the use of cervical and thoracic manipulation. To ensure all examination, outcome assessments, and treatment procedures were standardized, all participating physical therapists were required to study a manual of standard operating procedures and participate in a 4 h training session with the principal investigator.

Examination Procedures

All patients provided demographic information, completed the Neck Pain Medical Screening Questionnaire, and completed a number of self-report measures, followed by a standardized history and physical examination at baseline. Self-report measures included headache intensity as measured by the NPRS (0�10), the NDI (0�50), headache frequency (number of days with headache in the last week), headache duration (total hours of headache in the last week), and medication intake (number of times the patient had taken narcotic or over-the-counter pain medication in the past week).

The standardized physical examination was not limited to, but included measurements of C1-2 (atlanto-axial joint) passive right and left rotation ROM using the Flexion-Rotation Test (FRT). The inter-rater reliability for the FRT has been found to be excellent (ICC: 0.93; 95 % CI: 0.87, 0.96) [30].

Outcome Measures

The primary outcome measure used in this study was the patient�s headache intensity as measured by the NPRS. Patients were asked to indicate the average intensity of headache pain over the past week using an 11-point scale ranging from 0 (�no pain�) to 10 (�worst pain imaginable�) at baseline, 1-week, 1-month, and 3-months following the initial treatment session [31]. The NPRS is a reliable and valid instrument to assess pain intensity [32�34]. Although no data exists in patients with CH, the MCID for the NPRS has been shown to be 1.3 in patients with mechanical neck pain [32] and 1.74 in patients with a variety of chronic pain conditions [34]. Therefore, we chose to only include patients with an NPRS score of 2 points (20 %) or greater.

Secondary outcome measures included the NDI, the Global Rating of Change (GRC), headache frequency, headache duration, and medication intake. The NDI is the most widely used instrument for assessing self-rated disability in patients with neck pain [35�37]. The NDI is a self-report questionnaire with 10-items rated from 0 (no disability) to five (complete disability) [38]. The numeric responses for each item are summed for a total score ranging between 0 and 50; however, some evaluators have chosen to multiply the raw score by two, and then report the NDI on a 0�100 % scale [36, 39]. Higher scores represent increased levels of disability. The NDI has been found to possess excellent test-retest reliability, strong construct validity, strong internal consistency and good responsiveness in assessing disability in patients with mechanical neck pain [36], cervical radiculopathy [33, 40], whiplash associated disorder [38, 41, 42], and mixed non-specific neck pain [43, 44]. Although no studies have examined the psychometric properties of the NDI in patients with CH, we chose to only include patients with an NDI score of ten points (20 %) or greater, because this cut-off score captures the MCID for the NDI, which has been reported to approximate four, eight, and nine points (0�50) in patients with mixed non-specific neck pain [44], mechanical neck pain [45], and cervical radiculopathy [33], respectively. Headache frequency was measured as the number of days with headache in the last week, ranging from 0 to 7 days. Headache duration was measured as the total hours of headache in the last week, with six possible ranges: (1) 0�5 h, (2) 6�10 h, (3) 11�15 h, (4) 16�20 h, (5) 21�25 h, or (6) 26 or more hours. Medication intake was measured as the number of times the patient had taken prescription or over-the-counter analgesic or anti-inflammatory medication in the past week for their headaches, with five options: (1) not at all, (2) once a week, (3) once every couple of days, (4) once or twice a day, or (5) three or more times a day.

Patients returned for 1-week, 4-weeks, and 3-months follow-ups where the aforementioned outcome measures were again collected. In addition, at the 1-week, 4-weeks and 3-months follow-ups, patients completed a 15-point GRC question based on a scale described by Jaeschke et al. [46] to rate their own perception of improved function. The scale ranges from -7 (a very great deal worse) to zero (about the same) to +7 (a very great deal better). Intermittent descriptors of worsening or improving are assigned values from -1 to -6 and +1 to +6, respectively. The MCID for the GRC has not been specifically reported but scores of +4 and +5 have typically been indicative of moderate changes in patient status [46]. However, it should be noted that recently Schmitt and Abbott reported that the GRC might not correlate with changes in function in a population with hip and ankle injuries [47]. All outcome measures were collected by an assessor blind to group assignment.

On the initial visit patients completed all outcome measures then received the first treatment session. Patients completed 6�8 treatment sessions of either manipulation or mobilization combined with exercise over 4 weeks. Additionally, subjects were asked if they had experienced any �major� adverse events [48, 49] (stroke or permanent neurological deficits) at each follow-up period.

Randomization

Following the baseline examination, patients were randomly assigned to receive either manipulation or mobilization and exercise. Concealed allocation was performed by using a computer-generated randomized table of numbers created by an individual not involved with recruiting patients prior to the beginning of the study. Individual, sequentially numbered index cards with the random assignment were prepared for each of 8 data collection sites. The index cards were folded and placed in sealed opaque envelopes. Blinded to the baseline examination, the treating therapist opened the envelope and proceeded with treatment according to the group assignment. Patients were instructed not to discuss the particular treatment procedure received with the examining therapist. The examining therapist remained blind to the patient�s treatment group assignment at all times; however, based on the nature of the interventions it was not possible to blind patients or treating therapists.

Manipulation Group

Manipulations targeting the right and left C1-2 articulations and bilateral T1-2 articulations were performed on at least one of the 6�8 treatment sessions (Figs. 1 and ?and2).2). On other treatment sessions, therapists either repeated the C1-2 and/or T1-2 manipulations or targeted other spinal articulations (i.e., C0-1, C2-3, C3-7, T2-9, ribs 1�9) using manipulation. The selection of the spinal segments to target was left to the discretion of the treating therapist and it was based on the combination of patient reports and manual examination. For both the upper cervical and upper thoracic manipulations, if no popping or cracking sound was heard on the first attempt, the therapist repositioned the patient and performed a second manipulation. A maximum of 2 attempts were performed on each patient similar to other studies [14, 50�53]. The clinicians were instructed that the manipulations are likely to be accompanied by multiple audible popping sounds [54�58]. Patients were encouraged to maintain usual activity within the limits of pain; however, mobilization and the prescription of exercises, or any use of other modalities, were not provided to this group.

Figure 1 HVLA Thrust Manipulation Directed to the right C1-2 Articulation | El Paso, TX Chiropractor

Figure 2 HVLA Thrust Manipulation Directed Bilaterally to the Upper Thoracic Spine | El Paso, TX Chiropractor

The manipulation targeting C1-2 was performed with the patient in supine. For this technique, the patient�s left posterior arch of the atlas was contacted with the lateral aspect of the proximal phalanx of the therapist�s left second finger using a �cradle hold�. To localize the forces to the left C1-2 articulation, the patient was positioned using extension, a posterior-anterior (PA) shift, ipsilateral side-bend and contralateral side-shift. While maintaining this position, the therapist performed a single high-velocity, low-amplitude thrust manipulation to the left atlanto-axial joint using right rotation in an arc toward the underside eye and translation toward the table (Fig. 1). This was repeated using the same procedure but directed to the right C1-2 articulation.

The manipulation targeting T1-2 was performed with the patient in supine. For this technique, the patient held her/his arms and forearms across the chest with the elbows aligned in a superoinferior direction. The therapist contacted the transverse processes of the lower vertebrae of the target motion segment with the thenar eminence and middle phalanx of the third digit. The upper lever was localized to the target motion segment by adding rotation away and side-bend towards the therapist while the underside hand used pronation and radial deviation to achieve rotation toward and side-bend away moments, respectively. The space inferior to the xiphoid process and costochondral margin of the therapist was used as the contact point against the patient�s elbows to deliver a manipulation in an anterior to posterior direction targeting T1-2 bilaterally (Fig. 2).

Mobilization and Exercise Group

Mobilizations targeting the right and left C1-2 articulations and bilateral T1-2 articulations were performed on at least one of the 6�8 treatment sessions. On other treatment sessions, therapists either repeated the C1-2 and/or T1-2 mobilizations or targeted other spinal articulations (i.e., C0-1, C2/3, C3-7, T2-9, ribs 1�9) using mobilization. The selection of the spinal segments to target was left to the discretion of the treating therapist and it was based on the combination of patient reports and manual examination. However, in order to avoid a �contact� or �attention effect� when compared with the manipulation group, therapists were instructed to mobilize one cervical segment (i.e., right and left) and one thoracic segment or rib articulation on each treatment session.

The mobilization targeting the C1-2 articulation was performed in prone. For this technique, the therapist performed one 30 s bout of left-sided unilateral grade IV PA mobilizations to the C1-2 motion segment as described by Maitland [7]. This same procedure was repeated for one 30 s bout to the right atlanto-axial joint. In addition, and on at least one session, mobilization directed to the upper thoracic (T1-2) spine with the patient prone was performed. For this technique, the therapist performed one 30 s bout of central grade IV PA mobilizations to the T1-2 motion segment as described by Maitland [7]. Therefore, we used 180 (i.e., three 30 s bouts at approximately 2 Hz) end-range oscillations in total on each subject for the mobilization treatment. Notably, there is no high quality evidence to date to suggest that longer durations of mobilization result in greater pain reduction than shorter durations or dosages of mobilization [59, 60].

Cranio-cervical flexion exercises [11, 61�63] were performed with the patient in supine, with the knees bent and the position of the head standardized by placing the craniocervical and cervical spines in a mid-position, such that a line between the subject�s forehead and chin was horizontal, and a horizontal line from the tragus of the ear bisected the neck longitudinally. An air-filled pressure biofeedback unit (Chattanooga Group, Inc., Hixson, TN) was placed suboccipitally behind the patient�s neck and preinflated to a baseline of 20 mmHg [63]. For the staged exercises, patients were required to perform the craniocervical flexion action (�a nod of the head, similar to indicating yes�) [63] and attempt to visually target pressures of 22, 24, 26, 28, and 30 mmHg from a resting baseline of 20 mmHg and to hold the position steady for 10 s [61, 62]. The action of nodding was performed in a gentle and slow manner. A 10 s rest was allowed between trials. If the pressure deviated below the target pressure, the pressure was not held steady, substitution with the superficial flexors (sternocleidomastoid or anterior scalene) occurred, or neck retraction was noticed before the completion of the 10 s isometric hold, it was regarded as a failure [63]. The last successful target pressure was used to determine each patient�s exercise level wherein 3 sets of 10 repetitions with a 10 s isometric hold were performed. In addition to mobilizations and cranio-cervical flexion exercises, patients were required to perform 10 min of progressive resistance exercises (i.e., using Therabands� or free weights) to the muscles of the shoulder girdle during each treatment session, within their own tolerance, and specifically focusing on the lower trapezius and serratus anterior [11].

Sample Size

The sample size and power calculations were performed using online software from the MGH Biostatistics Center (Boston, MA). The calculations were based on detecting a 2-point (or 20 %) difference in the NPRS (headache intensity) at the 3 months follow-up, assuming a standard deviation of three points, a 2-tailed test, and an alpha level equal to 0.05. This generated a sample size of 49 patients per group. Allowing for a conservative dropout rate of 10 %, we planned to recruit at least 108 patients into the study. This sample size yielded greater than 90 % power to detect a statistically significant change in the NPRS scores.

Data Analysis

Descriptive statistics, including frequency counts for categorical variables and measures of central tendency and dispersion for continuous variables were calculated to summarize the data. The effects of treatment on headache intensity and disability were each examined with a 2-by-4 mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between-subjects variable and time (baseline, 1 week, 4 weeks, and 3 months follow-up) as the within-subjects variable. Separate ANOVAs were performed with the NPRS (headache intensity) and NDI (disability) as the dependent variable. For each ANOVA, the hypothesis of interest was the 2-way interaction (group by time).

An independent t-test was used to determine the between group differences for the percentage change from baseline to 3-month follow-up in both headache intensity and disability. Separate Mann�Whitney U tests were performed with the headache frequency, GRC, headache duration and medication intake as the dependent variable. We performed Little�s Missing Completely at Random (MCAR) test [64] to determine if missing data points associated with dropouts were missing at random or missing for systematic reasons. Intention-to-treat analysis was performed by using Expectation-Maximization whereby missing data are computed using regression equations. Planned pairwise comparisons were performed examining the difference between baseline and follow-up periods between-groups using the Bonferroni correction at an alpha level of .05.

We dichotomized patients as responders at the 3-month follow-up using a cut score of 2 points improvement for headache intensity as measured by the NPRS. Numbers needed to treat (NNT) and 95 % confidence intervals (CI) were also calculated at the 3 months follow-up period using each of these definitions for a successful outcome. Data analysis was performed using SPSS 21.0.

Results

Two hundred and fifty-one patients with a primary complaint of headaches were screened for possible eligibility. The reasons for ineligibility can be found in Fig. 3, the flow diagram of patient recruitment and retention. Of the 251 patients screened, 110 patients, with a mean age of 35.16 years (SD 11.48) and a mean duration of symptoms of 4.56 years (SD 6.27), satisfied the eligibility criteria, agreed to participate, and were randomized into manipulation (n?=?58) and mobilization and exercise (n?=?52) groups. Baseline variables for each group can be found in Table 1. Twelve therapists from 8 outpatient physical therapy clinics each treated 25, 23, 20, 14, 13, 7, 6 or 2 patients, respectively; furthermore, each of the 12 therapists treated approximately an equal proportion of patients in each group. There was no significant difference (p?=?0.227) between the mean number of completed treatment sessions for the manipulation group (7.17, SD 0.96) and the mobilization and exercise group (6.90, SD 1.35). In addition, the mean number of treatment sessions that targeted the C1-2 articulation was 6.41 (SD 1.63) for the manipulation group and 6.52 (SD 2.01) for the mobilization and exercise group, and this was not significantly different (p?=?0.762). One hundred seven of the 110 patients completed all outcome measures through 3 months (97 % follow-up). Little�s Missing Completely at Random (MCAR) test was not statistically significant (p?=?0.281); therefore, we used the Expectation-Maximization imputation technique to replace missing values with predicted values for the missing 3-month outcomes.

Figure 3 Flow Diagram of Patient Recruitment and Retention | El Paso, TX Chiropractor

Table 1 Baseline Variables, Demographics and Outcome Measures | El Paso, TX Chiropractor

The overall group by time interaction for the primary outcome of headache intensity was statistically significant for the NPRS (F(3,106)?=?11.196; p?<?0.001; partial eta squared?=?0.24). Between-group differences revealed that the manipulation group experienced statistically significant greater improvement in the NPRS at both the 1-week (2.1, 95 % CI: 1.2, 2.9), 4-week (2.3, 95 % CI: 1.5, 3.1) and 3-month (2.1, 95 % CI: 1.2, 3.0) follow-up periods (Table 2). In addition, an independent samples t-test revealed the between-group difference in percentage change in headache intensity (36.58 %, 95 % CI: 22.52, 50.64) from baseline to 3-month follow-up was statistically significant (t(108)?=?5.156; p?<?0.001) in favor of manipulation. See Table 3 for the percentage of subjects gaining 50, 75, and 100 % reduction in headache intensity at 3 months.

Table 2 Changes in Headache Intensity and Disability | El Paso, TX Chiropractor

Table 3 Percentage of Subjects Gaining 50, 75, and 100 Percent Reduction | El Paso, TX Chiropractor

For secondary outcomes a significant group by time interaction existed for the NDI (F(3,106)?=?8.57; p?<?0.001; partial eta squared?=?0.20). At each follow-up period the manipulation group had superior outcomes in disability reduction as compared to the mobilization and exercise group. An independent samples t- test revealed the between-group mean percentage change in disability (35.56 %, 95 % CI: 24.95, 46.17) from baseline to 3 months follow-up was statistically significant (t(108)?=?6.646, p?<?0.001); indicating the manipulation group experienced a significantly greater percentage in disability reduction (Table 3).

Mann�Whitney U tests revealed that patients in the upper cervical and upper thoracic manipulation group experienced less frequent headaches at 1 week (p?<?0.001; median 2.0 versus 3.0), 4 weeks (p?<?0.001; median 1.0 versus 3.0) and 3 months (p?<?0.001; median 1.0 versus 2.5) than patients in the mobilization and exercise group. Headache duration was significantly lower at 1 week (p?=?0.005; median 2.0 versus 3.0, 4 weeks (p?<?0.001; median 1.0 versus 2.0) and 3 months (p?<?0.001; median 1.0 versus 2.0) in the manipulation group. Additionally, patient perceived improvement as measured by the GRC was significantly greater at 1 week (p?<?0.001, 4.0 versus 1.0), 4 weeks (p?<?0.001, 6.0 versus 3.0) and 3 months (p?<?0.001, 6.0 versus 3.0) than patients in the mobilization and exercise group. At 3 months, patients receiving upper cervical and upper thoracic manipulation experienced significantly (p?<?0.001) greater reductions in medication intake as compared to the mobilization and exercise group. Based on the cutoff score of 2 points on the NPRS, the NNT was 4.0 (95 % CI: 2.3, 7.7) in favor of the manipulation group at 3-month follow-up.

We did not collect any data on the occurrence of �minor� adverse events [48, 49] (transient neurological symptoms, increased stiffness, radiating pain, fatigue or other); however, no �major� adverse events [48, 49] (stroke or permanent neurological deficits) were reported for either group.

Discussion

Statement of Principal Findings

To our knowledge, this study is the first randomized clinical trial to directly compare the effectiveness of both cervical and thoracic manipulation to mobilization and exercise in patients with CH. The results suggest 6�8 sessions of manipulation over 4 weeks, directed mainly to both the upper cervical (C1-2) and upper thoracic (T1-2) spines, resulted in greater improvements in headache intensity, disability, headache frequency, headache duration, and medication intake than mobilization combined with exercises. The point estimates for between-group changes in headache intensity (2.1 points) and disability (6.0 points or 12.0 %) exceeded the reported MCIDs for both measures. Although the MCID for the NDI in patients with CH has not yet been investigated, it should however be noted that the lower bound estimate of the 95 % CI for disability (3.5 points) was slightly below (or approximated in two cases) the MCID that has been found to be 3.5 [65], 5 [66], and 7.5 [45] points in patients with mechanical neck pain, 8.5 [33] points in patients with cervical radiculopathy, and 3.5 [44] points in patients with mixed, non-specific neck pain. However, it should be recognized that both groups made clinical improvement. In addition, the NNT suggests for every four patients treated with manipulation, rather than mobilization, one additional patient achieves clinically important pain reduction at 3 months follow-up.

Strengths and Weaknesses of the Study

The inclusion of 12 treating physical therapists from 8 private clinics in 6 different geographical states enhances the overall generalizability of our findings. Although significant differences were recognized up to 3 months, it is not known if these benefits would have been sustained at long-term. In addition, we used high-velocity, low-amplitude manipulation techniques that employed bidirectional thrusts into rotation and translation simultaneously and Maitland based grade IV PA mobilization techniques; thus, we cannot be certain that these results are generalizable to other kinds of manual therapy techniques. Some might argue that the comparison group might have not received adequate intervention. We sought to balance internal and external validity so standardized treatment for both groups and provided a very explicit description of the techniques used which will also allow for replication. Furthermore, we did not measure minor adverse events and only asked about two potential major adverse events. Another limitation is that we included multiple secondary outcomes. Therapist preferences as to which technique they thought would be superior was not collected and potentially could impact the results.

Strengths and Weaknesses in Relation to Other Studies: Important Differences in Results

Jull et al. [11] demonstrated treatment efficacy for manipulative therapy and exercise in the management of CH; however, this treatment package included both mobilization and manipulation. The current study may provide evidence that the management of patients with CH should include some form of manipulation despite the fact it is often suggested that cervical manipulation should be avoided because of the risk of serious adverse events [67, 68]. Furthermore, it has been shown that individuals receiving spinal manipulation for neck pain and headaches are no more likely to experience a vertebrobasilar stroke than if they received treatment by their medical physician [69]. Additionally, after reviewing 134 case reports, Puentedura et al. concluded that with appropriate selection of patients by careful screening of red flags and contraindications, the majority of adverse events associated with cervical manipulation could have been prevented [70].

Meaning of the Study: Possible Explanations and Implications for Clinicians and Policymakers

Based on the results of the current study clinicians should consider incorporating spinal manipulation for individuals with CH. A recent systematic review found both mobilization and manipulation to be effective for the management of patients with CH but was unable to determine which technique was superior [8]. Additionally, clinical guidelines reported that manipulation, mobilization and exercise were all effective for the management of patients with CH; however, the guideline made no suggestions regarding the superiority of either technique. [71] The current results may assist authors of future systematic reviews and clinical guidelines in providing more specific recommendations about the use of spinal manipulation in this population.

Unanswered Questions and Future Research

The underlying mechanisms as to why manipulation may have resulted in greater improvements remains to be elucidated. It has been suggested that high-velocity displacement of vertebrae with impulse durations of less than 200 ms may alter afferent discharge rates [72] by stimulating mechanoreceptors and proprioceptors, thereby changing alpha motorneuron excitability levels and subsequent muscle activity [72�74]. Manipulation might also stimulate receptors in the deep paraspinal musculature, and mobilization might be more likely to facilitate receptors in the superficial muscles [75]. Biomechanical [76, 77], spinal or segmental [78, 79] and central descending inhibitory pain pathway [80�83] models are plausible explanations for the hypoalgesic effects observed following manipulation. Recently, the biomechanical effects of manipulation have been under scientific scrutiny [84], and it is plausible that the clinical benefits found in our study are associated with a neurophysiological response involving temporal sensory summation at the dorsal horn of the spinal cord [78]; however, this proposed model is currently supported only on findings from transient, experimentally induced pain in healthy subjects [85, 86], not patients with CH. Future studies should examine different manual therapy techniques with varying dosages and include a 1-year follow-up. Furthermore, future studies examining the neurophysiological effects of both manipulation and mobilization will be important for determining why there may or may not be a difference in clinical effects between these two treatments.

Conclusion

The results of the current study demonstrated that patients with CH who received cervical and thoracic manipulation experienced significantly greater reductions in headache intensity, disability, headache frequency, headache duration, and medication intake as compared to the group that received mobilization and exercise; furthermore, the effects were maintained at 3 months follow-up. Future studies should examine the effectiveness of different types and dosages of manipulation and include a long-term follow-up.

Acknowledgements

None of the authors received any funding for this study. The authors wish to thank all the participants of the study.

Footnotes

Competing interests: Dr. James Dunning is the President of the American Academy of Manipulative Therapy (AAMT). AAMT provides postgraduate training programs in spinal manipulation, spinal mobilization, dry needling, extremity manipulation, extremity mobilization, instrument-assisted soft-tissue mobilization and therapeutic exercise to licensed physical therapists, osteopaths and medical doctors. Drs. James Dunning, Raymond Butts, Thomas Perreault, and Firas Mourad are senior instructors for AAMT. The other authors declare that they have no competing interests.
Authors� contributions: JRD participated in the conception, design, data acquisition, statistical analyses and drafting of the manuscript. RB and IY participated in the design, data collection, statistical analyses and revision of the manuscript. FM participated in the design, statistical analyses, data interpretation and revision of the manuscript. MH participated in the conception, design and revision of the manuscript. CF and JC were involved in the statistical analyses, interpretation of data, and critical revision of the manuscript for important intellectual content. TS, JD, DB, and TH were involved in data collection and revision of the manuscript. All authors read and approved the final manuscript.

Contributor Information

Ncbi.nlm.nih.gov/pmc/articles/PMC4744384/

In conclusion,�head pain caused by secondary headache due to a health issue along the surrounding structures of the cervical spine, or neck, can cause painful and debilitating symptoms which can affect the patient’s quality of life. Spinal manipulation and mobilization can be safely and effectively utilized to help improve cervicogenic headache symptoms. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

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

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EXTRA IMPORTANT TOPIC: Migraine Pain Treatment

Lower Back Pain During Pregnancy Treatment El Paso, TX | Video

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Back Pain, Case Control Studies, Conditions Treated, Injury Care, Lower Back Pain, Testimonies

Truide Torres, office manager, first received chiropractic care with Dr. Alex Jimenez during her pregnancy for her lower back pain. Mrs. Torres experienced aggravating symptoms throughout the progression of her pregnancy, which led her to seek a natural treatment approach for her own health as well as that of her own baby. Once Truide Torres started chiropractic treatment with Dr. Alex Jimenez, she recovered her quality of life and was able to return to her original state of well-being. As an office manager, Truide Torres also receives regular chiropractic care for any lower back pain which may occur as a result of her job. Mrs. Truide expresses how important it is to continue her spinal maintenance and she highly recommends Dr. Alex Jimenez as the non-surgical choice for a variety of health issues.

Low back pain (LBP) is a frequent health issue involving the muscles, nerves, and bones of the spine. Pain may differ from a dull persistent pain to a sudden sharp sensation. Low back pain can be classified by length and severity (pain lasting less than 6 months), sub-chronic (6 to 12 months), or chronic (over 12 months). The status could be further categorized by the underlying cause as both bodily, non-mechanical, or referred pain. The symptoms of low back pain may generally improve in a couple weeks from the time they begin, however, some cases may require additional treatment. In the majority of episodes of lower back pain, a specific underlying cause isn’t identified or properly cared for, and healthcare professionals may attribute it to mechanical issues like joint or muscle strain.

Prenatal Yoga Exercises For Low Back Pain

Back Clinic News Extra: Migraine Pain Treatment With Chiropractic

Damaris Foreman suffered from migraines for about 23 years. After receiving traditional treatment for her migraine pain without much improvement, she was finally recommended to seek migraine pain treatment with Dr. Alex Jimenez, a chiropractor in El Paso, TX. Damaris greatly benefitted from chiropractic care and she experienced a tremendous sense of relief following her first spinal adjustment and manual manipulation. Damaris Foreman was able to confront many of her misconceptions and she learned very much about her migraine pain. Damaris describes Dr. Alex Jimenez’s migraine pain treatment as one of the best treatment she’s received and she highly recommends chiropractic care as the best non-surgical choice for improving and managing her migraines.

A migraine can be identified as a primary headache disorder characterized by recurrent headaches characterized from moderate to severe in intensity. Typically, the headaches affect one half of the head, are pulsating in nature, and can last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. The pain may be aggravated by physical activity. Up to one-third of people who suffer from migraines experience migraine with aura: typically a brief period of visual disturbance that signals that the headache will soon happen. An aura can occur with little or no headache pain following it.

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Lifestyle Change Vs. Diets In El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Diets, Nutrition

Diets: The statistics are sobering. The typical American diet far exceeds the daily recommended intake levels in calories from sugars and solid fats, sodium, refined grains, and saturated fat. It is also lacking in the recommended amounts of fruits, vegetables, dairy, whole grains, and oils. The result is obesity and experts project that by 2030, in the United States alone, half of all adults will be obese.

That�s when people start dieting � and that is what gets them into trouble.

Contents

Diet vs. Lifestyle Change

Bottom line, diets are temporary. There are some serious consequences that can come from dieting, especially fad or crash diets. The effects of these types of diets can also seriously impact your chiropractic care, hindering your progress.

Also, because diets are temporary, once you return to your regular eating habits the weight usually comes back.

A lifestyle change is a far better choice. It involves making smart, healthy eating choices � choices that you maintain for the rest of your life. This also impacts your chiropractic care by strengthening your body and keeping it healthy so that it is in an optimal state for healing and responds well to treatment.

Types Of Diets

There are all sorts of diets out there. Some are blatantly unhealthy but others are sneaky. They come with claims of being healthy, of being created or endorsed by doctors, or include tons of vitamin supplements but very limited food intake. It is important to be able to spot these destructive fad diets so you don�t get suckered into their hype.

Some of the most common types of fad diets include high protein, low or no carb, liquid, cabbage, grapefruit, broth or juice, and food combining. Some of these can cause serious health problems including vital organ damage. Others can cause vitamin deficiencies and dehydration. None of them can (or should) be maintained over a long period of time, much less the rest of your life.

The Dangers Of Diets

Unhealthy dieting can come with some pretty scary dangers. Because they typically omit key foods or food groups your body can become imbalanced. Some of the dangers of dieting include dehydration, fatigue, weakness, vitamin and mineral deficiency, headaches, nausea, diarrhea, constipation, mental fogginess, loss of muscle mass, organ damage, and even heart attack and stroke.

One popular diet restricts carbs, often cutting them out completely. This includes all whole grains (which have vital minerals and fiber) as well as many fruits and vegetables. The result is a diet that is mostly protein and fat.

While the dieter may lose some weight on this plan, it is at a great cost. The extremely high intake of protein which exceeds the levels that the body should have can cause liver and kidney failure. The omission of vital grains, fruits, and vegetables can lead to serious vitamin deficiencies while the increased fat intake can lead to heart attack and stroke.

If a diet eliminates any of the key foods (lean meats, whole grains, fruits, and vegetables), it advocates losing more than 2 or 3 pounds a week, or it restricts caloric intake to less than 1,200 calories a day it is potentially unhealthy and should only be done 1) under a doctor�s close supervision, and 2) on a very temporary basis.

Healthy Eating Is A Lifestyle

When you make the life changing commitment to adopt a healthy eating lifestyle you open yourself up to a world of better health, more energy, and better focus. Your body will heal faster and you will feel better.

A diet of fresh fruits and vegetables, lean meats, fresh fish, and whole grains, along with lots of water should become a way of life. It is far healthier than the temporary diets that are out there and more effective too.

If you or a loved one need additional dietary guidance, give us a call. Our Doctor of Chiropractic is here to help!

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Chiropractic Headache Treatment Guidelines in El Paso, TX

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Randomized Controlled Trial

Headache pain is one of the most prevalent reasons for doctor office visits. The majority of people experience them at some point in their life and they can affect anyone, regardless of age, race and gender. The International Headache Society, or IHS, categorizes headaches as primary, when they are not caused by another injury and/or condition, or secondary, when there is an underlying cause behind them. From migraines to cluster headaches and tension headaches, people who suffer from constant head pain may find it difficult to participate in their everyday activities. Many healthcare professionals treat headache pain, however, chiropractic care has become a popular alternative treatment option for a variety of health issues. The purpose of the following article is to demonstrate evidence-based guidelines for the chiropractic treatment of adults with headache.

Evidence-Based Guidelines for the Chiropractic Treatment of Adults with Headache

Abstract

Objective: The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults.
Methods: Systematic literature searches of controlled clinical trials published through August 2009 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations.
Results: Twenty-one articles met inclusion criteria and were used to develop recommendations. Evidence did not exceed a moderate level. For migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache. A recommendation cannot be made for or against the use of spinal manipulation for patients with chronic tension-type headache. Low-load craniocervical mobilization may be beneficial for longer term management of patients with episodic or chronic tension-type headaches. For cervicogenic headache, spinal manipulation is recommended. Joint mobilization or deep neck flexor exercises may improve symptoms. There is no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor.
Conclusions: Evidence suggests that chiropractic care, including spinal manipulation, improves migraine
and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal. (J Manipulative Physiol Ther 2011;34:274-289)
Key Indexing Terms: Spinal Manipulation; Migraine Disorders; Tension-Type Headache; Post-traumatic Headache; Practice Guideline; Chiropractic

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Headache, or head pain, including migraine and other types of headaches, is one of the most common types of pain reported among the general population. These may occur on one or both sides of the head, can be isolated to a specific location or they may radiate across the head from one point. While headache symptoms can vary depending on the type of head pain as well as due to the source of the health issue, headaches are considered to be a general complaint regardless of their severity and form. Headache, or head pain, may occur as a result of spinal misalignment, or subluxation, along the length of the spine. Through the use of spinal adjustments and manual manipulations, chiropractic care can safely and effectively realign the spine, reducing stress and pressure on the surrounding structures of the spine, to ultimately help improve migraine headache pain symptoms as well as overall health and wellness.

Headache is a common experience in adults. Recurring headaches negatively impact family life, social activity, and work capacity.[1,2] Worldwide, according to the World Health Organization, migraine alone is 19th among all causes of years lived with disability. Headache is third among reasons for seeking chiropractic care in North America.[3]

Accurate diagnosis is key to management and treatment, and a wide range of headache types are described in the International Classification of Headache Disorders 2 (International Headache Society [IHS]).[4] The categories are intended for clinical as well as research use. The most common headaches, tension-type and migraine, are considered primary headaches that are episodic or chronic in nature. Episodic migraine or tension-type headaches occur fewer than 15 days per month, whereas chronic headaches occur more than 15 days per month for at least 3 (migraine) or 6 months (tension-type headache).[4] Secondary headaches are attributed to underlying clinical problems in the head or neck that may also be episodic or chronic. Cervicogenic headaches are secondary headaches commonly treated by chiropractors and involve pain referred from a source in the neck and perceived in 1 or more regions of the head. The IHS recognizes cervicogenic headache as a distinct disorder,[4] and evidence that headache can be attributed to a neck disorder or lesion based on history and clinical features (history of neck trauma, mechanical exacerbation of pain, reduced cervical range of motion, and focal neck tenderness, excluding myofascial pain alone) is relevant to diagnosis but is not without controversy in the literature.[4,5] When myofascial pain alone is the cause, the patient should be managed as having tension-type headaches.[4]

Treatment modalities typically used by chiropractors to care for patients with headaches include spinal manipulation, mobilization, device-assisted spinal manipulation, education about modifiable lifestyle factors, physical therapy modalities, heat/ice, massage, advanced soft tissue therapies such as trigger point therapy, and strengthening and stretching exercises. There is a growing expectation for health professions, including chiropractic, to adopt and use research-based knowledge, taking sufficient account of the quality of available research evidence to inform clinical practice. As a result, the purpose of the Canadian Chiropractic Association (CCA) and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (Federation) Clinical Practice Guidelines Project is to develop guidelines for practice based on available evidence. The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults.

Methods

The Guidelines Development Committee (GDC) planned for and adapted systematic processes for literature�searching, screening, review, analysis, and interpretation. Methods are consistent with criteria proposed by the �Appraisal of Guidelines Research and Evaluation� collaboration (http://www.agreecollaboration.org). This guideline is a supportive tool for practitioners. It is not intended as a standard of care. The guideline links available published evidence to clinical practice and is only 1 component of an evidence-informed approach to patient care.

Data Sources and Searches

Systematic search and evaluation of the treatment literature were conducted using methods recommended by The Cochrane Collaboration Back Review Group[6] and Oxman and Guyatt.[7] The search strategy was developed in MEDLINE by exploring MeSH terms related to chiropractic and specific interventions and later modified for other databases. The literature search strategy was intentionally broad. Chiropractic treatment was defined as including the most common therapies used by practitioners and was not restricted to treatment modalities delivered only by chiropractors. A wide net was cast to include treatments that may be administered in chiropractic care as well as those that could also be delivered in the context of care by other health care professionals in a specific research study (Appendix A). Spinal manipulation was defined as a high-velocity low-amplitude thrust delivered to the spine. Excluded therapies included invasive analgesic or neurostimulation procedures, pharmacotherapy, injections of botulinum toxin, cognitive or behavioral therapies, and acupuncture.

Literature searches were completed from April to May 2006, updated in 2007 (phase 1), and updated again in August 2009 (phase 2). Databases searched included MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library (Appendix A). Searches included articles published in English or with English abstracts. The search strategy was limited to adults (?18 years); although research studies with subject inclusion criteria encompassing a broad range of ages, such as adults and adolescents, were retrieved using the search strategy. Reference lists provided in systematic reviews (SRs) were also reviewed by the GDC to minimize relevant articles from being missed.

Evidence Selection Criteria

Search results were screened electronically, and multi-stage screening was applied (Appendix B): stage 1A (title), 1B (abstract); stage 2A (full text), 2B (full text-methodology, relevance); and stage 3 (full text-final GDC screening as clinical content experts). Duplicate citations were removed, and relevant articles were retrieved as electronic�and/or hard copies for detailed analysis. Different assessors, using the same criteria, completed the literature screens in 2007 and 2009 due to the time span between searches.

Only controlled clinical trials (CCTs); randomized, controlled trials (RCTs); and systematic reviews (SRs) were selected as the evidence base for this guideline consistent with current standards for interpreting clinical findings. The GDC did not rate observational studies, case series, or case reports because of their uncontrolled nature and probable low methodological quality vs CCTs. This approach is consistent with updated methods for SRs published by the Cochrane Back Review Group.[8] If multiple SRs were published by the same authors on a given topic, only the most recent publication was counted and used for evidence synthesis. Systematic reviews of SRs were also excluded to avoid double counting of research results.

Literature Assessment and Interpretation

Quality ratings of CCTs or RCTs included 11 criteria answered by �yes (score 1)� or �no (score 0)/do not know (score 0)� (Table 1). The GDC documented 2 additional criteria of interest: (1) researchers’ use of IHS diagnostic criteria for subject enrollment and (2) evaluation of side effects (Table 1, columns L and M). Use of IHS criteria[4] was relevant to this Clinical Practice Guideline (CPG) process to confirm diagnostic specificity within and across research studies. Studies were excluded if IHS diagnostic criteria were not applied by the researchers for subject inclusion into a study (Appendix C); and if before 2004, before cervicogenic headache was included in the IHS classification, the diagnostic criteria of the Cervicogenic Headache International Study Group[9] were not used. Side effects were reviewed as a proxy for potential risk(s) with treatment. No weighting factor(s) was applied to individual criteria, and possible quality ratings ranged from 0 to 11. Both blinding of subjects and care providers were rated in the research articles by the GDC, since these items are listed in the quality rating tool.[6] The GDC’s methods did not adapt or alter the rating tool. The rationale for this approach was that certain treatment modalities (eg, transcutaneous electrical nerve stimulation [TENS], ultrasound) and trial designs may achieve patient and/or practitioner blinding.[10] The GDC did not limit the evaluation of these benchmarks of quality if indeed they were reported in clinical studies for the treatment of headache disorders. The GDC also considered it outside their scope of expertise to modify, without validation, a widely used rating tool used to assess the clinical literature.[6] New research tools for the analysis and rating of the manual therapy literature, however, are urgently needed and are noted as an area for future research in the discussion section below.

Table 1 Qualitative Ratings of Controlled Trials of Physical Treatments for the Management of Headache Disorders

Literature assessors were project contributors separate from the GDC and were unblinded as to study authors, institutions, and source journals. Three members of the GDC (MD, RR, and LS) corroborated quality rating methods by completing quality assessments on a random subset of 10 articles.[11-20] A high level of agreement was confirmed across quality ratings. Complete agreement on all items was achieved for 5 studies: in 10 of 11 items for 4 studies and 8 of 11 items for the 1 remaining study. All discrepancies were easily resolved through discussion and�consensus by the GDC (Table 1). Due to heterogeneity of research methods across trials, no meta-analysis or statistical pooling of trial results was done. Trials scoring more than half of the total possible rating (ie, ?6) were considered high quality. Trials scoring 0 through 5 were considered low quality. Studies with major methodological flaws or investigating specialized treatment techniques were excluded (eg, treatment not considered relevant by the GDC for the chiropractic care of patients with headache; Appendix Table 3).

Quality rating of SRs included 9 criteria answered by yes (score 1) or no (score 0)/do not know (score 0) and a qualitative response for item J �no flaws,� �minor flaws,� or �major flaws� (Table 2). Possible ratings ranged from 0 to 9. The determination of overall scientific quality of SRs with major flaws, minor flaws, or no flaws, as listed in column J (Table 2), was based on the literature raters’ answers to the previous 9 items. The following parameters were used to derive the overall scientific quality of a SR: if the no/do not know response was used, an SR was likely to have minor flaws at best. However, if �No� was used on items B, D, F, or H, the review was likely to have major flaws.[21] Systematic reviews scoring more than half of the total possible rating (ie, ?5) with no or minor flaws were rated as high quality. Systematic reviews scoring 4 or less and/or with major flaws were excluded.

Table 2 Qualitative Ratings of Systematic Reviews of Physical Treatments for the Management of Headache Disorders

Reviews were defined as systematic if they included an explicit and repeatable method for searching and analyzing the literature and if inclusion and exclusion criteria for studies were described. Methods, inclusion criteria, methods for rating study quality, characteristics of included studies, methods for synthesizing data, and results were evaluated. Raters achieved complete agreement for all rating items for 7 SRs[22-28] and for 7 of 9 items for the 2�additional SRs.[29,30] The discrepancies were deemed minor and easily resolved through GDC review and consensus (Table 2).

Developing Recommendations for Practice

The GDC interpreted the evidence relevant to chiropractic treatment of headache patients. A detailed summary of the relevant articles will be posted to the CCA/Federation Clinical Practice Guidelines Project web site.

Randomized, controlled trials and their findings were appraised to inform treatment recommendations. To assign an overall strength of evidence (strong, moderate, limited, conflicting, or no evidence),[6] the GDC considered the number, quality, and consistency of research results (Table 3). Strong evidence was considered only when multiple high-quality RCTs corroborated the findings of other researchers in other settings. Only high-quality SRs were appraised in relation to the body of evidence and to inform treatment recommendations. The GDC considered treatment modalities to have proven benefit(s) when supported by a minimum of moderate level of evidence.

Table 3 Strength of Evidence

Recommendations for practice were developed in collaborative working group meetings.

Results

Table 4 Literature Summary of !uality Ratings of the Evidence for Interventions for Migraine Headache with or without Aura

Table 5 Literature Summary and Quality Ratings of the Evidence for Interventions for Tension-Type Headache

Table 6 Literature Summary and Quality Ratings of the Evidence for Interventions for Cervicogenic Headache

Table 7 Literature Summary and Quality Ratings of Systematic Reviews of Physical Treatments for the Management of Headache Disorders

Literature

From the literature searches, initially 6206 citations were identified. Twenty-one articles met final criteria for inclusion and were considered in developing practice recommendations (16 CCTs/RCTs[11-20,31-36] and 5 SRs[24-27,29]). Quality ratings of the included articles are provided in Tables 1 and 2. Appendix Table 3 lists articles excluded in final screening by the GDC and reason(s) for their exclusion. Absence of subject and practitioner blinding and unsatisfactory descriptions of cointerventions were commonly identified methodological limitations of the controlled trials. Headache types evaluated in these trials included migraine (Table 4), tension-type headache (Table 5), and cervicogenic headache (Table 6). Consequently, only these headache types are represented by the evidence and practice recommendations in this CPG. Evidence summaries of SRs are provided in Table 7.

Practice Recommendations: Treatment of Migraine

Spinal manipulation is recommended for the management of patients with episodic or chronic migraine with or without aura. This recommendation is based on studies that used a treatment frequency 1 to 2 times per week for 8 weeks (evidence level, moderate). One high-quality RCT,[20] 1 low-quality RCT,[17] and 1 high- quality SR[24] support the use of spinal manipulation for patients with episodic or chronic migraine (Tables 4 and 7).
Weekly massage therapy is recommended for reducing episodic migraine frequency and for improving affective symptoms potentially linked to headache pain (evidence level, moderate). One high-quality RCT[16] supports this practice recommendation (Table 4). Researchers used a 45-minute massage with focus on neuromuscular and trigger point framework of the back, shoulder, neck, and head.
Multimodal multidisciplinary care (exercise, relaxation, stress and nutritional counseling, massage therapy) is recommended for the management of patients with episodic or chronic migraine. Refer as appropriate (evidence level, moderate). One high-quality RCT[32] supports the effectiveness of multi-modal multidisciplinary intervention for migraine (Table 4). The intervention prioritizes a general management approach consisting of exercise, education, lifestyle change, and self-management.
There are insufficient clinical data to recommend for or against the use of exercise alone or exercise combined with multimodal physical therapies for the management of patients with episodic or chronic migraine (aerobic exercise, cervical range of motion [cROM], or whole body stretching). Three low-quality CCTs[13,33,34] contribute to this conclusion (Table 4).

Practice Recommendations: Tension-Type Headache

Low-load craniocervical mobilization (eg, Thera-Band, Resistive Exercise Systems; Hygenic Corporation, Akron, OH) is recommended for longer term (eg, 6 months) management of patients with episodic or�chronic tension-type headaches (evidence level, moderate). One high-quality RCT[36] showed that low-load mobilization significantly reduced symptoms of tension-type headaches for patients during the longer term (Table 5).
Spinal manipulation cannot be recommended for the management of patients with episodic tension-type headache (evidence level, moderate). There is moderate-level evidence that spinal manipulation after premanipulative soft tissue therapy provides no additional benefit for patients with tension-type headaches. One high-quality RCT[12] (Table 5) and observations reported in 4 SRs[24-27] (Table 7) suggest no benefit of spinal manipulation for patients with episodic tension-type headaches.
A recommendation cannot be made for or against the use of spinal manipulation (2 times per week for 6 weeks) for patients with chronic tension-type headache. Authors of 1 RCT[11] rated as high quality by the quality assessment tool[6] (Table 1), and summaries of this study in 2 SRs[24,26] suggest that spinal manipulation may be effective for chronic tension-type headache. However, the GDC considers the RCT[11] difficult to interpret and inconclusive (Table 5). The trial is inadequately controlled with imbalances in the number of subject-clinician encounters between study groups (eg, 12 visits for subjects in the soft tissue therapy plus spinal manipulation group vs 2 visits for subjects in the amitriptyline group). There is no way of knowing whether a comparable level of personal attention for subjects in the amitriptyline group may have impacted the study outcomes. These considerations and interpretations from 2 other SRs[25,27]contribute to this conclusion (Table 7).
There is insufficient evidence to recommend for or against the use of manual traction, connective tissue manipulation, Cyriax’s mobilization, or exercise/ physical training for patients with episodic or chronic tension-type headache. Three low-quality inconclusive studies[19,31,35] (Table 5), 1 low-quality negative RCT,[14] and 1 SR[25] contribute to this conclusion (Table 7).

Practice Recommendations: Cervicogenic Headache

Spinal manipulation is recommended for the management of patients with cervicogenic headache. This recommendation is based on 1 study that used a treatment frequency of 2 times per week for 3 weeks (evidence level, moderate). In a high-quality RCT, Nilsson et al[18] (Table 6) showed a significantly positive effect of high-velocity, low-amplitude spinal manipulation for patients with cervicogenic headache. Evidence synthesis from 2 SRs[24,29] (Table 7) supports this practice recommendation.
Joint mobilization is recommended for the management of patients with cervicogenic headache (evidence level, moderate). Jull et al[15] examined the effects of Maitland joint mobilization 8 to 12 treatments for 6 weeks in a high-quality RCT (Table 6). Mobilization followed typical clinical practice, in which the choice of low-velocity and high-velocity techniques was based on initial and progressive assessments of patients’ cervical joint dysfunction. Beneficial effects were reported for headache frequency, intensity, as well as neck pain and disability. Evidence synthesis from 2 SRs[24,29] (Table 7) supports this practice recommendation.
Deep neck flexor exercises are recommended for the management of patients with cervicogenic headache (evidence level, moderate). This recommendation is based on a study of 2 times daily for 6 weeks. There is no consistently additive benefit of combining deep neck flexor exercises and joint mobilization for cervicogenic headache. One high-quality RCT[15] (Table 6) and observations provided in 2 SRs[24,29] (Table 7) support this practice recommendation.

Safety

Practitioners select treatment modalities in conjunction with all available clinical information for a given patient. Of the 16 CCTs/RCTS[11-20,31-36] included in the body of evidence for this CPG, only 6 studies[11,12,15,20,32,36] adequately assessed or discussed patient side effects or safety parameters (Table 1, column M). Overall, reported risks were low. Three of the trials reported safety information for spinal manipulation.[11,12,20] Boline et al[11] reported that 4.3% of subjects experienced neck stiffness after initial spinal manipulation that disappeared for all cases after the first 2 weeks of treatment. Soreness or increase in headaches after spinal manipulation (n = 2) were reasons for treatment discontinuation cited by Tuchin et al.[20] No side effects were experienced by any subjects studied by Bove et al[12] using spinal manipulation for the treatment of episodic tension-type headache. Treatment trials to evaluate efficacy outcomes may not enroll adequate numbers of subjects to assess the incidence of rare adverse events. Other research methods are required to�develop a full understanding of the balance between benefits and risks.

Discussion

Spinal manipulation and other manual therapies commonly used in chiropractic have been studied in several CCTs that are heterogeneous in subject enrollment, design, and overall quality. Patient and headache types systematically represented in the evidence base are migraine, tension-type headaches, and cervicogenic headache. The primary health status outcomes reported are typically headache frequency, intensity, duration, and quality-of-life measures. The evidence is no greater than a moderate level at this time.

The evidence supports the use of spinal manipulation for the chiropractic management of patients with migraine or cervicogenic headaches but not tension-type headaches. For migraine, multidisciplinary care using weekly 45-minute massage therapy and multimodal care (exercise, relaxation, and stress and nutritional counseling) may also be effective. Alternatively, joint mobilization or deep neck flexor exercises are recommended for improving symptoms of cervicogenic headache. There appears to be no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Moderate evidence support the use of low-load craniocervical mobilization for longer term management of tension-type headaches.

Limitations

Shortcomings for this guideline include the quantity and quality of supporting evidence found during the searches. No recent adequately controlled high-quality research studies with reproducible clinical findings have been published for the chiropractic care of headache patients. Studies are needed to further our understanding of specific manual therapies in isolation or in well-controlled combinations for the treatment of migraine, tension-type headache, cervicogenic headache, or other headache types presenting to clinicians (eg, cluster, posttraumatic head- ache). Another shortcoming of this literature synthesis is the reliance on published research studies with small sample sizes (Tables 4-6), short-term treatment paradigms, and follow-up periods. Well-designed clinical trials with sufficient numbers of subjects, longer term treatments, and follow-up periods need to be funded to advance chiropractic care, and spinal manipulation in particular, for the management of patients with headache disorders. As with any literature review and clinical practice guideline, foundational information and published literature are evolving. Studies that may have informed this work may have been published after the conclusion of this study.[37-39]

Considerations for Future Research

The GDC consensus is that there is a need for further chiropractic studies with patients with headache disorders.

More high-quality clinical research is needed. Future research requires study designs using active comparators and nontreatment and/or placebo group(s) to enhance the evidence base for patient care. Patient blinding to physical interventions to manage expectancy results is needed and has been explored by researchers in chiropractic for other pain conditions.[10] The lack of systematically reported studies presents a practical challenge for generating evidence-based treatment recommendations. All future studies should be structured using systematic validated methods (eg, Consolidated Standards of Reporting Trials [CONSORT] and Transparent Reporting of Evaluations with Non-randomized Designs [TREND]).
Systematic reporting of safety data is needed in chiropractic research. All clinical trials must collect and report on potential side effects or harms even if none are observed.
Develop novel quantitative tools for evaluating manual therapy research. Blinding serves to control expectancy effects and nonspecific effects of subject-provider interactions across study groups. It is typically not possible to blind subjects and providers in efficacy studies of manual therapies. Despite inherent limitations, both blinding of subjects and care providers were rated in the research articles by the GDC, since these items are included in high-quality rating instruments.[6] Advanced research tools for analyzing and subsequent rating of the manual therapy literature are urgently needed.
To advance research on functional outcomes in the chiropractic care of headache. This guideline identified that headache studies use a variable range of measures in evaluating the effect of treatment on health outcomes. Headache frequency, intensity, and duration are the most consistently used outcomes (Tables 4-6). Serious efforts are needed to include validated patient-centered outcome measures in chiropractic research that are congruent with improvements in daily living and resumption of meaningful routines.
Cost-effectiveness. No research studies were retrieved on cost-effectiveness of spinal manipulation for the treatment of headache disorders. Future clinical trials of spinal manipulation should evaluate cost-effectiveness.

Other research methods are required to develop a full understanding of the balance between benefits and risks. This CPG does not provide a review of all chiropractic treatments. Any omissions reflect gaps in the clinical literature. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and knowledge of the patient until higher levels of evidence are available.

Conclusions

There is a baseline of evidence to support chiropractic care, including spinal manipulation, for the management of migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and knowledge of the patient. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal. More research is needed.
Practice guidelines link the best available evidence to good clinical practice and are only 1 component of an evidence-informed approach to providing good care. This guideline is intended to be a resource for the delivery of chiropractic care for patients with headache. It is a �living document� and subject to revision with the emergence of new data. Furthermore, it is not a substitute for a practitioner’s clinical experience and expertise. This document is not intended to serve as a standard of care. Rather, the guideline attests to the commitment of the profession to advance evidence-based practice through engaging a knowledge exchange and transfer process to support the movement of research knowledge into practice.

Practical Applications

This guideline is a resource for the delivery of chiropractic care for patients with headache.
Spinal manipulation is recommended for the management of patients with migraine or cervicogenic headaches.
Multimodal multidisciplinary interventions including massage may benefit patients with migraine.
Joint mobilization or deep neck flexor exercises may improve symptoms of cervicogenic headache.
Low-load craniocervical mobilization may improve tension-type headaches.

Acknowledgements

The authors thank the following for input on this guideline: Ron Brady, DC; Grayden Bridge, DC; H James Duncan; Wanda Lee MacPhee, DC; Keith Thomson, DC, ND; Dean Wright, DC; and Peter Waite (Members of the Clinical Practice Guidelines Task Force). The authors thank the following for assistance with the Phase I literature search assessment: Simon Dagenais, DC, PhD; and Thor Eglinton, MSc, RN. The authors thank the following for assistance with the Phase II additional literature search and evidence rating: Seema Bhatt, PhD; Mary-Doug Wright, MLS. The�authors thank Karin Sorra, PhD for assistance with literature searches, evidence rating, and editorial support.

Funding Sources and Potential Conflicts of Interest

Funding was provided by the CCA, Canadian Chiropractic Protective Association, and provincial chiropractic contributions from all provinces except British Columbia. This work was sponsored by The CCA and the Federation. No conflicts of interest were reported for this study.

In conclusion, headache is one of the most common reasons people seek medical attention. Although many healthcare professionals can treat headaches, chiropractic care is a well-known alternative treatment option frequently used to treat a variety of health issues, including several types of headaches. According to the article above, evidence suggests that chiropractic care, including spinal adjustments and manual manipulations, can improve headache and migraine. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

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EXTRA IMPORTANT TOPIC:�Neck Pain Treatment El Paso, TX Chiropractor

Chronic Fatigue Syndrome Chiropractic Helps In El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Adrenal Fatigue (AF)

Chronic fatigue syndrome (CFS) is a condition that is not as straightforward as other illnesses. The symptoms can often mimic other states, including some that are pretty serious, so they must all be ruled out before a diagnosis of CFS can be determined.

This is usually not a quick process, so the patient is left dealing with troubling and often debilitating symptoms and no real answers for months or even years. By the time a patient receives a diagnosis of CFS, they are usually physically and emotionally exhausted.

Contents

Overview Of Chronic Fatigue Syndrome

According to the Centers for Disease Control (CDC), more than one million people in the United States have CFS. It is more prevalent in the U.S. than lupus, multiple sclerosis, and many types of cancer.

It is found more often in women than men; women are four times more likely to get it. While anyone of any age can get CFS, it seems to be most common in people in their 40s and 50s. Researchers have found no evidence to suggest that CFS is contagious, but they believe there may be a genetic or familial link.

Symptoms of CFS include:

Extreme fatigue
Memory loss
Unexplained muscular pain
Lack of concentration or fuzziness
Joint pain that is not accompanied by redness or swelling and moves to various joints in the body
Enlarged lymph nodes in the armpits and neck
Extreme exhaustion that persists more than 24 hours after exertion that is either physical or mental
Headache
Unrefreshing sleep
Sore throat

Complications that can come from CFS include depression, increased absence from work, lifestyle restrictions, and inability to carry out normal daily activities like caring for children, housekeeping, or wedding functions. It can cause significant social isolation and loneliness.

Chiropractic For Chronic Fatigue Syndrome

Many people have found that chiropractic for CFS helps reduce the pain that accompanies the condition and increases injury in some patients. The chiropractor uses spinal manipulation to treat the CFS patient, allowing many symptoms associated with the disease without invasive treatments or medication.

Many CFS patients report more energy, less pain or no pain, greater flexibility, increased mobility, and reduced inflammation of joints after just a few chiropractic adjustments. Often, the patient will be recommended to attend several sessions a week for spinal adjustments and counseling on supplements and diet. All these treatments work together to relieve the symptoms, strengthen the immune system, and help the patient feel more in control of their body and condition.

Whole Patient Treatment

One of the benefits of chiropractic treatment for CFS is that it treats the whole patient, not just the symptoms. A doctor of chiropractic may recommend various chiropractic services such as spinal adjustments. Still, they will also sit with the patient and discuss that patient’s diet, daily routine, and any medications or supplements they are taking.

The chiropractor will then make dietary recommendations, including supplements that help CFS, such as:

Omega 3 fatty acids
- Eiscosapentaenoic acid (EPA)
- Docosahexaenoic acid (DHA)
Magnesium
Malic Acid
Linoleic Acid

Depending on the patient, they may also recommend a liver detox program and a more structured diet and exercise program.

Hope For Patients With CFS

Chiropractic care can give much-needed hope to patients with CFS. The whole patient care they receive helps not only the physical and emotional suffering as well.

The changes in diet, recommended supplements, and chiropractic treatments help the patient’s physical symptoms but also address the emotional ones, particularly depression and frustration. It is essential that patients with CFS know that there is someone who hears them, understands their difficulties, and wants to help them on every level, not just symptom control. Chiropractic care addresses all of these for optimal whole patient care.

Clinic News – Dr. Jimenez Takes A Look At Stress Management

Degenerative Disk Disease Treatment El Paso, TX

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Conditions Treated, Spine Care

George Lara, now retired, found relief with Dr. Alex Jimenez, back pain specialist and chiropractor, for his degenerative disk disease following two back injuries he experienced several years ago. After using drugs/medications and experiencing constant symptoms due to his DDD, Mr. Lara describes how Dr. Jimenez’s chiropractic treatment greatly helped restore his quality of life as well as promote his overall health and wellness. George Lara highly recommends Dr. Alex Jimenez as a non-surgical treatment choice for degenerative disc disease, and praises his dedication for treating his patients.

Degenerative disk disease, or DDD, refers to the natural breakdown of an intervertebral disk of the spine. Despite its title, DDD isn’t regarded as a disorder, nor is it degenerative. To the contrary, disk degeneration is frequently the consequence of ordinary daily stresses and minor accidents that cause spinal disks to slowly eliminate water in the anulus fibrosus, or even through the stiff outer layer of a disk. As water content decreases, they start to collapse. This could lead to pressure being placed on the nerves causing weakness and pain. While not necessarily symptomatic, DDD may lead to acute or chronic low back or neck pain in addition to nerve pain based on the positioning of the affected disk and the amount of strain it puts around the surrounding nerve roots.

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Hydration Is Important To Spinal Health In El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Spinal Hygiene

Hydration: There is no denying that a healthy diet is integral to overall wellness and staying hydrated is absolutely vital. Every organ, every cell in your body contains water. In fact, when you don�t drink enough water and keep your body properly hydrated, it does not function as it should.

The health of your spine and back depends heavily on whether you are properly hydrated. In fact, if you don�t drink enough water plain, pure water, it could affect your back, causing pain and limiting mobility.

Contents

Hydration

Overview Of Spinal Construction

To understand water�s role in spinal health, you first need to understand how the spine is constructed. The row of bones that make up the spine are called vertebrae. Between each vertebrae is a disc. This disc works like a shock absorber so as you bend, flex, and move about the disc provides a buffer so the bones do not rub together.

Each disc is comprised of two parts. The center of the disc is the nucleus pulposis. It is made up mostly of water. The nucleus pulposis is surrounded by a tough, flexible ring that contains a gelatinous substance. It protects the inner area which is the cushion for the vertebrae. Two factors that further complicate the rehydration of the discs are aging and sedentary lifestyles.

How Water Is Good For Your Back

As you go about your daily activities, each time you move, the spine compresses the disc, squeezing out the water within. Even walking or sitting upright can cause this as gravity causes the spine to compress. When the disc does not have adequate water, the result is pain and lack of mobility as well as increased risk of spinal injury.

When you are not properly hydrated your body cannot replenish the water in the discs, causing them to remain compressed. Beverages like soda are not adequate for effective hydration. You need to make sure that you drink enough water every day.

For years we were told that 8 eight ounce glasses of water a day was the rule for proper hydration, and that works for many people. However, an article in the Harvard Health Letter suggests that the body can be properly hydrated with 30 to 50 ounces of water a day. The article goes on to suggest that water can also be found in foods like spinach, watermelon, soups, and lettuce are also good sources for hydration.

Spinal Problems Caused By Dehydration

When the body is dehydrated the discs remain compressed instead of refilling. When that happens the overall function of the spine is compromised. Your constant back pain may actually be caused by dehydration. When the discs cannot refill they can�t do their job. This leads to immobility and a compromised range of motion.

Hydration also plays an important role in how the cerebrospinal fluid moves and works. While it does require more than water to function properly, water does play an important role. When the body is dehydrated this fluid cannot move as it should which can even affect brain function.

On a larger scale, when the body is dehydrated it begins to retrieve water from other parts of the body so it can reroute it to the vital organs and sustain life. The extremities are the first places it pulls water from and the spine is another. When it deprives the spine of water in order to supply the organs then you remain in a constant deficit which can cause pain and mobility problems.

How The Spine Rehydrates

As the body rehydrates itself, it does not assign the spine as a priority. The vital organs take precedence so the spine basically gets what is left over. If there is already a deficiency present, then there is nothing left over to rehydrate the spine.

When there is adequate water in the body, normal activity and movement aids in the rehydration of the discs. The most significant rehydration occurs while you sleep though. When you lie down and rest your body is best able to initiate the process of rehydrating your spinal discs via osmosis.

Chiropractic care is another way to adjust the spine and encourage the refilling of the discs. That depends, of course, on proper water intake. Be good to your spine; it�s the only one you have.

Herniated Disc | El Paso, Texas

Sciatic Nerve Pain Treatment El Paso, TX | George Lara

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Case Control Studies, Sciatica Nerve Pain, Testimonies

George Lara, now a retired construction contractor, experienced a back injury 20 years ago which affected his original state of well-being. Although he was promptly treated at the time of the incident, Mr. Lara suffered another back injury which manifested into sciatic nerve pain. George Lara had been greatly affected by his back injury, fortunately, he found Dr. Alex Jimenez, a back pain specialist, who restored his quality of life. Mr. Lara expresses his gratitude towards Dr. Alex Jimenez’s services and he greatly recommends chiropractic care as the non-surgical choice for alleviating back pain and sciatica.

Sciatic nerve pain�is a medical condition characterized by radiating pain down the leg from the lower back. Onset is often sudden following tasks like heavy lifting, even though slow onset may also occur. Normally, symptoms are only on one side of the body. Certain triggers, however, could lead to pain on both sides. Weakness or numbness may occur in a variety of areas of the affected leg and foot. About 90 percent of the time sciatica is due to a spinal disc herniation pressing on the lumbar or sacral nerve roots. Other problems that may bring about sciatica comprise of spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumors, and compression.

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Migraine Headache Pain Chiropractic Therapy in El Paso, TX

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Randomized Controlled Trial

Migraine headaches have been considered to be one of the most frustrating ailments when compared to other common health issues. Generally triggered by stress, the symptoms of migraines, including the debilitating head pain, sensitivity to light and sound as well as the nausea, can tremendously affect a migraineur’s quality of life. However, research studies have found that chiropractic care can help reduce the frequency and the severity of your migraine pain. Many healthcare professionals have demonstrated that a spinal misalignment, or subluxation, may be the source of migraine headache pain. The purpose of the article below is to demonstrate the outcome measures of chiropractic spinal manipulative therapy for migraine.

Chiropractic Spinal Manipulative Therapy for Migraine: a Three?Armed, Single?Blinded, Placebo, Randomized Controlled Trial

Abstract

Background and purpose: To investigate the efficacy of chiropractic spinal manipulative therapy (CSMT) for migraineurs.
Methods: This was a prospective three?armed, single?blinded, placebo, randomized controlled trial (RCT) of 17 months duration including 104 migraineurs with at least one migraine attack per month. The RCT was conducted at Akershus University Hospital, Oslo, Norway. Active treatment consisted of CSMT, whereas placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region. The control group continued their usual pharmacological management. The RCT consisted of a 1?month run?in, 3 months intervention and outcome measures at the end of the intervention and at 3, 6 and 12 months follow?up. The primary end?point was the number of migraine days per month, whereas secondary end?points were migraine duration, migraine intensity and headache index, and medicine consumption.
Results: Migraine days were significantly reduced within all three groups from baseline to post?treatment (P < 0.001). The effect continued in the CSMT and placebo group at all follow?up time points, whereas the control group returned to baseline. The reduction in migraine days was not significantly different between the groups (P > 0.025 for interaction). Migraine duration and headache index were reduced significantly more in the CSMT than the control group towards the end of follow?up (P = 0.02 and P = 0.04 for interaction, respectively). Adverse events were few, mild and transient. Blinding was strongly sustained throughout the RCT.
Conclusions: It is possible to conduct a manual?therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.
Keywords: chiropractic, headache, migraine, randomized controlled trial, spinal manipulative therapy

Dr. Alex Jimenez’s Insight

Neck pain and headaches are the third most common reason people seek chiropractic care. Many research studies have demonstrated that chiropractic spinal manipulative therapy is a safe and effective alternative treatment option for migraines. Chiropractic care can carefully correct any spinal misalignment, or subluxation, found along the length of the spine, which has been shown to be a source for migraine headaches. In addition, spinal adjustments and manual manipulations can help reduce stress and muscle tension by decreasing the amount of pressure being placed against the complex structures of the spine as a result of a spinal misalignment, or subluxation. By realigning the spine as well as reducing stress and muscle tension, chiropractic care can improve migraine symptoms and decrease their frequency.

Introduction

The socio?economic costs of migraine are enormous due to its high prevalence and disability during attacks [1, 2, 3]. Acute pharmacological treatment is usually the first treatment option for migraine in adults. Migraineurs with frequent attacks, insufficient effect and/or contraindication to acute medication are potential candidates for prophylactic treatment. Migraine prophylactic treatment is often pharmacological, but manual therapy is not unusual, especially if pharmacological treatment fails or if the patient wishes to avoid medicine [4]. Research has suggested that spinal manipulative therapy may stimulate neural inhibitory systems at different spinal cord levels because it might activate various central descending inhibitory pathways [5, 6, 7, 8, 9, 10].

Pharmacological randomized controlled trials (RCTs) are usually double?blinded, but this is not possible in manual?therapy RCTs, as the interventional therapist cannot be blinded. At present there is no consensus on a sham procedure in manual?therapy RCTs that mimics placebo in pharmacological RCTs [11]. Lack of a proper sham procedure is a major limitation in all previous manual?therapy RCTs [12, 13]. Recently, we developed a sham chiropractic spinal manipulative therapy (CSMT) procedure, where participants with migraine were unable to distinguish between real and sham CSMT evaluated after each of 12 individual interventions over a 3?month period [14].

The first objective of this study was to conduct a manual?therapy three?armed, single?blinded, placebo RCT for migraineurs with a methodological standard similar to that of pharmacological RCTs.

The second objective was to assess the efficacy of CSMT versus sham manipulation (placebo) and CSMT versus controls, i.e. participants who continued their usual pharmacological management.

Methods

Study Design

The study was a three?armed, single?blinded, placebo RCT over 17 months. The RCT consisted of a 1?month baseline, 12 treatment sessions over 3 months with follow?up measures at the end of intervention, 3, 6 and 12 months later.

Participants were, before baseline, randomized equally into three groups: CSMT, placebo (sham manipulation) and control (continued their usual pharmacological management).

The design of the study conformed to the recommendations of the International Headache Society (IHS) and CONSORT (Appendix S1) [1, 15, 16]. The Norwegian Regional Committee for Medical Research Ethics and the Norwegian Social Science Data Services approved the project. The RCT was registered at ClinicalTrials.gov (ID no: NCT01741714). The full trial protocol has been published previously [17].

Participants

Participants were recruited from January to September 2013 primarily through the Department of Neurology, Akershus University Hospital. Some participants were also recruited through General Practitioners from Akershus and Oslo Counties or media advertisement. All participants received posted information about the project followed by a telephone interview.

Eligible participants were migraineurs of 18�70 years old with at least one migraine attack per month and were allowed to have concomitant tension?type headache but no other primary headaches. All participants were diagnosed by a chiropractor with experience in headache diagnostics during the interview and according to the International Classification of Headache Disorders?II (ICHD?II) 2. A neurologist had diagnosed all migraineurs from Akershus University Hospital.

Exclusion criteria were contraindication to spinal manipulative therapy, spinal radiculopathy, pregnancy, depression and CSMT within the previous 12 months. Participants who received manual therapy [18], changed their prophylactic migraine medicine or became pregnant during the RCT were informed that they would be withdrawn from the study at that time and regarded as drop?outs. Participants were allowed to continue and change acute migraine medication throughout the study period.

Eligible participants were invited to an interview and physical assessment including meticulous spinal column investigation by a chiropractor (A.C.). Participants randomized to the CSMT or the placebo group had a full spine radiographic examination.

Randomization and Masking

After written consent was obtained, participants were equally randomized into one of the three study arms by drawing one single lot. Numbered sealed lots with the three study arms were each subdivided into four subgroups by age and gender, i.e. 18�39 or 40�70 years, and men or women.

After each treatment session, the participants in the CSMT and the placebo group completed a questionnaire on whether they believed CSMT treatment was received, and how certain they were that active treatment was received on a 0�10 numeric rating scale, where 10 represented absolute certainty [14].

Both the block randomization and the blinding questionnaire were exclusively administered by a single external party.

Interventions

The CSMT group received spinal manipulative therapy using the Gonstead method, a specific contact, high?velocity, low?amplitude, short?lever spinal with no post?adjustment recoil that was directed to spinal biomechanical dysfunction (full spine approach) as diagnosed by standard chiropractic tests at each individual treatment session [19].

The placebo group received sham manipulation, a broad non?specific contact, low?velocity, low?amplitude sham push manoeuvre in a non?intentional and non?therapeutic directional line of the lateral edge of the scapula and/or the gluteal region [14]. All of the non?therapeutic contacts were performed outside the spinal column with adequate joint slack and without soft tissue pre?tension so that no joint cavitations occurred. The sham manipulation alternatives were pre?set and equally interchanged among the placebo participants according to protocol during the 12?week treatment period to strengthen the study validity. The placebo procedure is described in detail in the available trial protocol [17].

Each intervention session lasted for 15 min and both groups underwent the same structural and motion assessments prior to and after each intervention. No other intervention or advice was given to participants during the trial period. Both groups received interventions at Akershus University Hospital by a single experienced chiropractor (A.C.).

The control group continued their usual pharmacological management without receiving manual intervention by the clinical investigator.

Outcomes

The participants filled in a validated diagnostic headache diary throughout the study and returned them on a monthly basis [20]. In the case of unreturned diaries or missing data, the participants were contacted by phone to secure compliance.

The primary end?point was number of migraine days per month (30 days/month). At least 25% reduction of migraine days from baseline to end of intervention, with the same level maintained at 3, 6 and 12 months follow?up was expected in the CSMT group.

Secondary end?points were migraine duration, migraine intensity and headache index (HI), and medicine consumption. At least 25% reduction in duration, intensity and HI, and at least 50% reduction in medicine consumption were expected from baseline to end of intervention, with the same level maintained at 3, 6 and 12 months follow?up in the CSMT group.

No change was expected for primary and secondary end?point in the placebo and the control group.

A migraine day was defined as a day on which migraine with aura, migraine without aura or probable migraine occurred. Migraine attacks lasting for >24 h were calculated as one attack unless pain?free intervals of ?48 h had occurred [21]. If a patient fell asleep during a migraine attack and woke up without a migraine, in accordance with the ICHD?III ?, the duration of the attack was recorded as persisting until the time of awakening [22]. The minimum duration of a migraine attack was 4 h unless a triptan or drug containing ergotamine was used, in which case we specified no minimum duration. HI was calculated as mean migraine days per month (30 days) � mean migraine duration (h/day) � mean intensity (0�10 numeric rating scale).

The primary and secondary end?points were chosen based on the Task Force of the IHS Clinical Trial Subcommittee’s clinical trial guidelines [1, 15]. Based on previous reviews on migraine, a 25% reduction was considered to be a conservative estimate [12, 13].

The outcome analyses were calculated during the 30 days after the last intervention session and 30 days after the follow?up time points, i.e. 3, 6 and 12 months, respectively.

All adverse events (AEs) were recorded after each intervention in accordance with the recommendations of CONSORT and the IHS Task Force on AEs in migraine trials [16, 23].

Statistical Analysis

We based the power calculation on a recent study of topiramate in migraineurs [24]. We hypothesized the average difference in reduction of number of migraine days per month between the active and the placebo, and between the active and the control groups of 2.5 days, with SD of 2.5 for reduction in each group. As primary analysis includes two group comparisons, the significance level was set at 0.025. For the power of 80%, a sample size of 20 patients was required in each group to detect a significant difference in reduction of 2.5 days.

Patient characteristics at baseline were presented as means and SD or frequencies and percentages in each group and compared by independent samples t?test and ? 2 test.

Time profiles of all end?points were compared between the groups. Due to repeated measurements for each patient, linear mixed models accounting for the intra?individual variations were estimated for all end?points. Fixed effects for (non?linear) time, group allocation and interaction between the two were included. Random effects for patients and slopes were entered into the model. As the residuals were skewed, the bootstrap inference based on 1000 cluster samples was used. Pairwise comparisons were performed by deriving individual time point contrasts within each group at each time point with the corresponding P?values and 95% confidence intervals. Medicine consumption within groups was reported by mean doses with SD, and groups were compared by an independent samples median test. A dose was defined as a single administration of a triptan or ergotamine; paracetamol 1000 mg � codeine; non?steroidal anti?inflammatory drugs (tolfenamic acid, 200 mg; diclofenac, 50 mg; aspirin, 1000 mg; ibuprofen, 600 mg; naproxen, 500 mg); and morphinomimetics (tramadol, 50 mg). None of the patients changed study arm and none of the drop?outs filled in headache diaries after withdrawal from the study. Hence, only per protocol analysis was relevant.

The analyses were blinded to treatment allocation and conducted in SPSS v22 (IBM Corporation, Armonk, NY, USA) and STATA v14 (JSB) (StataCorp LP, College Station, TX, USA). A significance level of 0.025 was applied for the primary end?point, whereas elsewhere a level of 0.05 was used.

Ethics

Good clinical practice guidelines were followed [25]. Oral and written information about the project was provided in advance of inclusion and group allocation. Written consent was obtained from all participants. Participants in the placebo and control group were promised CSMT treatment after the RCT, if the active intervention was found to be effective. Insurance was provided through the Norwegian System of Compensation to Patients (Patient Injury Compensation), an independent national body that compensates patients injured by treatments provided by the Norwegian health service. A stopping rule was defined for withdrawing participants from this study in accordance with the recommendations in the CONSORT extension for Better Reporting of Harms [26]. All AEs were monitored during the intervention period and acted on as they occurred according to the recommendations of CONSORT and the IHS Task Force on AEs in migraine trials [16, 23]. In case of severe AE, the participant would be withdrawn from the study and referred to the General Practitioner or hospital emergency department depending on the event. The investigator (A.C.) was available by mobile phone at any time throughout the study treatment period.

Results

Figure ?1 shows a flow chart of the 104 migraineurs included in the study. Baseline and demographic characteristics were similar across the three groups (Table 1).

Figure 1: Study flow chart.

Table 1 Baseline Demographic and Clinical Characteristics

Outcome Measures

The results on all end?points are presented in Fig. ?2a�d and Tables 2, 3, 4.

Figure 2: (a) Headache days; (b) headache duration; (c) headache intensity; (d) headache index. Time profiles in primary and secondary end?points, means and error bars represent 95% confidence intervals. BL, baseline; control, control group (�); CSMT, chiropractic spinal manipulative therapy (?); placebo, sham manipulation (?); PT, post?treatment; 3 m, 3?month follow?up; 6 m, 6?month follow?up; 12 m, 12?month follow?up; VAS, visual analogue scale.

Table 2 Regression Coefficients and SE

Primary end?point. Migraine days were significantly reduced within all groups from baseline to post?treatment (P < 0.001). The effect continued in the CSMT and the placebo groups at 3, 6 and 12 months follow?up, whereas migraine days reverted to baseline level in the control group (Fig. ?2a). The linear mixed model showed no overall significant differences in change in migraine days between the CSMT and the placebo groups (P = 0.04) or between the CSMT and the control group (P = 0.06; Table 2). However, the pairwise comparisons at individual time points showed significant differences between the CSMT and the control group at all time points starting at post?treatment (Table 3).

Secondary end?points. There was a significant reduction from baseline to post?treatment in migraine duration, intensity and HI in the CSMT (P = 0.003, P = 0.002 and P < 0.001, respectively) and the placebo (P < 0.001, P = 0.001 and P < 0.001, respectively) groups, and the effect continued at 3, 6 and 12 months follow?up.

The only significant differences between the CSMT and control groups were change in migraine duration (P = 0.02) and in HI (P = 0.04; Table 2).

At 12 months follow?up, change in consumption of paracetamol was significantly lower in the CSMT group as compared with the placebo (P = 0.04) and control (P = 0.03) groups (Table 4).

Blinding. After each of the 12 intervention sessions, >80% of the participants believed they had received CSMT regardless of group allocation. The odds ratio for believing that CSMT treatment was received was >10 at all treatment sessions in both groups (all P < 0.001).

Adverse effects. A total of 703 of the potential 770 intervention sessions were assessed for AEs (355 in the CSMT group and 348 in the placebo group). Reasons for missed AE assessment were drop?out or missed intervention sessions. AEs were significantly more frequent in the CSMT than the placebo intervention sessions (83/355 vs. 32/348; P < 0.001). Local tenderness was the most common AE reported by 11.3% (95% CI, 8.4�15.0) in the CSMT group and 6.9% (95% CI, 4.7�10.1) in the placebo group, whereas tiredness on the intervention day and neck pain were reported by 8.5% and 2.0% (95% CI, 6.0�11.8 and 1.0�4.0), and 1.4% and 0.3% (95% CI, 0.6�3.3 and 0.1�1.9), respectively. All other AEs (lower back pain, face numbness, nausea, provoked migraine attack and fatigue in arms) were rare (<1%). No severe or serious AEs were reported.

Discussion

To our knowledge, this is the first manual?therapy RCT with a documented successful blinding. Our three?armed, single?blinded, placebo RCT evaluated the efficacy of CSMT in the treatment of migraine versus placebo (sham chiropractic) and control (usual pharmacological treatment). The results showed that migraine days were significantly reduced within all three groups from baseline to post?treatment. The effect continued in the CSMT and placebo groups at all follow?up time points, whereas the control group returned to baseline. AEs were mild and transient, which is in accordance with previous studies.

The study design adhered to the recommendations for pharmacological RCTs as given by the IHS and CONSORT [1, 15, 16]. Manual?therapy RCTs have three major obstacles as compared with pharmacological RCTs. Firstly, it is impossible to blind the investigator in relation to the applied treatment. Secondly, consensus on an inert placebo treatment is lacking [11]. Thirdly, previous attempts to include a placebo group have omitted validating the blinding, thus, it remains unknown whether active and placebo treatment were concealed [27]. Due to these challenges we decided to conduct a three?armed, single?blinded RCT, which also included a control group that continued usual pharmacological treatment in order to obtain an indication of the magnitude of the placebo response.

It has been suggested that, in pharmacological double?blind placebo RCTs, only 50% will believe that they receive active treatment in each group, if the blinding is perfect. However, this may not be true in manual?therapy RCTs, because the active and placebo physical stimulus might be more convincing than a tablet [28]. A single investigator reduces inter?investigator variability by providing similar information to all participants and it is generally recommended that the placebo intervention should resemble the active treatment in terms of procedure, treatment frequency and time spent with the investigator to allow for similar expectations in both groups [28]. The importance of our successful blinding is emphasized by the fact that all previous manual?therapy RCTs on headache lack placebo. Thus, we believe that our results discussed below are valid at the same level as a pharmacological RCT [14].

Prospective data are more reliable than retrospective data in terms of recall bias; however, non?compliance can be a challenge, especially at the end of the study. We believe the frequent contact between participants and the investigator, including monthly contact in the follow?up period, probably maintained high compliance throughout our study.

Although our study sample ended with 104 participants in the three groups, the power calculation assumption and the high completion rate support the data achieved being valid for the investigated population. The Gonstead method is used by 59% of chiropractors [19] and, thus, the results are generalizable for the profession. Diagnostic certainty is one of our major strengths as nearly all of the participants had been diagnosed by a neurologist according to the ICHD?II [2]. In contrast to previous chiropractic migraine RCTs that recruited participants through media such as newspapers and radio advertisement [12], the majority of our participants were recruited from the Department of Neurology, Akershus University Hospital, indicating that the migraineurs may have more frequent/severe attacks that are difficult to treat than the general population, as they were referred by their General Practitioner and/or practicing neurologist. Thus, our study is representative of primarily the tertiary clinic population, and the outcome might have been different if participants had been recruited from the general population. The percentage of neck pain has been found to be high in patients with migraine [29] and, thus, the high percentage of non?radicular spinal pain in our study might be a confounder for which effect was seen on migraine days.

Three pragmatic chiropractic manual?therapy RCTs using the diversified technique have previously been conducted for migraineurs [12, 30, 31, 32]. An Australian RCT showed within?group reduction in migraine frequency, duration and intensity of 40%, 43% and 36%, respectively, at 2 months follow?up [30]. An American study found migraine frequency and intensity to reduce within?group by 33% and 42%, respectively, at 1 month follow?up [31]. Another Australian study, which was the only RCT to include a control group, i.e. detuned ultrasound, found a within?group reduction of migraine frequency and duration of 35% and 40%, respectively, at 2 months follow?up in the CSMT group, as compared with a within?group reduction of 17% and 20% in the control group, respectively [32]. The reduction in migraine days was similar to ours (40%) in the CSMT group from baseline to 3 months follow?up, whereas migraine duration and intensity were less reduced at 3 months follow?up, i.e. 21% and 14%, respectively. Long?term follow?up comparisons are impossible as neither of the previous studies included a sufficient follow?up period. Our study design including strong internal validity allows us to interpret the effect seen as a placebo response.

Our RCT had fewer AEs as compared with previous manual?therapy studies, but of similar transient and mild character [33, 34, 35, 36, 37, 38, 39]. However, it was not sufficiently powered to detect uncommon serious AEs. In comparison, AEs in pharmacological migraine prophylactic placebo RCTs are common including non?mild and non?transient AEs [40, 41].

Conclusion

The blinding was strongly sustained throughout the RCT, AEs were few and mild, and the effect in the CSMT and placebo group was probably a placebo response. Because some migraineurs do not tolerate medication because of AEs or co?morbid disorders, CSMT might be considered in situations where other therapeutic options are ineffective or poorly tolerated.

Disclosure of Conflicts of Interest

All authors have completed the International Committee of Medical Journal Editors uniform disclosure form and declare no financial or other conflicts of interest.

Supporting Information

Ncbi.nlm.nih.gov/pmc/articles/PMC5214068/#ene13166-tbl-0001

Acknowledgements

The authors want to express their sincere gratitude to Akershus University Hospital, which kindly provided the research facilities, and Chiropractor Clinic 1, Oslo, Norway, which performed all x?ray assessments. This study was supported by grants from Extrastiftelsen, the Norwegian Chiropractic Association, Akershus University Hospital and University of Oslo in Norway.

In conclusion, the debilitating symptoms of migraines, including the severe head pain and the sensitivity to light and sound as well as the nausea, can affect an individual’s quality of life, fortunately, chiropractic care has been demonstrated to be a safe and effective treatment option for migraine headache pain. Furthermore, the article above demonstrated that migraineurs experienced reduced symptoms and migraine days as a result of chiropractic care.�Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Additional Topics: Back Pain

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EXTRA IMPORTANT TOPIC:�Neck Pain Treatment El Paso, TX Chiropractor

Chiropractic Helps Tendonitis In El Paso, TX.

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Conditions Treated, Injury Care

Chiropractic Helps: Tendonitis is a condition that occurs when a tendon that connects bone to muscle is injured, overused, or used improperly. The result is inflammation, pain and sometimes swelling. In the case of an injury where the tendon is stressed to otherwise injured, soft tissue around the area may also become involved. Each year more than 4 million people in the U.S. seek medical treatment for symptoms of tendonitis.

Common types of tendonitis include runner�s knee, tennis elbow, and pitcher�s shoulder. However, other tendons in the body can also experience tendonitis symptoms. The Achilles tendon, ankle, wrist, and even fingers can all become inflamed from the condition.

Often a primary care physician diagnoses the injury, but once there is a definitive diagnosis, the best treatment is one that is natural and holistic. Chiropractic care is an outstanding choice for treatment.

Contents

Chiropractic Helps: Thorough Healing

Tendonitis often recurs in many people. This is due, at least in part to improper or incomplete healing. Many people will resume normal activities as soon as the pain subsides when they should continue caring for the injury so that it can heal completely. This leads to inflammation of the area again as the original injury is aggravated, but it can also lead to re-injury in that same area. Chiropractic care can help tendonitis heal completely and help prevent re-injury to the area.

Chiropractic Helps: Tendonitis

Since tendonitis symptoms can mimic other serious conditions, the first step in treatment is confirming the diagnosis. The doctor may use X-rays, MRIs, or CAT scans to make a positive diagnosis of tendonitis.

From there, the chiropractor will work with the patient to develop a treatment plan that is natural and effective, tailored to the patient�s unique needs. At the core of this treatment is a targeted plan that treats the cause of the problem, not just the symptoms.

If there is a great deal of inflammation the chiropractor may employ inflammation reducing techniques such as bracing, rest, ice, electrical muscle stimulation, and other therapies. This helps to loosen the tendon and lessen the inflammation so that treatment can progress.

Once the inflammation is under control, the chiropractor may begin massage, physical therapy, joint manipulation, or strengthening exercises. If the patient has diminished or limited joint mobility then joint manipulation or adjustments may be the best option.

Chiropractic Helps: Length Of Treatment

The initial pain may subside or even disappear within the first two to three weeks. However, that does not mean that the patient is out of the woods. This is where many patients go wrong. They mistakenly believe that once the pain is gone the condition is healed.

This is not true. While the inflammation may indeed decrease over the first three weeks, the complete healing takes around six weeks and often longer. Scar tissue is formed during this time which helps the body repair the injury. Once the injury is repaired though, that scar tissue must be broken down in order for the area to regain its mobility and flexibility.

The chiropractor will use various techniques including massage and ultrasound to break down the scar tissue. Mild stretches may be incorporated into the treatment plan. Once the tissues are fully healed, exercise can aid in breaking down the scar tissue even more. These exercises will work the muscles but they won�t involve the tendons.

Chiropractic Helps: Healing Tendonitis For Good

Tendonitis can be healed completely and a good chiropractor can help. Most chiropractors take a whole body approach, including diet, specific supplements, and lifestyle choices that will help the healing process of tendonitis. Once chiropractic treatment is complete for tendonitis, the patient can usually return to normal activities without the risk of re-injury or re-inflammation.

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Upper Cervical and Upper Thoracic Manipulation Versus Mobilization and Exercise in Patients with Cervicogenic Headache: a Multi-Center Randomized Clinical Trial

Abstract

Dr. Alex Jimenez’s Insight

Background

Methods

Participants

Treating Therapists

Examination Procedures

Outcome Measures

Randomization

Manipulation Group

Mobilization and Exercise Group

Sample Size

Data Analysis

Results

Discussion

Statement of Principal Findings

Strengths and Weaknesses of the Study

Strengths and Weaknesses in Relation to Other Studies: Important Differences in Results

Meaning of the Study: Possible Explanations and Implications for Clinicians and Policymakers

Unanswered Questions and Future Research

Conclusion

Acknowledgements

Footnotes

Contributor Information

Additional Topics: Back Pain

Blank

References

Close Accordion

Back Clinic News Extra: Migraine Pain Treatment With Chiropractic

Diet vs. Lifestyle Change

Types Of Diets

The Dangers Of Diets

Healthy Eating Is A Lifestyle

Choosing The Right Vitamins

Dr. Jimenez Takes A Look At Motivational Fitness

Evidence-Based Guidelines for the Chiropractic Treatment of Adults with Headache

Abstract

Dr. Alex Jimenez’s Insight

Methods

Data Sources and Searches

Evidence Selection Criteria

Literature Assessment and Interpretation

Developing Recommendations for Practice

Results

Literature

Practice Recommendations: Treatment of Migraine

Practice Recommendations: Tension-Type Headache

Practice Recommendations: Cervicogenic Headache

Safety

Discussion

Limitations

Considerations for Future Research

Conclusions

Practical Applications

Acknowledgements

Funding Sources and Potential Conflicts of Interest

Additional Topics: Back Pain

Blank

References

Close Accordion

Overview Of Chronic Fatigue Syndrome

Chiropractic For Chronic Fatigue Syndrome

Whole Patient Treatment

Hope For Patients With CFS

Clinic News – Dr. Jimenez Takes A Look At Stress Management

Hydration

Overview Of Spinal Construction

How Water Is Good For Your Back

Spinal Problems Caused By Dehydration

How The Spine Rehydrates

Herniated Disc | El Paso, Texas

Chiropractic Spinal Manipulative Therapy for Migraine: a Three?Armed, Single?Blinded, Placebo, Randomized Controlled Trial

Abstract

Dr. Alex Jimenez’s Insight

Introduction

Methods