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Headache Trigger Points and Bio-Chiropractic Treatment

Headache Trigger Points and Bio-Chiropractic Treatment

Individuals that experience frequent headaches can have sensitive headache trigger points. Every case is different and requires a thorough examination before a proper and personalized chiropractic treatment plan can begin. Headaches can be brought on from a variety of causes. This could be:

  • Drug reactions
  • Temporomandibular joint dysfunction (TMJ)
  • Tightness in the neck muscles
  • Low blood sugar
  • High blood pressure
  • Stress
  • Fatigue

The majority of recurrent headaches fall into three types:

  • Tension headaches, also known as cervicogenic headaches
  • Migraine headaches
  • Cluster headaches, which are related to migraines.

Headache Trigger Points and Bio-Chiropractic Treatment

Tension

Tension headaches are the most common and affect around 77% of individuals experiencing chronic headaches. Most individuals describe a tension headache as a consistent dull ache on one side of the head and sometimes both sides. They are often described as having a tight band/belt around the head or behind the eyes. These headaches usually start slowly, gradually and can last for a few minutes or days. They tend to start in the middle of the day or before the end of the day.

These headaches can be the result of stress and/or poor posture. The most common cause is subluxations in the upper back and neck, usually combined with active headache trigger points. This stresses the spinal muscles in the upper back and neck. A tension headache or stress headache can last 30 minutes to a few days. Chronic tension headaches can last for months. The pain can be severe; however, these headaches are typically not associated with symptoms like throbbing, nausea, or vomiting.

If the top cervical vertebrae shift out of their position and lose their normal motion, a small muscle called the rectus capitis posterior minor/RCPM begins to spasm. This small muscle has a tendon that slips between the upper neck and the base of the skull. It attaches to a thin, sensitive tissue called the dura mater that covers the brain. The dura mater is very pain-sensitive. When the RCPM muscle goes into spasm, the tendon pulls the dura mater causing a headache. Individuals that work at a desk station for long hours tend to experience headaches from this cause. Another cause comes from referred pain caused by headache trigger points in the Sternocleidomastoid/SCM or levator muscle on the side of the neck. This cause tends to happen more to individuals that have suffered a whiplash injury with muscle damage in the neck region.

Migraine Headaches

Migraines are intense and throbbing headaches that are associated with nausea and sensitivity to light or noise. They can last for a few hours to a few days. Many experience visual symptoms known as an aura just before they come on. This is described as seeing flashing lights or when things take on a dream-like appearance. However, even in individuals that don’t experience the aura, most can tell that a migraine is getting ready to present. Individuals usually have their first attack before age 30. They tend to run in families supporting a genetic component. Some have attacks several times a month, while others can have less than one a year. Most individuals find that migraines happen less and become less severe as they get older.

These headaches are caused by the constriction of blood vessels in the brain. During the constriction period, there is a decrease in blood circulation. This is followed by dilation/enlargening of the blood vessels. This is what leads to the visual symptoms. Then the blood vessels dilate, generating a rapid increase in blood pressure inside the head. This increased pressure is what leads to a pounding headache. Every time the heart beats, it sends another shock wave through the carotid arteries in the neck into the brain. There are different theories as to why the blood vessels constrict, but they are still unknown. What is known is that several factors can trigger a migraine. This includes:

  • Lack of sleep
  • Stress
  • Flickering lights
  • Strong smells
  • Changing weather
  • Foods that are high in an amino acid known as tyramine

Cluster

Cluster headaches are very short excruciating headaches. They are usually felt on one side of the head behind the eyes. These headaches affect about 1 million individuals and are more common in men. This type of headache tends to happen at night. They are called cluster headaches because they tend to happen one to four times a day over several days. After one cluster is over, it could be months or even years before they present again. Like migraines, cluster headaches cause the dilation of the blood vessels in the brain, increasing the pressure.

Trigger Points

Headache trigger point therapy involves four muscles. These are the:

The Splenius muscles involve two individual muscles, the Splenius Capitis and the Splenius Cervicis. These muscles run along the upper back to the skull base or the upper cervical/neck vertebrae. Trigger points in the Splenius muscles are a common contributor to pain that travels through the head to the back of the eye and top of the head.

The Suboccipitals are a group of four small muscles that maintain proper movement and positioning between the first cervical vertebra and the skull base. Trigger points in these muscles can cause pain that feels like it’s happening inside the head, from the back to the eye and forehead. Individuals report that the whole side of the head hurts. This is a pain pattern similar to a migraine.

The Sternocleidomastoid muscle runs along the base of the skull, behind the ear, down the side of the neck. It attaches to the top of the sternum/breastbone. Although most are not aware of this muscle’s trigger points, the effects are evident. This includes:

  • Referred pain
  • Balance issues
  • Visual symptoms

Referred pain tends to be eye pain, headaches over the eye, and can even cause earaches. An unusual characteristic of SCM headache trigger points is that they can cause dizziness, nausea, and balance problems.

The trapezius muscle is the large, flat muscle in the upper and middle back. Pain can be felt in the temple and back of the head. A common trigger point is located at the top of the muscle. This particular point can activate secondary trigger points in the temple or jaw muscles, leading to jaw or tooth pain.

Headache Triggers

  • Stress can be a trigger.
  • Depression, anxiety, frustration, and even pleasant excitement can be associated with headache development.
  • A headache diary can help determine whether factors like food, weather, and/or mood correlate with headache patterns.
  • Repeated exposure to nitrite compounds can result in a dull headache accompanied by a flushed face. Nitrite dilates blood vessels and is found in products like heart medications, and is also used as a chemical to preserve meat. Processed meats containing sodium nitrite can contribute to headaches.
  • Foods prepared with monosodium glutamate or MSG can result in headaches. Soy sauce, meat tenderizers, and various packaged foods contain this chemical as a flavor enhancer.
  • Exposure to poisons, even household varieties like insecticides, carbon tetrachloride, and lead, can contribute.
  • Contact with lead batteries or lead-glazed pottery.
  • Foods that are high in the amino acid tyramine should be avoided. This could be ripened cheeses like cheddar, brie, chocolate, and pickled or fermented food.

Bio-Chiropractic

Chiropractic adjustments are highly effective for treating tension headaches, especially those that originate in the neck. Research has found that spinal manipulation resulted in almost immediate improvement and had fewer side effects and longer-lasting relief than taking common medications. There is a significant improvement by manipulating the upper two cervical vertebrae, combined with adjustments to the area between the cervical and thoracic spine.


Body Composition Testing


Vibration Exercise

Vibration exercise is believed to stimulate the muscle fibers without going to a gym or stressing the bones. One study broke up postmenopausal women into three groups: resistance training, vibration training combined with resistance training, or no exercise/training. Their body composition was measured before starting the study. After the study was completed, the findings included:

  • Both the resistance group and the resistance group with vibration training increased lean tissue mass.
  • The control group did not show an increase in lean tissue and, in fact, gained body fat.
  • The combination group, using vibration training with resistance training, showed a drop in body fat.

Another study placed male athletes in a training program that included vibration training. The first group had lower-limb strength training combined with vibration training, and the other had lower-limb strength training without vibration training. The researchers found that the athletes in the vibration training group improved leg extension strength by five percent. In addition, the vibration training groups balancing ability and vertical lift/jumping test improved as well.

References

Bryans, Roland et al. “Evidence-based guidelines for the chiropractic treatment of adults with headache.” Journal of manipulative and physiological therapeutics vol. 34,5 (2011): 274-89. doi:10.1016/j.jmpt.2011.04.008

Chaibi, Aleksander et al. “Chiropractic spinal manipulative therapy for cervicogenic headache: a single-blinded, placebo, randomized controlled trial.” BMC research notes vol. 10,1 310. 24 Jul. 2017, doi:10.1186/s13104-017-2651-4

Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with neck pain. J Manipulative Physiol Ther 2014; 37: 42-63.

Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther 2011; 34: 274-89.

Eliminate Migraines From The Source with Chiropractic Treatment

Eliminate Migraines From The Source with Chiropractic Treatment

Chiropractic adjustments can eliminate headaches and migraines from the source. Many individuals visit medical doctors complaining of headaches and migraines. Most hope for immediate relief from these debilitating issues. However, most are sent home after a quick exam and are given a prescription for medication. Finding, treating, and eliminating the root cause should be the objective, instead of just taking medication after medication.  
11860 Vista Del Sol, Ste. 128 Eliminate Migraines From The Source with Chiropractic Treatment
 

Root Cause

The root cause can be traced back to dehydration and misalignment of the spine specifically the neck. Most doctors will take out the prescription pad and move on without fully addressing the problem. There has been a significant rise in poor health and disease. This comes from unhealthy lifestyle choices and poor posture habits. Many of us lean and hunch over at a desk station then go home to more computers and television screens. Constant phone check-ins with the head tilted down creates massive pressure on the neck’s muscles and nerves.  
11860 Vista Del Sol, Ste. 128 Eliminate Migraines From The Source with Chiropractic Treatment
 

Spinal Misalignment Nerve Pressure

Unhealthy lifestyle choices are major contributors to causing spinal misalignment. This places unnecessary and potentially dangerous pressure on the nerves responsible for the function of the organs. When the nerve’s energy is not properly dispersed and cannot reach the organs, a state of dysfunction begins to set in, which can lead to disease and chronic conditions. Healthy lifestyle changes can include learning how to improve standing, sitting, and sleeping posture habits, proper hydration, and chiropractic spinal re-alignment will eliminate headaches and migraines from the source and ensure a healthy body for the future.  

Re-Alignment

There is no need to continue suffering from neck/back pain, headaches, migraines, poor posture, and diminished health. Chiropractic will help an individual regain health and vitality. Injury Medical Chiropractic Clinic Physical Therapy and Health Coaching Team Can Help.

Migraine Treatment


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Dr. Alex Jimenez�s Blog Post Disclaimer

The scope of our information is limited to chiropractic, musculoskeletal, physical medicines, wellness, and sensitive health issues and/or functional medicine articles, topics, and discussions. We use functional health & wellness protocols to treat and support care for injuries or disorders of the musculoskeletal system. Our posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate and support directly or indirectly our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We also make copies of supporting research studies available to the board and or the public upon request. We understand that we cover matters that require an additional explanation as to how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900. The provider(s) Licensed in Texas& New Mexico*
References
Bryans, Roland et al. �Evidence-based guidelines for the chiropractic treatment of adults with headache.��Journal of manipulative and physiological therapeutics�vol. 34,5 (2011): 274-89. doi:10.1016/j.jmpt.2011.04.008
Migraine Pain Chiropractic Care | Video | El Paso, TX.

Migraine Pain Chiropractic Care | Video | El Paso, TX.

Damaris Foreman suffered from migraines before she received chiropractic care with the chiropractor, Dr. Alex Jimenez. After various treatment approaches were unable to provide Damaris Foreman with the migraine pain relief she needed, she was skeptical at first about chiropractic care. However, following the migraine pain relief she found with Dr. Alex Jimenez, Damaris Foreman highly recommends chiropractic care. She emphasizes how much Dr. Jimenez has helped her and how much she has learned about her health issue. Damaris Foreman states that Dr. Alex Jimenez has provided her with the best treatment approach she has ever received for her migraines. Dr. Jimenez is the non-surgical choice for a variety of injuries and conditions, including headaches and migraines.�

Chiropractic Therapy

migraine chiropractic relief el paso tx.

We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.

Our services are specialized and focused on injuries and the complete recovery process.�Our areas of practice includeWellness & Nutrition, Chronic Pain,�Personal Injury,�Auto Accident Care, Work Injuries, Back Injury, Low�Back Pain, Neck Pain, Migraine Treatment, Sports Injuries,�Severe Sciatica, Scoliosis, Complex Herniated Discs,�Fibromyalgia, Chronic Pain, Stress Management, and Complex Injuries.

As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.

We want you to live a life that is fulfilled with more energy, positive attitude, better sleep, less pain, proper body weight and educated on how to maintain this way of life. I have made a life of taking care of every one of my patients.

I assure you, I will only accept the best for you�

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How Chiropractic Can Help Prevent Migraine Headaches

How Chiropractic Can Help Prevent Migraine Headaches

Migraines affect an estimated 38 million people, including children, in the United States alone. Worldwide, that total jumps to 1 billion. Migraine ranks number three among common illnesses in the world and number six among disabling illnesses. More than 90% of people who suffer from migraines cannot function normally or work during an attack.

A migraine attack is often debilitating and extremely painful. It is also challenging to stop once it starts. The best treatment for migraines is to prevent them from ever occurring. Several methods work for some people, but chiropractic is a popular preventative measure that many people have found to help them be migraine-free.

Migraine Symptoms

A severe headache is the first thing people think of regarding migraines, but there are other symptoms which include:

  • Pain located on one or both sides of the head
  • Photophobia (sensitivity to light)
  • Blurred vision or other visual disturbances
  • Pain that is pulsing or throbbing
  • Lightheaded and possibly fainting
  • Hypersensitivity to smell, taste, or touch
  • Loss of motor function or, in more severe cases, partial paralysis (such as with hemiplegic migraine)

Some migraineurs experience auras before an attack, usually around 20 to 60 minutes. This can give the patient time to take specific measures to stop the attack or minimize it. However, it is still the right course of action to incorporate certain activities into your lifestyle to prevent migraines.

prevent migraine headaches chiropractic el paso tx.

Causes of Migraines

Doctors don’t know the exact causes of migraines, but research does indicate that certain triggers can initiate an attack. Some of the more common migraine triggers include:

  • Foods  Processed foods, salty foods, aged cheeses, and chocolate.
  • Beverages  Coffee and other caffeinated drinks as well as alcohol (particularly wine)
  • Hormonal changes occur mainly in women, usually during menopause, menstruation, and pregnancy.
  • Food additives  Monosodium glutamate (MSG) and aspartame, as well as certain dyes.
  • Stress  Environmental, stress at home or work, or illness that puts strain on the body.
  • Sleep problems  Getting too much sleep or not getting enough sleep.
  • Sensory stimuli  Sun glare and bright lights, strong smells like secondhand smoke and perfume, and specific tactile stimulation.
  • Medication  Vasodilators (nitroglycerin) and oral contraceptives.
  • Physical exertion  Intense exercise or other physical exertion.
  • Jet lag
  • Weather changes
  • Skipping meals
  • Change in barometric pressure

Some research also shows a possible serotonin component. Serotonin is integral to regulating pain in the nervous system.

 During a migraine attack, serotonin levels drop. Migraine Treatments

Migraine treatments are classified as either abortive or preventative. Abortive medications primarily treat symptoms, usually pain relief. They are taken once a migraine attack has already begun and are designed to stop it. Preventative medications are typically taken daily to reduce the frequency of migraines and the severity of attacks. Most of these medications can only be obtained by prescription, and many have unpleasant side effects.

A migraine specialist can recommend medications and other treatments, including acupuncture, massage therapy, chiropractic, acupressure, herbal remedies, and lifestyle changes. Adequate sleep, relaxation exercises, and dietary changes may also help.

Chiropractic for Migraines

A chiropractor will use a variety of techniques when treating migraines. Spinal manipulation of one of the most common, usually focusing on the cervical spine. By bringing the body into balance, it can relieve the pain and prevent future migraines. They may also recommend vitamin, mineral, and herbal supplements and lifestyle changes, which usually eliminate triggers.

One migraine study found that 72% of sufferers benefitted from chiropractic treatment with noticeable or substantial improvement. This is proof that chiropractic is an effective treatment for relieving pain and preventing migraines.

Chiropractic Migraine Relief

Migraine Chiropractic Treatment | Video

Migraine Chiropractic Treatment | Video

Damaris Foreman experienced migraine headaches for approximately 23 years. After visiting many healthcare professionals due to her migraine pain without seeing a great deal of progress, she was finally advised to find migraine pain treatment with Dr. Alex Jimenez, a chiropractor located in the city of El Paso, TX. Damaris significantly benefitted from chiropractic care and she experienced a massive sense of relief after her first spinal adjustment and manual manipulation. Damaris Foreman was able to confront a great deal of her questions and concerns and she was efficiently taught how to deal with her migraine pain. Damaris clarifies how Dr. Alex Jimenez’s migraine treatment is one of the best treatments she’s received and she highly recommends chiropractic care as the best non-surgical choice for enhancing and healing her migraine headaches.

Chiropractic Migraine Treatment & Relief

 

A migraine is commonly referred to as a primary headache disorder characterized by recurrent headaches as well as identified by moderate to severe in intensity. Ordinarily, the migraine headaches affect one half of the brain, are pulsating in personality, and might last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, noise, or odor. The pain could be aggravated by bodily activity. One third of people who suffer with migraines experience migraine with aura: normally a brief number of visual disturbance suggests that the headache will soon happen. It can also occur with minimal if any aggravation pain following it.

migraine treatment el paso tx.

We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.

Our services are specialized and focused on injuries and the complete recovery process.�Our areas of practice include:Wellness & Nutrition, Chronic Pain,�Personal Injury,�Auto Accident Care, Work Injuries, Back Injury, Low�Back Pain, Neck Pain, Migraine Treatment, Sport Injuries,�Severe Sciatica, Scoliosis, Complex Herniated Discs,�Fibromyalgia, Chronic Pain, Stress Management, and Complex Injuries.

As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.

If you have enjoyed this video and/or we have helped you in any way please feel free to subscribe and recommend�us.

Recommend: Dr. Alex Jimenez � Chiropractor

Health Grades: http://www.healthgrades.com/review/3SDJ4

Facebook Clinical Page: https://www.facebook.com/dralexjimene…

Facebook Sports Page: https://www.facebook.com/pushasrx/

Facebook Injuries Page: https://www.facebook.com/elpasochirop…

Facebook Neuropathy Page: https://www.facebook.com/ElPasoNeurop…

Yelp: http://goo.gl/pwY2n2

Clinical Testimonies: https://www.dralexjimenez.com/categor…

Information: Dr. Alex Jimenez � Chiropractor

Clinical Site: https://www.dralexjimenez.com

Injury Site: https://personalinjurydoctorgroup.com

Sports Injury Site: https://chiropracticscientist.com

Back Injury Site: https://elpasobackclinic.com

Linked In: https://www.linkedin.com/in/dralexjim…

Pinterest: https://www.pinterest.com/dralexjimenez/

Twitter: https://twitter.com/dralexjimenez

Twitter: https://twitter.com/crossfitdoctor

Recommend: PUSH-as-Rx ��

Rehabilitation Center: https://www.pushasrx.com

Facebook: https://www.facebook.com/PUSHftinessa…

PUSH-as-Rx: http://www.push4fitness.com/team/

Understanding Neck Pain and Headaches

Understanding Neck Pain and Headaches

My treatment with Dr. Alex Jimenez has been helping me by simply making me less tired. I’m not experiencing as many headaches. The headaches are going down dramatically and my back feels much better. I would highly recommend Dr. Alex Jimenez. He’s very friendly, his staff is very friendly and everybody goes well beyond what they can do to help you. -�Shane Scott

 

A majority of the populations has suffered from this well-known nagging health issue, however, did you know that headaches can sometimes be caused by neck pain? While these headaches are commonly referred to as as cervicogenic headaches, other types of headaches, such as cluster headaches and even migraines, have also been determined to be caused by neck pain. Neck pain can develop due to a variety of reasons and it can vary tremendously from mild to severe.

 

Therefore, it’s fundamental to seek a proper diagnosis if you’ve experienced headaches or neck pain to determine the root cause of your symptoms as well as to properly determine what treatment option will be best for your specific health issue. Healthcare professionals will assess your upper back, or the cervical spine, including your neck, base of the skull and cranium, and also all the surrounding muscles and nerves to find the source of your symptoms. Before seeking help from a doctor, however, it’s important to understand how neck pain can cause headaches. Below, we will discuss the anatomy of the cervical spine, or neck, as well as demonstrate how neck pain is connected to headaches.

 

How Neck Pain Causes Headaches

 

The muscles located between the shoulder blades, upper portion of the shoulders and those surrounding the neck, or cervical spine, may all cause neck pain if they become too tight or stiff. This can generally occur due to trauma or damage from an injury, as well as in consequence to bad posture or poor sitting, lifting or work habits. The tight muscles will result in your neck joints feeling stiff or compressed and it can even radiate pain towards your shoulders. Over time, the balance of the neck muscles changes and those specific muscles which are meant to support the neck become weak and can ultimately begin to make the head start to feel heavy, increasing the risk of experiencing neck pain as well as headaches..

 

Furthermore, the roots of the upper 3 cervical spinal nerves, which are found at C1, C2, and C3, share a pain nucleus, which routes pain signals to the brain, along with the trigeminal nerve. The trigeminal nerve is the main sensory nerve that is in charge of carrying messages from the face to your brain. Because of the shared nerve tracts, pain is misunderstood and thus “felt” by the brain as being located in the head. Fortunately, many healthcare professionals�are experienced in the assessment and correction of muscular imbalances which may lead to neck pain and headaches. Moreover, they can help to relieve muscle tension, enhance muscle length and joint mobility, and retrain correct posture.

 

What Causes Neck Pain and Headaches?

 

Cervicogenic headaches, otherwise known as “neck headaches”, are caused by painful neck joints, tendons or other structures surrounding the neck, or cervical spine, which may refer pain to the bottom of the skull, to your face or head. Researchers believe that neck headaches, or cervicogenic headaches, account for approximately 20 percent of all headaches diagnosed clinically. Cervicogenic headaches and neck pain are closely associated with each other, although other types of headaches can also cause neck pain.

 

This type of head pain generally starts because of an injury, stiffness or lack of proper functioning of the joints found at the top of your neck, as well as tight neck muscles or swollen nerves, which could trigger pain signals that the brain then interprets as neck pain. The usual cause of neck headaches is dysfunction in the upper three neck joints, or 0/C1, C1/C2, C2/C3, including added tension in the sub-occipital muscles. Other causes for cervicogenic headaches and neck pain can include:

 

  • Cranial tension or trauma
  • TMJ (JAW) tension or altered bite
  • Stress
  • Migraine headaches
  • Eye strain

 

The Link Between Migraines and Neck Pain

Neck pain and migraines also have an intricate connection with each other. While in some cases, severe trauma, damage or injury to the neck can lead to severe headaches like migraine, in other situations neck pain might be the result of a migraine headache. However, it’s never a good idea to assume that one is the end result of the other. Seeking treatment for neck pain when the reason for your concern is in fact a migraine, often will not lead to effective pain management or pain relief. The best thing that you can do if you’re experiencing neck pain and headaches is to seek immediate medical attention from a specialized healthcare professional in order to determine the cause of your pain, as well as to determine the root cause of the symptoms.

 

Unfortunately, neck pain, as well as a variety of headaches, are commonly misdiagnosed or even sometimes go undiagnosed for an extended period of time. As a matter of fact, one of the top reasons as to why neck pain may be so difficult to treat is primarily because it takes a long time for people to take this health issue seriously and seek a proper diagnosis. Waiting an extended amount of time to take care of your neck pain, especially after an injury, may lead to acute pain and it may even make the symptoms more difficult to control, turning them into chronic pain. By the time a patient seeks diagnosis for their neck pain, it may have already been a persistent problem. Also, the most frequent reasons people seek treatment for neck pain and headaches include:

 

  • Chronic migraines and headaches
  • Restricted neck function, including difficulties moving the head
  • Soreness in the neck, upper back and shoulders
  • Stabbing pain and other symptoms, particularly in the neck
  • Pain radiating from the neck and shoulders to the fingertips

 

Aside from the symptoms mentioned above, individuals with neck pain and headaches can also experience additional symptoms, including nausea, diminished eyesight, difficulty concentrating, severe fatigue, and even difficulty sleeping.While there are circumstances in which the cause of your headaches or neck pain may be apparent, such as being in a recent automobile accident or suffering from sport-related trauma, damage or injuries, in several instances, the cause may not be quite as obvious.

 

Because neck pain and headaches can also develop as a result of bad posture or even due to nutritional problems, it’s fundamental to find�the origin of the pain to increase the success of treatment, in addition to enabling you to prevent the health issue from happening again in the future. It’s common for a healthcare professional to devote their time working with you to ascertain what could have caused the pain in the first place.

 

A Health Issue You Can’t Ignore

 

Neck pain is typically not a problem which should be ignored. You may think that you’re only experiencing minor neck discomfort and that it’s irrelevant to any other health issues you may be having, but more frequently than not, you can’t know for sure till you receive a proper diagnosis for your symptoms. Patients who seek immediate medical attention and treatment for their neck-centered problems are surprised to learn that some of the other health issues they may be experiencing may actually be correlated, such as in the case of neck pain and headaches. Thus, even in the event that you think you can “live with” not being able to turn your neck completely, other health issues can develop, and these problems might be more challenging to deal with.

 

There are circumstances in which a pinched nerve in the neck is the main reason for chronic tension headaches, where a previous sports injury that was not properly addressed before is now the cause of the individual’s limited neck mobility and in which a bruised vertebrae at the base of the neck induces throbbing sensations throughout the spine, which radiates through the shoulders into the arms, hands and fingers. You might also blame your chronic migraines on a hectic schedule and stressful conditions, however, it might truly be a consequence of poor posture and the obligated hours that you spend hunched over a computer screen.�Untreated neck pain might even lead to problems you might never expect, such as balance problems or trouble gripping objects. This is because all the neural roots located on the upper ligaments of the cervical spine, or neck, are connected to other parts of the human body, from your biceps to each one of your small fingers.

 

Working with a healthcare professional to relieve the root cause of your neck pain and headaches may significantly enhance your quality of life and may be able to eliminate other symptoms from turning into a significant problem. While the most common causes of chronic migraines are generally caused by another health issue or nutritional deficiency, you might also be amazed to learn how often the outcome is something which may be resolved with concentrated exercises and stretches recommended by a healthcare professional, such as a chiropractor. Additionally, you may understand that the health issues you’ve been having often develop from compressed, pinched, irritated or inflamed nerves in your upper cervical nerves.

 

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Dr. Alex Jimenez’s Insight

Although it may be difficult to distinguish the various types of headaches, neck pain is generally considered to be a common symptom associated with head pain. Cervicogenic headaches are very similar to migraines, however, the primary difference between these two types of head pain is that a migraine occurs in the brain while a cervicogenic headache occurs in the base of the skull or in the cervical spine, or neck. Furthermore, some headaches may be caused by stress, tiredness, eyestrain and/or trauma or injury along the complex structures of the cervical spine, or neck. If you are experiencing neck pain and headaches, it’s important to seek help from a healthcare professional in order to determine the true cause of your symptoms.

 

Treatment for Neck Pain and Headaches

 

Foremost, a healthcare professional must�determine the cause of an individual’s symptoms through the use of appropriate diagnostic tools as well as to make sure they have the utmost success in relieving the headache and neck pain without prolonging the duration of the symptoms and extra cost of incorrect therapy. Once an individual’s source of neck pain and headaches has been diagnosed, the kind of treatment a patient receives ought to be dependent on the type of headache. As a rule of thumb, treatment starts once the diagnosis has been made.�A healthcare professional will work with you to create a treatment plan that’s appropriate for your specific health issues. In your sessions, you’ll be taken through procedures that help build flexibility and strength.

 

Chiropractic care is a well-known, alternative treatment option which focuses on the diagnosis, treatment and prevention of a variety of musculoskeletal and nervous system injuries and/or conditions. A doctor of chiropractic, or chiropractor, can help treat neck pain and headache symptoms by carefully correcting any spinal misalignments, or subluxations, in the cervical spine or neck, through the use of spinal adjustments and manual manipulations, among other therapeutic techniques. Chiropractors, as well as physical therapists, may also utilize�a combination of gentle Muscle Energy Techniques, muscle building, joint slides, cranio-sacral therapy, and specific posture and muscle re-education to lower the strain being placed on the structures surrounding the cervical spine.�The staff will also help you understand how to better position yourself during your daily life to prevent relapses, like ergonomic and posture tips. Contact a healthcare professional in order for them to be able to assist you immediately.

 

In cases where alternative treatment options have been utilized without any results, or sometimes simply being used together with other complementary treatment approaches, pain drugs and/or medications may be contemplated, such as non-steroidal anti-inflammatory drugs (NSAIDs), anti-seizure agents such as gabapentin, tricyclic anti-depressants, or migraine prescriptions. If pain medications prove ineffective, then injections may be contemplated, including peripheral nerve blocks, atlantoaxial joint block administered at C1-C2, or aspect joint blocks administered in C2-C3. Surgical interventions may also be other treatment options, however, healthcare professionals suggest attempting all other treatment options before considering surgery.�The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

 

Curated by Dr. Alex Jimenez

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Additional Topics: Back Pain

 

Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

 

 

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EXTRA IMPORTANT TOPIC:�Chiropractic Neck Pain Treatment�

 

 

Benign and Sinister Types of Headaches

Benign and Sinister Types of Headaches

Headaches are very common health issues, and lots of people treat themselves by using basic painkillers, drinking additional water, with rest, or by simply waiting for the headache to go away on its own. As a matter of fact, a headache is among the most common reasons for doctor office visits.

 

Just about everyone will experience a headache sometime during their life. Most headaches are not caused by serious or sinister conditions. However, people understandably worry if headaches feel different, whether they’re especially severe, particularly frequent or unusual in any other manner. But, the most common concern is whether the headache may be a symptom of an underlying health issue, such as a brain tumor.

 

The following article discusses headaches generally. It explains the various types of headaches you may experience and describes those very rare situations where a headache may be a symptom of a serious disease.

 

Types of Headaches

 

Headaches can be categorized as primary, or they can be classified as secondary, meaning they are a side-effect of another injury or condition.

 

A healthcare professional can usually determine the possible cause of your headaches from speaking to you and examining you. When they have found the cause then you’ll have the ability to decide the best treatment approach for your head pain symptoms. This may involve taking drugs only when you get the headaches, taking daily medication to stop them altogether, and/or even stopping medication you’re already taking. Very occasionally, headaches may need further diagnosis to rule out more serious underlying causes. Chiropractic care and physical therapy are also commonly utilized to help treat headaches. Below, we will discuss the different types of headaches.

 

Primary Headaches

 

The most common types of headaches, by far, are tension headaches and migraines.

 

Tension Headaches

 

Tension headaches are generally felt as a band around the forehead. They may last for many days. They may be tiring and uncomfortable, but they don’t normally disturb sleep. Most people can carry on working with a tension headache. These often have a tendency to worsen as the day progresses, however, they aren’t usually made worse with physical activities, though it’s not strange to be somewhat sensitive to bright light or noise.

 

Migraines

 

Migraines are also very common types of headaches. A typical migraine is described as a throbbing sensation. Headaches which are one-sided, headaches which throb and headaches that make you feel sick are more inclined to be migraines compared to anything else. Migraines are often severe enough to be disabling. Some individuals will need to go to bed to sleep off their aggravation.

 

Cluster Headaches

 

Cluster headaches are extremely severe headaches, sometimes called “suicide headaches”. They occur in clusters, often every day for a number of days or maybe weeks. Then they vanish for weeks on end. These types of headaches are rare and often occur particularly in adult male smokers. They’re intense, one-sided headaches, which are very disabling, meaning they stop routine activity. People often describe them as the worst pain they have ever felt. Cluster headaches are typically one-sided. Patients frequently have a red watery eye on the other hand, a stuffy runny nose and a droopy eyelid.

 

Chronic Tension Headaches

 

Chronic tension headaches (or chronic daily headache) is generally caused by muscle tension in the back of the neck and affects women more frequently than men. Chronic means that the problem is persistent and ongoing. These headaches can develop due to neck injuries or tiredness and may worsen with drug/medication overuse. A headache that occurs virtually every day for 3 weeks or more is known as a chronic daily headache or a chronic tension headaches.

 

Medication-Overuse Headaches

 

Medication-overuse headaches or medication-induced aggravation, is an unpleasant and long-term headache. It’s brought on by taking painkillers usually meant for headaches. Unfortunately, when painkillers are taken regularly for headaches, the body reacts by creating additional pain sensors in the brain. Finally, the pain sensors are so many that the head becomes super-sensitive and the headache won’t go away. Individuals who have these headaches often take an increasing number of painkillers to attempt and feel much better. But, the painkillers may have regularly long ceased to work. Medication-overuse headaches are the most common cause of secondary headache.

 

Exertional Headaches/Sexual Headaches

 

Exertional headaches are headaches associated with physical activity. They may get severe very quickly following a strenuous activity like coughing, running, with intercourse, and straining with bowel movements. They’re more commonly experienced by patients that also have migraines, or who have relatives with migraine.

 

Headaches associated with sex particularly worry patients. They can occur as sex starts, at orgasm, or following sex. Headaches at orgasm would be the most common type. They are generally acute, at the back of the head, behind the eyes or all around. They last about twenty minutes and aren’t usually an indication of any other underlying health issues or problems.

 

Exertional and sexual intercourse-related headaches aren’t typically an indication of serious underlying problems. Very occasionally, they can be a sign that there is a leaky blood vessel on the surface of the brain. As a result, if they are marked and repeated, it’s sensible to talk about them with your healthcare professional.

 

Primary Stabbing Headaches

 

Primary traumatic headaches are sometimes called “ice-pick headaches” or “idiopathic stabbing headache”. The term “idiopathic” is used by doctors for something that comes without a clear cause. These are brief, stabbing headaches that are extremely sudden and severe. They generally last between 5 and 30 seconds and they occur at any time of the day or night. They feel as though a sharp object, like an ice pick, is being stuck into your head. They frequently occur in or just behind the ear and they are sometimes quite frightening. Even though they aren’t migraines they’re more prevalent in those who suffer from migraines, nearly half of individuals who experience migraines have principal stabbing headaches.

 

They are often felt at the place on the head where the migraines have a tendency to happen. Primary stabbing headaches are too brief to take care of, even though migraine prevention medications may reduce their number.

 

Hemicrania Continua

 

Hemicrania continua is a major chronic daily headache. It typically induces a continuous but shifting pain on one side of the brain. The pain is generally continuous with episodes of severe pain, which can last between 20 minutes and several days. During those episodes of severe pain there may be other symptoms, such as watering or redness of the eye, runny or blocked nose, and drooping of the eyelid, around precisely the same side as the aggravation. Similar to a migraine, there may also be sensitivity to light, feeling sick, such as nausea, and being sick, such as vomiting. The headaches do not go away but there may be periods when you don’t have any headaches. Hemicrania continua headaches respond to medicine called indometacin.

 

Trigeminal Neuralgia

 

Trigeminal neuralgia causes facial pain. The pain consists of very short bursts of electric shock-like sensations in the face, particularly at the area of the eyes, nose, scalp, brow, lips or limbs. It’s usually one-sided and is more common in people over age 50. It may be triggered by touch or a light breeze on the surface area.

 

Headache Causes

 

Occasionally, headaches have underlying causes, and treatment of the headache involves treating the cause. Individuals often fear that headaches are caused by serious illness, or by high blood pressure. Both of these are extremely uncommon causes of headache, really increased blood pressure usually causes no symptoms in any way.

 

Chemicals, Drugs and Substance Withdrawal

 

Headaches can be because of a substance, or its withdrawal, for example:

 

  • Carbon monoxide, that is made by gas heaters which aren’t properly ventilated
  • Drinking alcohol, with headache often experienced the morning afterwards
  • Deficiency of body fluid or dehydration

 

Headaches Due to Referred Pain

 

Some headaches may be caused by pain in some other portion of the head, such as ear or tooth pain, pain in the jaw joint and pain in the neck.

 

Sinusitis is also a frequent cause of headaches. The sinuses are “holes” in the skull which are there to stop it from becoming too heavy for the neck to transport around. They are lined with mucous membranes, such as the lining of the nose, and this creates mucus in response to colds or allergy. The liner membranes also swell and can block the drainage of the mucus out of the space. It subsequently becomes cracked and infected, resulting in headache. The headache of sinusitis is often felt at the front of the head and also in the face or teeth.

 

Frequently the face feels tender to tension, particularly just below the eyes beside the nose. You might have a stuffy nose and the pain is often worse when you bend forwards. Acute sinusitis is the kind that comes on fast in conjunction with a cold or abrupt allergy. You may have a temperature and be generating a lot of mucus. Chronic sinusitis may be caused by allergy, by overusing decongestants or with the acute sinusitis that doesn’t settle. The sinuses become chronically infected and the nasal linings chronically swollen. The contents of this uterus may be thick but frequently not infected.

 

Acute glaucoma can cause severe headaches. In this condition, the pressure inside the eyes goes up suddenly and this causes a surprisingly, very severe headache behind the eye. Even the eyeball can feel really hard to touch, the eye is red, the front part of the eye, or cornea, can seem cloudy and the eyesight is generally blurred.

 

What Types of Headaches are Dangerous or Serious?

 

All headaches are unpleasant and some, such as headache from medication abuse, are serious in the sense that if not treated correctly they might never go away. But a few headaches are indications of serious underlying issues. These are uncommon, in many cases very rare. Dangerous headaches often occur suddenly, and also eventually become increasingly worse over time. They are more common in elderly people. They comprise of the following:

 

Bleeding Around the Brain (Subarachnoid Haemorrhage)

 

Subarachnoid haemorrhage is a really serious condition which occurs when a tiny blood vessel pops on the surface of the brain. Patients develop a serious headache and stiff neck and may become unconscious. This is a rare cause of acute headache.

 

Meningitis and Brain Infections

 

Meningitis is infection of the tissues around and on the surface of the brain and encephalitis is infection of the brain itself. Brain infections can be caused by germs called bacteria, viruses or parasites and they are thankfully rare. They cause a severe, disabling headache. Normally, patients may feel sick or vomit and can’t bear bright lights, something known as photophobia. Often they have a rigid neck, too stiff for your physician to have the ability to bend the head down so that the chin touches the chest, even in the event that you attempt to relax. Patients are generally also unwell, experiencing hot, sweaty and overall sick sensations.

 

Giant Cell Arteritis (Temporal Arteritis)

 

Giant cell arteritis (temporal arteritis) is, generally, just seen in people over the age of 50. It is due to swelling, or inflammation, of the arteries at the temples and behind the eye. It causes a headache behind the forehead, also referred to as a sinus headache. Typically the blood vessels at the forehead are tender and individuals detect pain from the scalp when they comb their own hair. Frequently the pain gets worse with chewing. Temporal arteritis is severe because if it’s not treated it can cause sudden loss of eyesight. Treatment is with a course of steroids. The need to keep these steroids is generally monitored by the GP through blood tests, and they are typically needed for several months.

 

Brain Tumors

 

Brain tumors are a very uncommon cause of headache, although most patients with long-term, severe or persistent headaches start to worry that this might be the reason. Brain tumors can lead to headaches. Usually the aggravation of brain tumors exists on waking in the morning, is worse on sitting up, and becoming steadily worse in the day to day, never easing and never disappearing. It can sometimes be worse on coughing and sneezing, as may sinus headaches and migraines.

 

When Should I Worry About a Headache?

 

Most headaches do not have a serious underlying cause. However, healthcare professionals are trained to ask you about the signs and symptoms that might suggest your headache needs further diagnosis, just to make certain it’s nothing serious.

 

The things which would suggest to your physician and nurse that your headache may need additional evaluation include the following. They don’t mean that your headache is severe or sinister, but they imply that the healthcare professional may wish to do some additional evaluations to make sure if:

 

  • You have had a substantial head injury in the previous three months.
  • Your headaches are worsening and accompanied with high temperature or fever.
  • Your headaches begin extremely unexpectedly.
  • You’ve developed problems with speech and balance as well as headache.
  • You’ve developed problems with your memory or changes in your behavior or personality in addition to headache.
  • You’re confused or muddled along with your headache.
  • Your headache started when you coughed, sneezed or strained.
  • Your headache is much worse when you sit or stand.
  • Your headache is associated with red or painful eyes.
  • Your headaches are not like anything you’ve ever experienced before.
  • You have unexplained nausea together with the aggravation.
  • You have low immunity, for instance, when you have HIV, or are about oral steroid medicine or immune suppressing drugs.
  • You have or have had a type of cancer that can spread throughout the body.

 

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Dr. Alex Jimenez’s Insight

Headaches are extremely common health issues which affect a wide range of the population around the world. Although frequent, a headache which is described to be like no other ever experienced before, may often become a concern. There are several types of headaches which can be caused by a variety of injuries and/or underlying conditions. As a healthcare professional, it’s essential to be able to determine between sinister or dangerous types of headaches and benign types of headaches, in order to decide the best treatment approach. By properly diagnosing the source of a patient’s headaches, both benign and sinister types of headaches can be treated accordingly.

 

Overview

 

Many headaches, whilst unpleasant, are harmless and react to a variety of treatments, including chiropractic care. Migraine, tension headaches and medication-overuse headaches are very common. The majority of the populace will experience one or more of these. Working out exactly the underlying cause of any headaches through discussion with your doctor is often the best method to resolve them. It is possible to develop a persistent or chronic and constant headache through taking drugs and/or medications that you took to get rid of your headache. Your physician can support you through the practice of quitting painkillers when that is the case.

 

Headaches are, quite infrequently, an indication of a serious or sinister underlying illness, and many headaches go away on their own.

 

If you have a headache which is uncommon for you then you need to discuss it with your doctor. You should also speak to your doctor about headaches which are particularly severe or that affect your regular activities, those that are associated with other symptoms, such as tingling or weakness, and those which make your own scalp tender, especially if you’re over 50 years old. Finally, always speak to a healthcare professional when you have an unremitting morning headache which is present for at least three days or is becoming gradually worse.

 

Remember that headaches are not as likely to occur in people who:

 

  • Handle their anxiety levels well.
  • Eat a balanced, regular diet.
  • Take balanced routine exercise.
  • Focus on posture and core muscles.
  • Sleep on two pillows or fewer.
  • Drink loads of water.
  • Have plenty of sleep.

 

Anything that you can do to enhance one or more of these aspects of your life will improve your health and well-being and cut back the number of headaches you experience. Make sure to seek the appropriate medical attention from a qualified and experienced healthcare professional in the event of a severe headache unlike anything you’ve ever experienced before. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Back Pain

 

Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

 

 

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EXTRA IMPORTANT TOPIC: Low Back Pain Management

 

MORE TOPICS: EXTRA EXTRA:�Chronic Pain & Treatments

 

Chiropractic Benefits Those That Suffer From Migraine Headaches

Chiropractic Benefits Those That Suffer From Migraine Headaches

Chiropractic Benefits: If you have ever had a migraine before then you know that it is much more than a simple headache. The symptoms of a migraine can be debilitating, lasting hours and even days. According to the Migraine Research Foundation, it is the eighth most disabling disease in the world. It is estimated that 38 million people in the United States alone suffer from migraine headaches. That�s around one in every ten people.

According to the Migraine Research Foundation, migraine headaches are extremely difficult to treat and even more difficult to control. This is mainly due to the fact that doctors still don�t know exactly what causes it. This leaves it undiagnosed in many patients and often terribly under treated in those with a diagnosis.

The best many doctors seem to be able to do is prescribe pain medication that has undesirable side effects in an effort to manage the symptoms. However, chiropractic has been shown in several studies to not only effectively manage the pain of migraines, it also helps stop and prevent them.

Anatomy Of A Migraine Headache

There are two types of migraines, those with an aura and those without an aura. An aura can appear up to an hour before the onset of a migraine. It is a warning sign that usually presents as a disturbance that is either visual or olfactory. The person may see flashes of light or smell particular odors before the headache begins. About one in six migraines are preceded by an aura.

Once the migraine itself begins, the pain is typically on one side of the head, although this is not always the case. Other symptoms may include nausea, vomiting, sensitivity to noise, sensitivity to light, and sensitivity to smell. Some patients experience an inability to concentrate, hot or cold flashes, stiffness in neck or shoulders, slurred speech, loss of coordination, and in rare cases, loss of consciousness.

The migraine can last several minutes, hours, or even days. Afterwards the patient may feel fatigued or washed out. They may be unable to concentrate and either lethargic or extremely energetic.

Studies Show: Chiropractic As A Migraine Treatment

There have been several clinical studies on chiropractic as a treatment for migraine headaches. The results of one study reported that 22 percent of patients who received chiropractic treatment for their migraines reported that their attacks were reduced by more than 90 percent. Additionally, 49 percent reported that the intensity of their migraines was significantly reduced.

Another study randomly assigned people with migraine headaches several different treatments. One group was given Elavil, a daily medication, another group was given chiropractic treatment and a third group received a combination of the two treatments. The results showed that chiropractic was as effective in reducing migraines as the medication and it had fewer side effects. Other studies have also found that chiropractic is as effective as medication for the treatment and prevention of migraine or tension headaches.

Chiropractic Benefits For Migraines Headaches

Spinal adjustments are very effective as a treatment for migraines. The whole body approach of chiropractic also utilizes dietary recommendations, including foods to avoid, as well as lifestyle changes.

The patient may be counseled on managing stress, advised to engage in exercise, and given supplements. The treatments may be used to reduce the pain and severity of a migraine once it begins or it can be used to prevent migraines and reduce their frequency.

Chiropractic benefits everyone and is a safer treatment with fewer side effects than�prescription medications. Chiropractic is quickly becoming the treatment of choice for many migraine sufferers. As the studies show, it works! So if you or a loved one suffer from migraines, give us a call. Our Doctor of Chiropractic is here to help!

Injury Chiropractic Clinic: Migraine Treatment & Recovery

Suffer From Migraine Headaches How Chiropractic Helps | El Paso, TX.

Suffer From Migraine Headaches How Chiropractic Helps | El Paso, TX.

Suffer Migraines: If you�ve ever had a migraine you know that it�s more than just a headache. The debilitating pain can be accompanied by nausea and other symptoms � and it�s more common than you may think. Research shows that in every four American households, one person is a migraine sufferer. In fact, 12 percent of the U.S. population suffers from migraines, including children. This means migraines affect more people that asthma and diabetes combined.

It is estimated that 18 percent of women suffer from migraines while 6 percent of men are migraine sufferers. It most commonly affects people who are between the ages of 25 and 55, but even young children have been diagnosed. Migraines can stop you in your tracks, but there are treatments that can help. Chiropractic care has been shown to help ease the pain, intensity, and frequency of migraines.

Suffer From Migraines

What Is A Migraine?

Migraines are vicious headaches that can last several minutes to several hours or even days. It is characterized by intense pulsing or a throbbing sensation that is typically confined to one area of the head. It is often accompanied by vomiting, nausea, and extreme sensitivity to sound and light. The pain can be so severe that you can barely function. Many people find themselves confined to bed in a darkened room, waiting for it to pass.

Many times migraine sufferers report experiencing an aura, or sensory warning symptoms, such as strange smells, blind spots, flashes of light, or tingling in your leg or arm. They also tend to run in families. If one parent is a migraine sufferer the child has a 40 percent chance of having migraines as well. If both parents get migraines that chance jumps to 90 percent. It is the 8th most debilitating illness on a global scale.

For the most part, doctors do not know much about what causes migraines. However, there are some things that have been identified as migraine triggers:

  • Hormonal changes � at certain times during the month, women experience fluctuations in estrogen which can trigger migraines
  • Oral contraceptives � medications that change or replace hormones can make headaches worse
  • Certain foods � processed foods, MSG, salty foods, aged cheeses
  • Fasting or skipping meals
  • Aspartame
  • Alcohol
  • Stress
  • Sensory overstimulation
  • Dehydration
  • Intense physical exertion
  • Too much or too little sleep
  • Medications

How Chiropractic Care Can Help Migraine Sufferers

Many doctors believe that headaches and migraines may be caused by a spine that is out of alignment. When your spine is misaligned your entire body suffers. It can irritate the nerves that run from the brain to the spine causing a headache. Chiropractic adjustments can help relieve the pain of migraines. In fact, many people report a distinct difference after just one session.

A Doctor of Chiropractic will align your spine and work with you to create a wellness plan that includes lifestyle changes and diet. Making changes to your sleep patterns and eliminating certain foods from your diet can help prevent migraines. By creating a whole body wellness program, you and your chiropractor can not only help prevent your migraines, but other health conditions as well.

Your chiropractor may also recommend that you keep a journal to help you pinpoint your own unique migraine triggers. You will record the foods you eat, environmental factors that may affect you, stressors, and sleep patterns, as well as when you have migraines, how long they last, and their severity. By tracking these things, you can determine what may be causing your migraines and make adjustments to your lifestyle, thus preventing them. Incorporating chiropractic care as part of your whole body maintenance, as well as migraine prevention, can help you stave off these headaches so you can get on with your life.

If you or a loved one suffers from migraine headaches, make sure you give us a call. Our Doctor of Chiropractic is here to help!

Chiropractic Clinic Extra: Migraine Treatment & Recovery

Whiplash Treatment Guidelines in El Paso, TX

Whiplash Treatment Guidelines in El Paso, TX

Whiplash is one of the most prevalent types of injuries resulting from an automobile accident, most commonly during rear-end auto collisions. However, whiplash-associated disorders can develop due to a variety of other circumstances, including sports injuries, amusement park rides or physical abuse. Whiplash occurs when the soft tissues of the neck, such as the muscles, tendons and ligaments, extend beyond their natural range of motion because of a sudden back-and-forth movement of the head. Furthermore, the sheer force of an impact can stretch and even tear the complex structures surrounding the cervical spine.

 

The symptoms of whiplash-associated disorders may take days, weeks or even months to manifest, which is why it’s important for individuals who’ve been involved in an automobile accident to seek immediate medical attention. There are many different types of treatment options which can safely and effectively help treat whiplash. The purpose of the following article is to demonstrate the treatment guidelines of neck pain-associated disorders and whiplash-associated disorders.

 

The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline

 

Abstract

 

  • Objective: The objective was to develop a clinical practice guideline on the management of neck pain�associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline replaces 2 prior chiropractic guidelines on NADs and WADs.
  • Methods: Pertinent systematic reviews on 6 topic areas (education, multimodal care, exercise, work disability, manual therapy, passive modalities) were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and data extracted from admissible randomized controlled trials. We incorporated risk of bias scores in the Grading of Recommendations Assessment, Development, and Evaluation. Evidence profiles were used to summarize judgments of the evidence quality, detail relative and absolute effects, and link recommendations to the supporting evidence. The guideline panel considered the balance of desirable and undesirable consequences. Consensus was achieved using a modified Delphi. The guideline was peer reviewed by a 10-member multidisciplinary (medical and chiropractic) external committee.
  • Results: For recent-onset (0-3 months) neck pain, we suggest offering multimodal care; manipulation or mobilization; range-of-motion home exercise, or multimodal manual therapy (for grades I-II NAD); supervised graded strengthening exercise (grade III NAD); and multimodal care (grade III WAD). For persistent (N3 months) neck pain, we suggest offering multimodal care or stress self-management; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises (grades I-II NAD); multimodal care or practitioner�s advice (grades I-III NAD); and supervised exercise with advice or advice alone (grades I-II WAD). For workers with persistent neck and shoulder pain, evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone (grades I-III NAD).
  • Conclusions: A multimodal approach including manual therapy, self-management advice, and exercise is an effective treatment strategy for both recent-onset and persistent neck pain. (J Manipulative Physiol Ther 2016;39:523-44.e20) Key
  • Indexing Terms: Practice Guideline; Neck Pain; Whiplash Injuries; Chiropractic; Therapeutic Intervention; Disease Management; Musculoskeletal Disorders

 

Dr. Alex Jimenez’s Insight

Whiplash occurs when the sheer force of an impact causes the head and neck to jolt abruptly back-and-forth in any direction, stretching the complex structures surrounding the cervical spine beyond their normal range. Neck pain, headache and radiating pain resulting from whiplash are common complaints frequently reported by individuals after being involved in an automobile accident. However, whiplash can also result from a variety of other circumstances. Whiplash-associated disorders are a prevalent source of disability and a common reason many auto accident victims seek medical attention from chiropractors, physical therapists and primary care physicians. Fortunately, many treatment guidelines exist to safely and effectively improve as well as manage the symptoms of whiplash. Chiropractic care is a well-known alternative treatment option for whiplash-associated disorders. Spinal adjustments and manual manipulations can safely and effectively restore the original alignment of the spine, reducing symptoms and alleviating whiplash complications.

 

Introduction

 

Neck pain and its associated disorders (NAD), including headache and radiating pain into the arm and upper back, are common and result in significant social, psychological, and economic burden.1-4 Neck pain, whether attributed to work, injury, or other activities,5 is a prevalent source of disability and a common reason for consulting primary health care providers, including chiropractors, physical therapists, and primary care physicians.6 The estimated annual incidence of neck pain measured in 4 studies ranged between 10.4% and 21.3%, with a higher incidence noted in office and computer workers.7 Although some studies report that between 33% and 65% of people have recovered from an episode of neck pain at 1 year, most cases follow an episodic course over a person�s lifetime, and thus, relapses are common.7 Neck pain is a leading cause of morbidity and chronic disability worldwide.5,8 In 2008 the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders reported that 50% to 75% of individuals with neck pain also report pain 1 to 5 years later.4 Several modifiable and nonmodifiable environmental and personal factors influence the course of neck pain, including age, previous neck injury, high pain intensity, self-perceived poor general health, and fear avoidance.7

 

Neck pain related to whiplash-associated disorders (WADs) most commonly results from motor vehicle accidents.9,10�Whiplash-associated disorders disrupt the daily lives of adults around the world and are associated with considerable pain, suffering, disability, and costs.3,11 Whiplash-associated disorders are defined as an injury to the neck that occurs with sudden acceleration or deceler- ation of the head and neck relative to other parts of the body, typically occurring during motor vehicle collisions.10,12 The majority of adults with traffic injuries report pain in the neck and upper limb pain. Other common symptoms of WADs include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.9,10 The global yearly incidence rate of emergency department visits as a result of acute whiplash injuries after road traffic crashes is between 235 and 300 per 100,000.3,13,14 In 2010, there were 3.9 million nonfatal traffic injuries in the United States.11 The economic costs of motor vehicle crashes that year totaled USD$242 billion, including $23.4 billion in medical costs and $77.4 billion in lost productivity (both market and household).11 In Ontario, traffic collisions are a leading cause of disability and health care use and�expenditures, resulting in the automobile insurance system paying nearly CND$4.5 billion in accident benefits in 2010.15

 

Diagram showing the process of whiplash resulting from an automobile accident.

 

More than 85% of patients experience neck pain after a motor vehicle accident, often associated with sprains and strains to the back and extremities, headache, psychological symptomatology, and mild traumatic brain injury.10 Whiplash injuries have an effect on general health, with recovery in the short term reported by 29% to 40% of individuals with WAD in Western countries that have compensation schemes for whiplash injuries. 16,17 The median time to first reported recovery is estimated at 101 days (95% confidence interval: 99-104) and about 23% are still not recovered after 1 year.13

 

Image displaying X-rays before and after whiplash.

 

Image demonstrating an X-ray of the neck during flexion and extension.

 

 

The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders recommended that all types of neck pain, including WADs,18 be included under the classification of NAD.19 NAD can be classified into 4 grades, distinguished by the severity of symptoms, signs, and impact on activities of daily life (Table 1).

 

The clinical management of musculoskeletal disorders, and neck pain in particular, can be complex and often involves combining multiple interventions (multimodal care) to address its symptoms and consequences.19�In this guideline, multimodal care refers to treatment involving at least 2 distinct therapeutic methods, provided by 1 or more health care disciplines.20 Manual therapy (including spinal manipulation), medication, and home exercise with advice are commonly used multimodal treatments for recent- onset and persistent neck pain.21,22 Thus, there is a need to determine which treatments or combinations of treatments are more effective for managing NAD and WAD.

 

Rationale for Developing This Guideline

 

The Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration20 recently updated the systematic reviews from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force).23 Consequently, it was deemed timely to update the recommendations of 2 chiropractic guidelines on NAD (2014)24 and WAD (2010)25 produced by the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (the �Federation�) into a single guideline.

 

Table 1 Classification of Neck Pain-Associated Disorders and Whiplash-Associated Disorders

 

Scope and Purpose

 

The aim of this clinical practice guideline (CPG) was to synthesize and disseminate the best available evidence on the management of adults and elderly patients with recent onset (0-3 months) and persistent (N3 months) neck pain and its associated disorders, with the goal of improving clinical decision making and the delivery of care for patients with NAD and WAD grades I to III. Guidelines are �Statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.�26

 

The target users of this guideline are chiropractors and other primary care health care providers delivering conservative care to patients with NADs and WADs, as well as policymakers. We define conservative care as treatment designed to avoid invasive medical therapeutic measures or operative procedures.

 

OPTIMa published a closely related guideline in the European Spine Journal.27 Although we reached similar results, OPTIMa developed recommendations using the modified Ontario Health Technology Advisory Committee (OHTAC) framework.28 In contrast, our guideline used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. GRADE provides a common, sensible, and transparent approach to grading quality (or certainty) of evidence and strength of recom- mendations (http://www.gradeworkinggroup.org). GRADE was the highest scoring instrument among 60 evidence grading systems29 and has been determined to be reproducible among trained raters.30 GRADE is now considered a standard in guideline development and has been adopted by many international guideline organizations and journals.31 The Canadian Chiropractic Guideline Initiative (CCGI) guideline panel considered available high-quality systematic reviews, updated the search of the peer-reviewed published reports up to December 2015, and then used the GRADE approach to formulate recommen- dations for the management of neck pain and associated disorders.

 

Framework

 

To inform its work, the CCGI considered recent advances in methods to conduct knowledge synthesis,32 derive evidence-based recommendations, 31,33 adapt high- quality guidelines, 34 and develop 35 and increase the uptake of CPGs.36,37 An overview of CCGI structure and methods is provided in Appendix 1.

 

Methods

 

Ethics

 

Because no novel human participant intervention was required and secondary analyses were considered, the research presented in this guideline is exempt from institutional ethics review board approval.

 

Selection of Guideline Development Panelists

 

The CCGI project lead (A.B.) appointed 2 co-chairs (J.O. and G.S.) for the guideline development group and nominated the project executive committee and the remaining guideline panelists. J.O. served as the lead methodologist on the guideline panel. G.S. helped ensure geographic representation of the panel and advised on specific duties of panel members, time commitment, and decision-making process for reaching consensus (develop- ment of key questions and of recommendations). To ensure a broad representation, the guideline panel included clinicians (P.D., J.W.), clinician researchers (F.A., M.D., C.H., S.P., I.P., J.S.) methodologists (J.O., A.B., M.S., J.H.), a professional leader/decision maker (G.S.), and 1 patient advocate (B.H.) to ensure that patient values and preferences were considered. One observer (J.R.) moni- tored the 3 face-to-face meetings of the guideline panel held in Toronto (June and September 2015 and April 2016).

 

All CCGI members, including guideline panelists and peer reviewers, were required to disclose any potential conflict of interest by topic before participation and during the guideline development process. There was no self- declaration of conflicts of interest among the panel or the reviewers.

 

Key Question Development

 

Six topic areas (exercise, multimodal care, education, work disability, manual therapy, passive modalities) on the conservative management of NAD and WAD grades I to III were covered in 5 recent systematic reviews by the OPTIMa Collaboration,38-42 among a total of 40 reviews on the management of musculoskeletal disorders.20 The panel met over 2 days in June 2015 to brainstorm about potential key questions.

 

Table 2 Topics and Key Questions Addressed by the Guideline Development Group

 

Table 2 Continued

 

Table 2 Continued (last)

 

Search Update and Study Selection

 

The panel assessed the quality of eligible systematic reviews using the AMSTAR tool43 and its 11 criteria (http://amstar.ca/Amstar_Checklist.php).

 

Because the last search dates of included systematic reviews were 2012,40,41 2013,38,39,42 and 2014,42 the panel updated the literature searches in Medline and Cochrane Central databases on December 24, 2015 using the published search strategies. We used a 2-phase screening process to select additional eligible studies. In phase 1, 2 independent reviewers screened titles and abstracts to determine the relevance and eligibility of studies. In phase 2, the same pairs of independent reviewers screened full-text articles to make a final determination of eligibility. Reviewers met to resolve disagreements and reach consensus on the eligibility of studies in both phases, with arbitration by a third reviewer if needed. Studies were included if they1 met the PICO (population, intervention, comparator, outcome) criteria and2 were randomized controlled trials (RCTs) with an inception cohort of at least 30 participants per treatment arm with the specified condition, because this sample size is considered the minimum needed for non-normal distributions to approx- imate the normal distribution.44

 

Data Abstraction and Quality Assessment

 

Data were extracted from the included studies identified in each systematic review, including study design, participants, intervention, control, outcomes, and funding.

 

The internal validity of included studies was assessed by the OPTIMa collaboration using the Scottish Intercollegiate Guidelines Network (SIGN) criteria.45

 

For articles retrieved from the updated search, pairs of independent reviewers critically appraised the internal validity of eligible studies using the SIGN criteria,46 similar to the OPTIMa collaboration reviews. Reviewers reached consensus through discussion. A third reviewer was used to resolve disagreements if consensus could not be reached. A quantitative score or a cutoff point to determine the internal validity of studies was not used. Instead, the SIGN criteria were used to assist reviewers in making an informed overall judgment on the risk of bias of included studies. 47

 

Synthesis of Results

 

J.O. extracted data from scientifically admissible studies into evidence tables. A second reviewer (A.B.) indepen- dently checked the extracted data. We performed a qualitative synthesis of findings and stratified results based on the type and duration of the disorder (ie, recent [symptoms lasting b3 months] vs persistent [symptoms lasting N3 months]).

 

Recommendation Development

 

We used the Guideline Development Tool (http:// www.guidelinedevelopment.org), and assessed the quality of the body of evidence for our outcomes of interest by�applying the GRADE approach.48 We used the evidence profiles to summarize the evidence.49 The quality of evidence rating (high, moderate, low, or very low) reflects our confidence in the estimate of the effect to support a recommendation and considers the strengths and limitations of the body of evidence stemming from risk of bias, imprecision, inconsistency, indirectness of results, and publication bias.50 Assessment of quality of evidence was carried out in the context of its relevance to the primary care setting.

 

Figure 1 PRISMA Flow Diagram

 

Using the Evidence to Decisions (EtD) Framework (http://www.decide-collaboration.eu/etd-evidence- decision-framework), the panel formally met in September 2015 and April 2016 to consider the balance of desirable and undesirable consequences to determine the strength of each recommendation, using informed judgment on the quality of evidence and effect sizes, resource use, equity, acceptability, and feasibility. To make a recommendation, the panel needed to express an average judgment that was beyond neutral with respect to the balance between desirable and undesirable consequences of an intervention, as outlined in the EtD. We defined the strength rating of a recommendation (strong or weak) as the extent to which the desirable consequences of an intervention outweigh its undesirable consequences. A strong recommendation can be made when the desirable consequences clearly outweigh the undesirable consequences. In contrast, a weak recommendation is made when, on the balance of probabilities, the desirable consequences likely outweigh the undesirable consequences. 49,51

 

Figure 2 PRISMA Flow Diagram

 

The panel provided recommendations based on the evidence if statistically and clinically significant differ- ences were found. The panel followed a 2-step process in making a recommendation. We first agreed that there should be evidence of clinically meaningful changes occurring over time in the study population and that a single consensus threshold of clinical effectiveness should be applied consistently. We reached a consensus decision that a 20% change in the outcome of interest within any study group was required to make a recommendation. The decision to use a 20% threshold was informed by current published reports and relevant available minimal clinically important differences (MCIDs).52-55

 

However, MCIDs can vary across populations, settings, and conditions and depending on whether within-group or between-group differences are being assessed. Therefore, the panel considered MCID values for the most relevant outcomes (ie, 10% for visual analog scale [VAS] or Neck Disability Index [NDI; 5/50 on the NDI], 20% for numerical rating scale [NRS]) and chose the more conservative of these values as the threshold when evaluating between group differences.52,54

 

Second, the results from relevant studies were used to formulate a recommendation where appropriate. A treat- ment determined to be effective (with statistically significant differences between baseline and follow-up scores and�clinical significance based on the MCID applied in the study) was recommended by our panel. If a study found 2 or more treatments to be equally effective based on our threshold, then the panel recommended all equivalently effective treatments.

 

Figure 3 PRISMA Flow Diagram

 

The EtD Frameworks were completed and recommen- dations were drafted over a series of conference calls with panel members after making judgments about 4 decision domains: quality of evidence (confidence in estimates of effect); balance of desirable (eg, reduced pain and disability) and undesirable outcomes (eg, adverse reactions); confidence about the values and preferences for the target population; and resource implications (costs).56,57 A synthe- sis of our judgments about the domains determined the direction (ie, for or against a management approach) and the strength of recommendations (the extent to which one can be confident that the desirable conse- quences of an intervention outweigh the undesirable consequences). A specific format was followed to formulate recommendations using patient description and the treatment comparator.56 Remarks were added for clarification if needed. If the desirable and undesirable consequences were judged to be evenly balanced and the evidence was not compelling, the panel decided not to write any recommendation.

 

A modified Delphi technique was used at an in-person meeting to achieve consensus on each recommendation.58 Using an online tool (www.polleverywhere.com), panelists�voted their level of agreement with each recommendation (including quality of evidence and strength of recom- mendation) based on a 3-point scale (yes, no, neutral). Before voting, panelists were encouraged to discuss and provide feedback on each recommendation in terms of suggested wording edits or general remarks. To achieve consensus and be included in the final manuscript, each recommendation had to have at least 80% agreement with a response rate of at least 75% of eligible panel members. All recommendations achieved consensus in the first round.

 

Figure 4 PRISMA Flow Diagram

 

Peer Review

 

A 10-member external committee composed of stake- holders, end-users, and researchers from Canada, the United States, and Lebanon (Appendix 2) independently reviewed the draft manuscript, recommendations, and supporting evidence. The AGREE II instrument was used to assess the methodological quality of the guideline.35 Feedback received was collected and considered in a revised draft for a second round of review. Chairs of the guideline panel provided a detailed response to reviewers� comments. For a glossary of terms, please see Appendix 3.

 

Figure 5 PRISMA Flow Diagram

 

Results

 

Key Question Development

 

Thirty-two standardized key questions were developed in line with the PICO (population, intervention, comparator, outcome) format. The panel recognized overlap in content and relevance among some key questions. After combining 3 questions, we ultimately addressed a total of 29 key questions (Table 2).

 

Study Selection and Quality Assessment: OPTIMa Reviews

 

OPTIMa searches yield 26 335 articles screened.38-42 After removal of duplicates and screening, 26 273 articles did not meet selection criteria, leaving 109 articles eligible for critical appraisal. Fifty-nine studies (62 articles) published from 2007 to 2013 were deemed scientifically admissible and included in the synthesis (Appendix 4). Each review used was rated as either moderate or high quality (AMSTAR score 8-11).59

 

Search Update and Study Selection

 

Our updated search yielded 7784 articles. We removed 1411 duplicates and screened 6373 articles for eligibility (Figs. 1-5). After screening, 6321 articles did not meet our selection criteria (phase 1), leaving 52 articles for full-text review (phase 2) and critical appraisal (studies on the topic of multimodal care (n = 12), structured patient education (n = 3),�exercise (n = 8), work disability interventions (n = 13), manual therapy (n = 4), soft tissues (n = 2), and passive modalities (n = 6). Of the 52 RCTs, 4 scientifically admissible studies were included in our synthesis. The remaining articles failed to address the key question (n = 1); selected population (n = 2), outcomes (n = 13), or intervention (n = 11); had no between estimates (n = 19); or were duplicates (n = 1) or a secondary analysis of an included study (n = 1) (Appendix 5).

 

Table 3 Neck Manipulation vs Neck Mobilization

 

Table 4 Multimodal Care vs Home Exercises vs Medication

 

Table 5 Strengthening Exercises vs Advice

 

Quality Assessment and Synthesis of Results

 

The GRADE evidence profile and risk of bias within included studies are presented in Tables 3-15 and Appendix 6, respectively.

 

Recommendations

 

We present recommendations as follows:

  • Recent-onset (0-3 months) grades I to III NAD
  • Recent-onset (0-3 months) grades I to III WAD
  • Persistent (N3 months) grades I to III NAD
  • Persistent (N3 months) grades I to III WAD

 

Recommendations for Recent-Onset (0-3 Months) Grades I to III NAD

 

Manual Therapy

 

Key Question 1: Should neck manipulation vs neck mobilization be used for recent-onset (0-3 months) grades I to II NAD?

 

Summary of Evidence. One RCT by Leaver et al. 60 evaluated the effectiveness of neck manipulation or neck mobilization delivered by physiotherapists, chiropractors, or osteopaths for recent-onset grades I to II neck pain (?2 NRS). All patients received advice, reassurance, or a continued exercise program as indicated for 4 treatments over 2 weeks unless recovery was achieved or a serious adverse event occurred. There was no statistically significant difference in Kaplan-Meier recovery curves between groups for recovery from neck pain and recovery of normal activity, and no statistically significant differences between groups for pain, disability, or other outcomes (function, global perceived effect, or health-related quality of life) at any follow-up point (Table 3).

 

One other RCT by Dunning et al.61 evaluated the effectiveness of a single high-velocity, low-amplitude (thrust) manipulation (n = 56) directed to the upper cervical spine (C1-C2) and upper thoracic spine (T1-T2) compared with a (nonthrust) mobilization (n = 51) directed to the same anatomical regions for 30 seconds for patients with neck pain. Findings indicated a greater reduction in pain (NPRS) and disability (NDI) in the thrust manipulation group compared with the mobilization at 48 hours. No serious adverse events were reported. Minor adverse events were not collected. This study did not inform our recommendation because1 patient complaints were not recent onset (mean�duration N337 days in both groups), and2 outcomes were measured at 48 hours only. The Guideline Development Group (GDG) considered this an important study limitation because one cannot assume these benefits would have carried on for a longer period. The panel acknowledged, however, that some patients may value obtaining fast pain relief even if temporary.

 

The panel determined that the overall certainty in the evidence was low, with large desirable relative to undesirable effects. The relative small cost of providing the option would make it more acceptable to stakeholders and feasible to implement. Although the panel decided the desirable and undesirable consequences were closely balanced, the following statement was provided:

 

Recommendation: For patients with recent (0-3 months) grades I to II NAD, we suggest manipulation or mobilization based on patient preference. (Weak recommendation, low-quality evidence)

 

Table 6 Multimodal Care vs Education

 

Table 7 Exercise vs No Treatment

 

Table 8 Yoga vs Education

 

Exercise

 

Key Question 2: Should integrated neuromuscular inhibition technique be used for recent-onset (0-3 months) grades I to II NAD?

 

Summary of Evidence. Nagrale et al.62 reported non� clinically significant differences for neck pain and disability outcomes at 4 weeks. This study suggested that a soft tissue therapy intervention to the upper trapezius, combining ischemic compression, strain-counterstrain, and muscle energy technique, provides similar clinical benefit compared with muscle energy technique alone. Participants were required to have neck pain of less than 3 months� duration.

 

The panel determined moderate certainty in the evidence, with small desirable and undesirable effects and no serious adverse events. Low costs are required for the intervention and no specific equipment is needed, with the exception of training to provide the technique. Because the intervention is widely practiced and taught, it is acceptable and feasible to implement. However, its effects on health equities cannot be determined. Overall, the panel decided the balance between the desirable and undesirable consequences was uncertain, and more evidence is needed before a recommendation can be made.

 

Multimodal Care

 

Key Question 3: Should multimodal care vs intramuscular ketorolac be used for recent (0-3 months) grades I to III NAD?

 

Summary of Evidence. McReynolds et al. 63 presented short-term outcomes of pain intensity and concluded that sessions of multimodal care (manipulation, soft tissue techniques) provided equivalent outcomes to an intramuscular injection of ketorolac. However, the follow-up time of 1 hour is generally atypical and the dosing was determined to be incomplete for multimodal care as reported. Furthermore, the study was limited to an emergency setting only.

 

The panel determined low certainty in the clinical evidence, with small desirable and undesirable effects. There is relatively low risk for multimodal care, considering the reported outcomes were equal. From a clinician standpoint, resources required are small assuming no additional staff are needed. However, one practitioner gave most multimodal therapies. Expenses may vary depending on the definition of multimodal care. This option should not create health inequities, except for those who cannot access clinicians or choose to pay out of pocket, and would be feasible to implement. Professional associ- ations would generally support the option, yet extended multimodal therapies can incur additional costs, which can be unfavorable to both payors and patients. Overall, the balance between the desirable and undesirable conse- quences is uncertain and more research is needed in this area before any recommendation can be made.

 

Table 9 Exercises vs Home Range or Motion or Stretching Exercises

 

Table 10 Multimodal Care vs Self-Management

 

Exercise

 

Key Question 4: Should multimodal care vs home exercises vs medication be used for recent-onset (0-3 months) grades I to II NAD?

 

Summary of Evidence. One RCT by Bronfort et al.22 evaluated the efficacy of multimodal care over 12 weeks compared with a 12-week home exercise and advice program or medication on neck pain (11-box NRS) and disability (NDI) in 181 adult patients with acute and subacute neck pain (2-12 weeks� duration and a score of ?3 on a 10-point scale). Multimodal care by a chiropractor (mean of 15.3 visits, range 2-23) included manipulation and mobilization, soft tissue massage, assisted stretching, hot and cold packs, and advice to stay active or modify activity as needed. Daily home exercise was to be done up to 6 to 8 times per day (individualized program including self- mobilization exercise of the neck and shoulder joints) with advice by a physical therapist (two 1-hour sessions, 1-2 weeks apart on posture and activity of daily living). Medication prescribed by a physician included nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioid analgesic, or muscle relaxants (dosage was not reported). The results displayed in Table 4 indicated that multimodal care and home exercises and advice were as effective as medication in reducing pain and disability at short term (26 weeks). However, medication was associated with a higher risk for adverse events (mostly gastrointestinal symptoms and drowsiness in 60% of participants) than home exercises. The choice of medications was based on the participant�s history and response to treatment. Clinicians and patients should be aware that current evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Importantly, evidence supports a dose-dependent risk for serious harms, including increased risk for overdose, dependence, and myocardial infarction.64

 

Recommendation: For patients with recent (0-3 months) neck pain grades I to II, we suggest either range-of-motion home exercises, medication, or multimodal manual therapy for reduction in pain and disability. (Weak recommendation, moderate- quality evidence)

 

Remark: Home exercises included education self-care advice, exercises, and instruction on activities of daily living. Medication included NSAIDs, acetaminophen, muscle relaxant, or a combination of these. Multimodal manual therapy included manipulation and mobilization with limited light soft tissue massage, assisted stretching, hot and cold packs, and advice to stay active or modify activity as needed.

 

Key Question 5: Should supervised graded strengthening exercises vs advice be used for recent-onset (0-3 months) grade III NAD?

 

Summary of Evidence. One RCT by Kuijper et al.65 evaluated the effectiveness of supervised strengthening exercises compared with advice to stay active for recent-onset grade III neck pain. This RCT reported that strengthening exercises (n = 70) were more effective than advice to stay active (n = 66).65 Trial participants were followed at 3 weeks, 6 weeks, and 6 months. Based on panel consensus, outcomes determined to be important in the assessment of effectiveness in this RCT included neck and arm pain (VAS) and disability (NDI). These outcomes were both statistically and clinically significant (Table 5).

 

In this RCT, the strengthening exercise program was delivered by physiotherapists 2 times per week for 6 weeks.65 It included supervised graded strengthening exercises for the shoulder and daily home exercises to strengthen the superficial and deep neck muscles (mobility, stability, and muscle strengthening). Participants in the comparison group were advised to continue daily activities. Both groups were allowed to use painkillers. See Key Question 6 for a recommendation on cervical collar.

 

Recommendation: For patients with recent (0-3 months) grade III neck and arm pain, we suggest supervised graded strengthening exercises* rather than advice alone.� (Weak recommendation, moderate-quality evidence)

 

Remark: *Supervised graded strengthening exercises con- sisted of strengthening and stability exercises twice a week for 6 weeks with daily home exercises (which included mobility, stability, and muscle strengthening). �Advice alone consisted of maintaining activity of daily living without specific treatment.

 

Table 11 Manipulation vs No Manipulation

 

Table 12 Massage vs No Treatment

 

Table 13 Multimodal Care vs Continued Practitioner Care

 

Table 14 Group Exercise vs Education or Advice

 

Table 15 General Exercise and Advice vs Advice Alone

 

Passive Physical Modalities

 

Key Question 6: Should cervical collar vs graded strengthening exercise program be used for recent-onset (0-3 months) grade III NAD?

 

Summary of Evidence. One RCT by Kuijper et al.65 randomly assigned 205 patients with recent-onset neck�cervical radiculopathy (NAD grade III) to 1 of 3 groups 1 : Rest and semi-hard cervical collar for 3 weeks, then weaned off during weeks 3-6 2 ; physiotherapy (mobilizing and stabilizing the cervical spine, standardized graded neck strengthening exercises twice per week for 6 weeks, and education to do daily home exercises); or3 a control group (wait and see with advice to continue daily activities). All patients received written and oral reassurance about the usually benign course of the symptoms and were allowed painkillers.

 

Wearing a semi-hard cervical collar or receiving standardized graded strengthening exercise program and home exercises for 6 weeks provided similar improvements in arm pain (VAS), neck pain (VAS), or disability (NDI) compared with a wait-and-see policy at 6 weeks. There were no between-group differences at 6 months.

 

Because of uncertainty about potential for iatrogenic disability associated with the prolonged use of cervical collar,27,42 one recommendation made in the current guideline favoring strengthening exercise programs over advice, and the lack of consensus among the guideline panel, the GDG decided not to make a recommendation against the use of cervical collar (first vote on the proposed recommendation with direct results from the study [11% agree, 11% neutral, 78% disagree, 1 abstained]). A second vote favored also removing the remark from the recommendation (27% agree, 9% neutral, 64% disagree, 1 did not vote). Choice should be based on patient�s preference and management changed if recovery is slow.66

 

Key Question 7: Should low-level laser therapy be used for recent-onset (0-3 months) grade III NAD?

 

Summary of Evidence. One RCT by Konstantinovic et al.67 evaluated the effectiveness of low-level laser therapy (LLLT) delivered 5 times per week for 3 weeks compared with placebo (inactive laser treatment) for recent-onset grade III neck pain. LLLT leads to statistically but not clinically significant improvements in neck pain and disability at 3 weeks compared with placebo. Transitional worsening in pain (20%) and persistent nausea (3.33%) were observed in the LLLT group, whereas no adverse events were reported in the placebo group.

 

The panel determined the overall certainty of the evidence was moderate, with small desirable effects and minor adverse events. LLLT can be expensive. If practitioners choose not to purchase, it may negatively affect health equities. However, the option is acceptable to stakeholders and is relatively easy to implement. The panel was uncertain about the balance between desirable and undesirable consequences and voted against making a recommendation because of a lack of clear evidence (LLLT was no better than placebo but both groups demonstrated within-group change over time).

 

Work Disability Prevention Interventions

 

Key Questions 8 and 9: Should work disability prevention interventions vs fitness and strengthening exercise program be used for recent-onset nonspecific work-related upper limb disorders?�Should work disability prevention interventions be used for recent-onset work-related neck and upper limb complaints?

 

In reviewing the evidence on work disability prevention interventions,41 the GDG concluded that the balance between desirable and undesirable consequences was �closely balanced or uncertain.� As a result, the guideline panel was unable to formulate recommendations for these key questions, yet future research is very likely to either positively or negatively support the various types of work disability prevention interventions.

 

Although some benefits were reported favoring computer-prompted and instructed exercise interventions,68 the incremental self-reported improvement was insufficient to formulate a recommendation considering1 a follow-up period of 8 weeks in reviewed studies is too short to estimate long-term sustained benefits; and2 the potential costs related to programming and worker instruction may be significant.

 

Overall, it appears that adding computer-prompted exercises (with workplace breaks), or workplace breaks alone, to a program of ergonomic modification and education improves self-perceived recovery and symptomatic benefits in computer workers with neck and upper back complaints.41 However, it is unclear whether the addition of computer- prompted exercises to the various established workplace interventions alters perceived or objective health outcomes. Future research may identify added benefits in order for stakeholders to consider the extra cost as being surmountable.

 

Recommendations for Recent-Onset (0-3 Months) Grades I to III WAD

 

Multimodal Care

 

Key Question 10: Should multimodal care vs education be used for recent (0-3 months) grades I to III WAD?

 

Summary of Evidence. A 2-part RCT by Lamb et al.69 evaluated the effectiveness of oral advice compared with written material for improving pain (self-rated neck pain) and disability (NDI) in patients with recent-onset grades I to III WAD. Lamb et al.69 included a total of 3851 participants with a history of WAD grades I to III of less than 6 weeks� duration who sought treatment at an emergency department. A total of 2253 participants received active management advice in the emergency department incorporating oral advice and the Whiplash Book, which included reassurance, exercises, encouragement to return to normal activities, and advice against using a collar;�1598 participants received usual care advice, including verbal and written advice along with anti-inflammatory medication, physiotherapy, and analgesics. No between-group difference was observed in self-rated neck pain and disability at 12-month follow-up and no difference in workdays lost was observed at 4-month follow-up (Table 6).

 

Lamb et al.69 included 599 participants with WAD grades I to III that persisted for 3 weeks after attending emergency departments. Three hundred participants were treated by a physiotherapist (maximum 6 sessions over 8 weeks) including psychological strategies (goal setting or pacing, coping, reassurance, relaxation, pain and recov- ery), self-management advice (posture and positioning), exercises (shoulder complex mobilization and range of motion [ROM]; cervical and scapular stability and proprioception), and cervical and thoracic spine Maitland mobilization and manipulation; a total of 299 received single-session reinforcement advice from a physiothera- pist during their previous visit to emergency department. No difference in self-rated disability was identified at 4-month follow-up; however, greater reductions in workdays lost after 8-month follow-up were determined with self-management advice over single-session rein- forcement. Similar findings were found in an earlier study.70

 

Recommendation: For adult patients with recent (0-3 months) WAD grades I to III, we suggest multimodal care over education alone. (Weak recommendation, moderate-quality evidence)

 

Remark: Multimodal care may consist of manual therapy (joint mobilization, other soft tissue techniques), education, and exercises.

 

Structured Education

 

Key Question 11: Should structured patient education vs education reinforcement be used for recent-onset (0-3 months) WAD?

 

Summary of Evidence. Lamb et al.69 reported outcomes at 4 months for self-rated disability, identifying no clinically significant differences between groups. The study sug- gested that oral advice and an educational pamphlet provide similar benefits.

 

The panel determined moderate quality in the clinical evidence, yet uncertain desirable effects with small, minor, and transient adverse events. Relatively few resources would be required for the intervention, and wide dissemination of educational materials through electronic tools can help reduce inequities. The option is acceptable to stakeholders and feasible to implement. Overall, the desirable consequences probably outweigh the undesirable consequences. The panel determined this topic and its evidence has substantial overlap with Key Question 10. Therefore, one recommendation was made, addressing both topics.

 

Recommendations for Persistent (N3 Months) Grades I to III NAD

 

Exercise

 

Key Question 12: Should supervised exercise (ie, qigong exercise) vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Two RCTs (Table 7) evaluated the effectiveness of supervised qigong compared with super- vised exercise therapy and no treatment on neck pain (101-point VAS), disability (NDI), and Neck Pain and Disability Scale in a total of 240 patients with chronic neck pain (N6 months). 71,72 Rendant et al. 72 reported that, in adults with chronic neck pain, supervised qigong is more effective than no treatment and as effective as exercise therapy in reducing neck pain and disability at 3 and 6 months. Conclusions regarding the effectiveness of these 2 interventions compared with no treatment in patients aged older than 55 years cannot be drawn from the included studies.

 

In their study of these interventions for neck pain in elderly patients, von Trott et al.71 observed a reduction in pain and disability in both intervention groups at 3 and 6 months (although not statistically significant). The quality of the evidence was downgraded to low based on the SIGN criteria (concealment method not reported). In the von Trott et al. study, the interventions consisted of two 45-minute sessions per week for 3 months (a total of 24 sessions),71 whereas in the Rendant et al. study, interventions consisted of 12 treatments in the first 3 months and 6 treatments in the following 3 months (total of 18 sessions).72 Exercise therapy in both studies included repeated active cervical rotations and strengthening and flexibility exercises in the form of Dantian qigong71 or Neiyanggong qigong.72 Similar minor transient side effects were reported in both the intervention and comparison groups.

 

Recommendation: For adult patients with persistent (N6 months) neck pain grades I to II, we suggest supervised group exercises* to reduce neck pain and disability. (Weak recommendation, moderate-quality evidence)

 

Remark: Patients received 18 to 24 group sessions during a period of 4 to 6 months. Patients considered had a rating of 40/100 on a pain scale (VAS). The intervention group reached suggested MCID level of 10% difference for pain and functional outcomes. *Exercises included qigong or ROM, flexibility, and strengthening exercises. No evidence of significant effect in the elderly population.

 

Key Question 13: Should supervised yoga vs education be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Yoga is an ancient Indian practice involving postural exercises, breathing control, and med-
itation. 20 One RCT by Michalsen et al. 73 evaluated the effectiveness of Iyengar yoga compared with a self-care/exercise program on neck pain (VAS) and disability (NDI) in 76 patients with chronic neck pain (pain for at least 3 months and a score of more than 40 mm on a 100-mm VAS). Yoga consisted of a weekly 90-minute session for 9 weeks of a wide range of postures aimed to enhance flexibility, alignment, stability, and mobility. The self-care/ exercise group had to practice for 10 to 15 minutes at least 3 times a week a series of 12 exercises focusing on muscle stretching and strengthening and joint mobility. The results indicated that yoga is more effective for reducing neck pain and disability at short term (4 and 10 weeks) than self-care/ exercise (Table 8). No serious adverse events were reported in either group. In this study, the quality of evidence was downgraded to low because blinding was �poorly ad- dressed.�45

 

One RCT by Jeitler et al.74 evaluated the effectiveness of Jyoti meditation compared with exercise on neck pain (VAS). The results showed that Jyoti meditation (sitting motionless, repeating a mantra, and visual concentration while keeping the eyes closed) is more effective than exercise (established and previously used self-care manual for specific exercise and education for chronic neck pain).74 Because Jyoti meditation only includes 1 of the 3 components of yoga (ie, meditation), Jeitler et al.74 was not considered in developing the following recommendation.

 

Recommendation: For patients with persistent (N3 months) grades I to II neck pain and disability, we suggest supervised yoga over education and home exercises for short- term improvement in neck pain and disability. (Weak recommendation, low-quality evidence)

 

Remark: Baseline intensity of pain was more than 40/100 and duration was at least 3 months. Yoga was specific to the Iyengar type, with a maximum of 9 sessions over 9 weeks.

 

Key Question 14: Should supervised strengthening exercises vs home ROM or stretching exercises be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Three RCTs evaluated the effectiveness of supervised strengthening exercises compared with home exercises for grades I to II neck pain and disability.38 Two RCTs (Hakkinen et al.75 and Salo et al.76) reported no significant between group differences at 1 year for primary or secondary outcomes. One RCT (N = 170) reported that supervised strengthening exercises were more effective than home ROM exercises.77 Two smaller RCTs (N = 107) found that both treatments are equally effective.75,76 All 3 trials had a follow-up of 1 year. Based on our panel�s consensus, outcomes determined to be important in the assessment of effectiveness for these RCTs included pain (NRS) and disability (NDI).

 

In the RCT by Evans et al.77 the strengthening exercise program (delivered by exercise therapists) was determined to be more effective than home exercises. The program�included 20 supervised sessions over a period of 12 weeks and consisted of neck and upper body dynamic resistance strengthening program with and without spinal manipula- tive therapy.77 Conversely, the home exercises included an individualized program of neck and shoulder self- mobilization with initial advice regarding posture and daily activities (Table 9). In the 2 RCTs demonstrating equivalence, the strengthening program included 10 supervised sessions over 6 weeks of isometric exercises for the neck flexors and extensors, dynamic shoulder and upper extremity exercises, abdominal and back exercises, and squats.43,44

 

A fourth RCT by Maiers et al.78 assessed the effectiveness of supervised rehabilitative exercises in combination with and compared with home exercises alone for persistent neck pain in individuals aged 65 years or older. All participants in the study received 12 weeks of care. One group received 20 supervised 1-hour exercise sessions in addition to home exercises. Home exercises consisted of four 45- to 60-minute sessions to improve flexibility, balance, and coordination and enhance trunk strength and endurance. Participants also received instruc- tions on pain management, practical demonstrations of body mechanics (lifting, pushing, pulling, and rising from a lying position), and massaging to stay active. Results favored supervised rehabilitative exercises combined with home exercises over home exercise for pain (NRS) and disability (NDI) at 12 weeks. However, between-group differences did not reach statistical significance.

 

Recommendation: For patients with persistent (N3 months) grades I to II neck pain, we suggest supervised strengthening exercises or home exercises. (Weak recommendation, low-quality evidence)

 

Remark: For reduction in pain, supervised strength- ening exercises, provided along with ROM exercises and advice, were evaluated at 12 weeks within 20 sessions. Home exercises include stretching or self-mobilization.

 

Key Question 15: Should strengthening exercises vs general strengthening exercises be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Griffiths et al.79 presented non� clinically significant outcomes for neck pain and disability among patients with persistent neck pain and concluded there is no added benefit of incorporating specific isometric exercise to a general exercise program. Dosages were up to 4 sessions per 6-week period, with advice for 5 to 10 times at home. The general exercise program consisted of postural exercise, active ROM, 5 to 10 times daily with reinforcement.

 

The panel determined there is low certainty in the clinical evidence and uncertainty in the desirable effects of the intervention. Isometric exercises have little anticipated adverse effects, require minimal resources, and are generally acceptable to stakeholders and feasible to�implement. Yet uncertainty remains regarding their effects on health equity and the overall balance between desirable and undesirable consequences. More research is needed in this area before a recommendation can be made.

 

Key Question 16: Should combined supervised strengthening, ROM, and flexibility exercises vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. von Trott et al. 71 and Rendant et al. 72 presented significant outcomes for reduction in neck pain and disability that favor combined strengthening, ROM, and flexibility exercises. Both studies address different popula- tions and lead to similar outcomes (von Trott et al.71 addressed elderly populations).

 

The panel determined there was moderate certainty in the clinical evidence, with large desirable and small undesirable anticipated effects. Yet there may be differences in adverse events for strengthening vs ROM and flexibility exercises, along with the chal- lenges of such adverse events being self-reported. For example, strengthening exercises likely coincide with short-term pain after the intervention. Further, signifi- cant space may be required for exercises, which may incur large costs that need to be considered up front. As a result, there is uncertainty about the feasibility to implement and whether this could widely affect health inequalities. However, the option would be acceptable to stakeholders. Overall, the desirable consequences would probably outweigh the undesirable consequences. The panel determined this topic and its evidence has substantial overlap with Key Question 12 (qigong was considered exercise). Therefore, 1 recommendation was made, addressing both topics.

 

Manual Therapy

 

Key Question 17: Should multimodal care vs self-management be used for persistent (N3 months) grades I-II NAD?

 

Summary of Evidence. One RCT by Gustavsson et al.80 evaluated the effectiveness of self-management of persis- tent musculoskeletal tension type neck pain for grades I to II neck pain. They compared treatment effects of a multicom- ponent pain and stress self-management group intervention (n = 77) to individually administered multimodal physical therapy (n = 79). Measures of pain (NRS) and disability (NDI) were collected at baseline and at 10 and 20 weeks. Both groups had within-group differences for decreased pain intensity and disability. At the 20-week follow-up after an average of 7 sessions, based on the measures used, the multicomponent pain and stress self-management group intervention had a greater treatment effect on coping with pain and patients� self-reported pain control and disability than the multimodal care group. The initial treatment effects were largely maintained over a 2-year follow-up period (Table 10).81

 

Recommendation: For patients with persistent (N3 months) neck pain and associated disorders grades I to II, we suggest multimodal care* or stress self-management� based on patient preference, prior response to care, and resources available. (Weak recommendation, low-quality evidence)

 

Remark: *Individualized multimodal care may include manual therapy (manipulation, mobilization, massage, trac- tion), acupuncture, heat, transcutaneous electrical nerve stimulation, exercise, and/or ultrasound. �Stress self-manage- ment may include relaxation, balance and body awareness exercises, pain and stress self-management lectures, and discussion. The multimodal care group received an average of 7 (range 4-8) sessions, compared with 11 (range 1-52) sessions for the stress self-management group over 20 weeks.

 

Education

 

Key Question 18: Should structured patient education vs massage therapy be used for persistent (N3 months) NAD?

 

Summary of Evidence. Sherman et al.82 reported non� clinically significant outcomes at 4 weeks for disability. This study suggests a mailed self-care book and a course in massage therapy provide similar clinical benefits for
patients with persistent neck pain.

 

The panel determined the overall certainty of the evidence was low, with relatively large anticipated effects and no serious adverse events noted from intervention (some headaches possibly). There is uncertainty in the costs required, including necessary staff, equipment, and mate- rials. Yet this option is feasible to implement in most settings and has strong implications for reducing health inequities. As a preventive strategy, the intervention is acceptable to stakeholders, including the chiropractic practitioners, patients, and policymakers. The panel was uncertain about the balance between the desirable and undesirable consequences. Additional high-quality studies are needed in this area before any recommendation can be made.

 

Manual Therapy

 

Key Question 19: Should manipulation be used for persistent grades I to II NAD?

 

Summary of Evidence. Evans et al.77 compared spinal manipulation in addition to 20 weeks of supervised exercise therapy (20 sessions) to supervised exercise therapy alone in adults with persistent grades I to II neck pain, whereas Maiers et al.78 compared spinal manipulation in addition to home exercises (20 sessions maximum) to home exercise alone in seniors with persistent grades I to II neck pain. Pain and disability outcomes at 12 and 52 weeks did not reach statistical significance in between-group differences, except for pain level at 12 weeks in the Maiers study.78 A third RCT by Lin et al.83 allocated 63 persistent neck pain patients (NAD I-II) to the experimental group (n = 33) treated with�cervical spine manipulation and traditional Chinese massage (TCM) compared with TCM alone (n = 30) over 3 weeks. Results favored cervical manipulation with TCM over TCM alone for pain (NPS) and disability (Northwick Park Neck Disability Questionnaire) at 3 months (Table 11).

 

The panel concluded low certainty in the evidence, with small desirable and undesirable effects of the intervention. Few resources are required for the intervention, and it is probably acceptable to stakeholders and feasible to implement. Although the panel decided the desirable and undesirable consequences were closely balanced, the following statement was provided.

 

Recommendation: For patients with persistent grades I to II NAD, we suggest manipulation in conjunction with soft tissue therapy. (Weak recommendation, low-quality evidence)

 

Remark: Evaluated after eight 20-minute sessions (over a 3-week period). Does not include manipulation as a standalone treatment.

 

Manual Therapy

 

Key Question 20: Should massage vs no treatment (wait listing) be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. Sherman et al.82 and Lauche et al.84 reported non�clinically significant differences in outcomes for disability at 4 and 12 weeks, respectively. Sherman et al.82 suggested Swedish and/or clinical massage with verbal self- care advice provides similar clinical benefit to a self-care book for disability outcomes. Lauche et al.84 suggested cupping massage and progressive muscle relaxation lead to similar changes in disability. Sherman et al.85 reported outcomes for neck pain and disability at 4 weeks and suggested that higher doses of massage provide superior clinical benefit (Table 12).

 

The panel determined low certainty in the evidence, with small desirable and undesirable effects. Additional costs may be needed to get clinical benefit. Sherman et al.85 suggested a minimum of 14 hours of staff time needed. Because of the costs associated with high-dose massage, it may not be entirely acceptable to patients or payors. However, this option is feasible and relatively easy to implement in educated and affluent populations similar to subjects primarily studied.85 Overall, the panel decided the desired consequences probably outweigh the undesirable consequences and suggest offering this option.

 

Recommendation: For patients with persistent (N3 months) grades I to II NAD, we suggest high-dose massage over no treatment (wait listing) based on patient preferences and resources available. (Weak recommendation, low-quality evidence)

 

Remark: Interventions were given 3 times for 60 minutes a week for 4 weeks. Lower dosages and duration did not have therapeutic benefit, and we cannot suggest offering as an option.

 

Passive Physical Modalities

 

Key Question 21: Should LLLT be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high-quality studies are needed in this area before certainty in judgments or recommendations can be made.

 

Key Question 22: Should transcutaneous electrical nerve stimulation vs multimodal soft tissue therapy program be used for persistent (N3 months) grades I to II NAD?

 

Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high quality studies are needed in this area before certainty in judgments or recommendations can be made.

 

Key Question 23: Should cervical traction be used for grade III NAD (variable duration)?

 

Summary of Evidence. After full-text screening and review, no studies addressing between-group differences among outcomes of pain or disability were included to inform this key question. The lack of evidence and uncertainty in the overall balance between desirable and undesirable consequences led the panel to decide not to write a recommendation for this topic at this time. More high-quality studies are needed in this area before certainty in judgments or recommendations can be made.

 

Multimodal Care

 

Key Question 24: Should multimodal care vs continued practitioner care be used for persistent grades I to III NAD?

 

Summary of Evidence. One RCT by Walker et al.86 evaluated the effectiveness of multimodal care for neck pain with or without unilateral upper extremity symptoms (grades I-III). They compared treatment effects of combined multimodal care and home exercises (n = 47) to multimodal minimal intervention (n = 47). Both intervention groups received on average of 2 sessions per week for 3 weeks. No interventions were rendered after 6 weeks. Baseline self- reported questionnaires included neck and arm pain (VAS) and disability (NDI). All measures were repeated at 3, 6, and 52 weeks. Patients in the multimodal care and home exercise group had significantly greater reduction in short-term neck pain and in short-term and long-term disability compared with the multimodal minimal interven- tion group (Table 13). A secondary analysis of the Walker et al. study87 determined that patients receiving both�cervical thrust and nonthrust manipulations did no better than the group receiving cervical nonthrust manipulations only. This underpowered secondary analysis prohibits any definitive statement regarding the presence or absence of a treatment advantage of one approach over the other. The reduction in pain reported by Walker�s multimodal care and exercise group compared favorably to the change scores reported by other studies, including Hoving et al.88,89

 

In an RCT, Monticone et al.90 evaluated the effective- ness of multimodal care for persistent neck pain. They compared treatment effect of multimodal care alone (n = 40) to multimodal care in conjunction with cognitive behavioral treatment (n = 40). Both groups had a reduction in pain (NRS) and disability (NPDS), but there were no clinically significant differences between the groups at 52 weeks. The addition of a cognitive behavioral treatment did not provide greater outcomes than multimodal care alone.

 

Recommendation: For patients presenting with persistent neck pain grades I to III, we suggest clinicians offer multimodal care* and/ or practitioner advice based on patient preference. (Weak recommendation, low-quality evidence)

 

Remark: *Multimodal care and exercises may consist of thrust/nonthrust joint manipulation, muscle energy, stretching, and home exercises (cervical retraction, deep neck flexor strengthening, cervical rotation ROM). �Multimodal minimal intervention may consist of postural advice, encouragement to maintain neck motion and daily activities, cervical rotation ROM exercise, instructions to continue prescribed medication, and therapeutic pulsed (10%) ultrasound at 0.1 W/cm2 for 10 minutes applied to the neck and cervical ROM exercises.

 

Exercise

 

Key Question 25: Should group exercises vs education or advice be used for workers with persistent neck and shoulder pain?

 

Summary of Evidence. We have combined the key questions for �Should structured patient education vs exercise programs be used for persistent neck pain and associated disorders in workers?� and �Should workplace-based exercises vs advice be used for neck pain in workers?� One large cluster RCT (n = 537) by Zebis et al.91 evaluated the effectiveness of strength training in the workplace compared with receiving advice to stay physically active on nonspecific neck and shoulder pain intensity. The findings indicated a similar reduction in neck and shoulder pain intensity at 20 weeks for the exercise program compared with advice (Table 14). The intervention consisted of 3 sessions per week, each lasting 20 minutes, for up to 20 weeks (total of 60 sessions).

 

The workplace exercise program consisted of high- intensity strength training relying on principles of progres- sive overload and involved local neck and shoulder muscles strengthening with 4 different dumbbell exercises and 1 exercise for the wrist extensor muscles. More than 15% of�workers assigned to the workplace exercise group reported minor and transient complaints. The comparison group reported no adverse events.

 

A subgroup analysis92 of the primary Zebis et al. study91 included 131 women with a baseline neck pain rating of at least 30 mm VAS from the 537 male and female participants. Results favored specific resistance training over advice to stay active for pain (VAS) at 4 weeks. This study was not included because findings were already considered in the primary study.

 

Recommendation: For workers with persistent neck and shoulder pain, we suggest mixed supervised and unsupervised high- intensity strength training or advice alone. (Weak recommendation, moderate-quality evidence)

 

Remark: For reduction in pain intensity, 3 sessions per week, each lasting 20 minutes, over a 20-week period. Exercise includes strengthening. Extra resources are likely required for complete exercise intervention implementation.

 

Structured Patient Education

 

Key Question 26: Should structured patient education vs exercise programs be used for persistent (N3 months) NAD in workers?

 

Summary of Evidence. Andersen et al.93 reported non� clinically significant outcomes at 10 weeks for neck and shoulder pain, suggesting weekly e-mailed information on general health behaviors and shoulder abduction exercise programs provide similar clinical benefit. Yet implementa- tion of high-intensity strength training exercises in industrial workplaces (implementation of exercise into day-to-day life and to increase active leisure time) is generally supported.94,95 In another RCT, pain reduction was significantly greater than in the group receiving advice alone. 91 Findings from Zebis et al. 91 are also included in the exercise intervention section of this guideline.

 

The panel determined moderate certainty in the clinical evidence, with small desirable and undesirable effects of the intervention. The resources required are relatively small, assuming the practitioner presents the education to the patient. Health inequities would be positively affected, and the intervention would be acceptable to stakeholders and feasible to implement. The panel decided not to repeat these findings in the current section. The panel felt that the benefits of increasing the frequency and intensity of exercise regimes was not restricted to those working in an industrial environment or to any specific population subgroup with the exception of older adults.

 

Work Disability Prevention Interventions

 

Key Questions 27-29: Should work-based hardening vs clinic-based hardening be used for persistent (N3 months) work-related rotator cuff tendinitis? Should work disability prevention interventions be used for persistent neck and shoulder pain?�Should work disability prevention interventions be used for persistent (N3 months) upper extremity symptoms?

 

Table 16 Treatment Interventions Not to be Offered for NAD

 

Summary of Evidence. In reviewing the evidence on work disability prevention interventions,41 the GDG concluded that the balance between desirable and undesirable consequences was �closely balanced or uncertain� for Key Questions 27-29. As a result, the guideline panel was unable to formulate recommendations for these key questions, yet future research is very likely to either positively or negatively support the various types of work disability prevention interventions.

 

Recommendations for Persistent (N3 Months) Grades I to III WAD Exercise

 

Key Question 30: Should supervised general exercise and advice vs advice alone be used for persistent (N3 months) grades I to II WAD?

 

Summary of Evidence. In an RCT, Stewart et al. (2007)96 evaluated the effectiveness of 3 advice sessions alone compared with 3 advice sessions combined with 12 exercise sessions over 6 weeks on neck pain (NRS) and disability�(NDI) among 134 patients with persistent grades I to II WAD. The results, presented in Table 15, indicated that supervised exercises with advice are as effective as advice alone at long term (12 months). Advice included standardized education, reassurance, and encouragement to resume light activity and consisted of 1 consultation and 2 follow-up phone contacts. However, the quality of the evidence was downgraded to low based on SIGN criteria (randomization and outcome measurement were �poorly addressed�) and the low number of participants and events.45

 

A pragmatic trial assigned 172 patients with persistent WAD grades I to II to receive a comprehensive 12-week exercise program (20 sessions including manual therapy technique the first week [no manipulation] and cognitive behavioral therapy delivered by physiotherapists) or advice (1 session and telephone support).97 The comprehensive exercise program was not more effective than advice alone for pain reduction or disability, although findings favored a comprehensive physiotherapy exercise program over advice.

 

The panel determined low certainty in the evidence, with small desirable and undesirable effects and no serious adverse events (5 patients who received the comprehensive exercise program and 4 who received advice had minor transient adverse events). Overall, the panel decided the balance between the desirable and undesirable conse- quences such as costs was uncertain, and more evidence is needed before a recommendation can be made.

 

In a 20-week cluster RCT, Gram et al. (2014)98 randomly assigned 351 office workers to 2 training groups receiving the same total amount of planned exercises 3 times per week, with 1 group supervised throughout the intervention period and the other receiving minimal supervision only initially, and a reference group (without exercise). Although results indicated that supervised training at the workplace reduced neck pain, results were not clinically significant and both training groups improved independently of the extent of supervision. The panel decided not to consider this study in formulating a recommendation because exercise was not directly com- pared with advice and an important loss to follow-up occurred across groups. Although supervised exercise appears to be beneficial, costs can be high. This could possibly be mitigated, however, by offering group treat- ment, which may increase compliance and accountability with a supervised group.

 

Recommendation: For patients with persistent (N3 months) grades I to II WAD, we suggest supervised exercises with advice or advice alone based on patient preference and resources available. (Weak recommendation, low-quality evidence)

 

Remark: Extra resources may be required for supervised exercises.

 

Multimodal Care

 

Key Question 31: Should multimodal care vs self- management program be used for persistent (N3 months) grade II WAD?

 

Summary of Evidence. Jull et al.99 reported no clinically or statistically significant outcomes for pain and disability at 10 weeks. They suggested that multimodal care (exercises, mobilization, education, and ergonomic advice) provided similar outcomes to a self-management program based on an educational booklet (mechanism of whiplash, reassur- ance of recovery, stay active, ergonomic advice, exercise). Care did not include high-velocity manipulation. Although this study is specific to physiotherapists, it is well within the scope of chiropractors (manual therapists).

 

One other RCT by Jull et al.100 evaluated the effectiveness of multidisciplinary individualized treat- ments for patients with acute whiplash (b4 weeks postinjury). Patients randomly assigned to pragmatic intervention (n = 49) could receive medication including opioid analgesia, multimodal physiotherapy, and psy- chology for post-traumatic stress over 10 weeks. No significant differences in frequency of recovery (NDI ? 8%) between pragmatic and usual care groups was found at 6 or 12 months. There was no improvement in current nonrecovery rates at 6 months (63.6%, pragmatic care; 48.8%, usual care), indicating no advantage of the early multiprofessional intervention.

 

The panel determined low certainty in the clinical evidence, with small desirable and undesirable effects reported. Yet there were relatively small costs and resources required to implement the intervention. Electronic dissem- ination of the educational component of multimodal care may reduce health inequities. The option may be acceptable to clinicians (assuming collaborative care approaches), policymakers, and patients and is likely feasible to implement in usual care settings. Overall, the balance between the desirable and undesirable consequences is uncertain, and no recommendation is given at this time. Further studies need to be conducted in this area and should involve multimodal care including high-velocity proce- dures or manipulation.

 

Education

 

Key Question 32: Should structured patient education vs advice be used for persistent (N3 months) WAD?

 

Summary of Evidence. Stewart et al. (2007)96 reported non�clinically significant between differences for pain and disability outcomes at 6 weeks. This study suggested that adding a physiotherapy-based graded exercise program to a structured advice intervention provided similar clinical benefit as structured education alone.

 

The panel determined low certainty of the evidence, with low desirable and undesirable anticipated effects. The main complaints were muscle pain, knee pain, and spinal pain with mild headaches.96 The small resources required for the intervention may reduce health inequities, and the option is acceptable to stakeholders and feasible to implement in most settings.

 

The panel determined that this key question had substantial overlap with Key Question 5 and decided to make 1 recommendation addressing both topics.

 

Discussion

 

This evidence-based guideline establishes the best practice for the management of NAD and WAD resulting from or aggravated by a motor vehicle collision and updates 2 previous guidelines on similar topics.24,25 This guideline covers recent-onset (0-3 months) and persistent (N3 months) NADs and WADs grades I to III. It does not cover the management of musculoskeletal thoracic spine or chest wall pain.

 

The primary outcomes reported in the selected studies were neck pain intensity and disability. Although all recommendations included in this guideline are based on low risk of bias RCTs, the overall quality of evidence is generally low considering other factors considered by GRADE such as imprecision, and thus the strength of recommendations is weak at this time. Weak recommen- dations mean that clinicians need to devote more time to the process of shared decision making and ensure that the informed choice reflects patient values and preferences.56 Interventions not described in this guideline cannot be recommended for the management of patients with NAD or WAD because of a lack of evidence about their effective- ness and safety (Table 16).

 

A recent systematic review and meta-analysis by Wiangkham (2015)101 on the effectiveness of conservative management for acute WAD grade II included 15 RCTs, all assessed as high risk of bias (n = 1676 participants), across 9 countries. Authors concluded that conservative interven- tions (noninvasive treatment), including active mobilization exercises, manual techniques, physical agents, multimodal therapy, behavioral approaches, and education, are gener- ally effective for recent-onset WAD grade II to reduce pain in the medium and long term and to improve cervical ROM in the short term compared with standard or control intervention.101 Although findings from the Wiangkham review are generally in line with those from the systematic reviews we included in this guideline,24,25 the pooling of high risk of bias and of clinically heterogeneous trials seriously challenges the validity of this more recent review.

 

Similarities and Differences With Recommendations by the OPTIMa Collaboration

 

First, the recommendations for the management of minor injuries of the neck were recently released by the Ministry�of Finance of Ontario in collaboration with the OPTIMa Collaboration 20 and published as a separate guideline. 27 They considered the risks of bias of included RCTs using the SIGN criteria45 and the guideline recommendations developed using the modified OHTAC framework,28 based on 3 decision determinants1: overall clinical benefit (evidence of effectiveness and safety) 2 ; value for money (evidence of cost-effectiveness where available); and3 consistency with expected societal and ethical values. In the current guideline, we used the GRADE approach, which, in addition to considering risk of bias of included RCTs, takes into account 4 other factors (imprecision, inconsistency, indirectness, publication bias) to rate the confidence in effect estimates (quality of evidence) for each outcome.102 As a result of imprecision of estimates in several RCTs, the overall quality of admissible studies was deemed low. GRADE considers similar decision determi- nants as the modified OHTAC to develop recommendations when subsequently making an overall rating of confidence in effect estimates across all outcomes based on those outcomes considered critical to a particular recommenda- tion.56 Accordingly, the guideline panel was asked to consider this low quality of evidence when judging the �desirable� consequences. When the benefits of important outcomes slightly outweighed undesirable effects of the intervention, a weak recommendation was made (ie, suggestions for care). This is likely to involve ensuring patients understand the implications of the choices they are making, possibly using a formal decision aid.56 However, if the judgment was �closely balanced or uncertain,� no recommendation could be made.

 

Second, OPTIMa 20 recommended that interventions should only be provided in accordance with published evidence for effectiveness, including parameters of dosage, duration, and frequency, and within the most appropriate phase. The emphasis during the early phase (0-3 months) should be on education, advice, reassurance, activity, and encouragement. Health care professionals should be encouraged to consider watchful waiting and clinical monitoring as evidence-based therapeutic options during the acute phase. For injured persons requiring therapy, time-limited and evidence-based interventions should be implemented on a shared decision-making basis, an approach that equally applies to patients in the persistent phase (4-6 months). Despite using slightly different methods to derive recommendations, the 2 processes generally led to similar guidance.

 

Third, OPTIMa20 reported that the following interven- tions are not recommended for recent-onset NAD: struc- tured patient education alone (either verbal or written); strain-counterstrain or relaxation massage; cervical collar; electroacupuncture (electrical stimulation of acupuncture points with acupuncture needles or electrotherapy applied to the skin), a topic not covered in our guideline; electric muscle stimulation; heat (clinic based). Similarly for�persistent NAD, programs solely of clinic-based supervised high-dose strengthening exercises, strain-counterstrain or relaxation massage, relaxation therapy for pain or disability outcomes, transcutaneous electrical nerve stimulation (TENS), electric muscle stimulation, pulsed shortwave diathermy, heat (clinic based), electroacupuncture, and botulinum toxin injec- tions are not recommended. In contrast, based on the RCT by Zebis et al.91 the current guideline suggests offering multimodal care and/or patient education for industrial workers presenting with neck pain grades I to III. Although structured patient education used alone cannot be expected to yield large benefits for patients with neck pain, this strategy may be of benefit during the recovery of patients with persistent WAD when used as an adjunct therapy.40 For persistent neck pain (grades I-II), Gustavsson et al.80 reported that multimodal care combining manual therapy (spinal manipulation, mobilization, massage, traction) and passive modalities (heat, TENS, exercise, and/or ultrasound) reduced neck disability. It should be noted, however, that past reviews were unable to make any definitive conclusions about the effectiveness of TENS as an isolated treatment for acute pain 103 or chronic pain 104 in adults, nor about the effectiveness of heat therapy.105,106

 

A comparison of the recommendations with 2 previous chiropractic guidelines 24,25 reveals that a multimodal approach including manual therapy, advice, and exercise remains the overall recommended strategy of choice for the treatment of neck pain. However, treatment modalities included in recommended multimodal care differed accord- ing to the quality of the evidence available at the time. The 2010 guideline on the management of WAD developed treatment recommendations based on low-quality evidence from 8 available RCTs and 3 cohort studies.25 Overall, recommendations for recent and persistent WAD are similar (multimodal care, and supervised exercise and multidisciplinary care, respectively). The 2014 guideline on neck pain24 developed 11 treatment recommendations from 41 RCTs. The current guideline developed 13 recommenda- tions from 26 low risk of bias RCTs. In line with the 2014 guideline24 for recent-onset neck pain, the current recom- mendations suggest offering multimodal care including mobilization, advice, and exercises. The current guideline recommendations also suggest offering supervised graded strengthening and stability exercises. Similar to the 2014 guideline for persistent neck pain (grades I-II),24 the current recommendations suggest offering multimodal care consisting of manual therapy (spinal manipulation therapy or mobilization) and exercises. Details on specific exercise modalities are now provided, including suggestions for supervised and unsuper- vised exercises, strength training, and supervised group exercises such as workplace exercise programs and supervised yoga.

 

Adverse Events

 

This guideline did not specifically review the evidence on adverse events from treatments. However, in the review�by Wong et al.42 on manual therapy and passive modalities, 22 of the low risk of bias RCTs addressed the risk of harm from conservative care. Most adverse events were mild to moderate and transient (mostly increased stiffness and pain at the site of treatment, with a mean rate of about 30%). No serious neurovascular adverse events were reported. Another review of published RCTs and prospective cohort studies confirmed that around half of people treated with manual therapy can expect minor to moderate adverse events after treatment, but that the risk of major adverse events is small.107 The pooling of data from RCTs of manual therapy on the incidence of adverse events indicated that the relative risk of minor or moderate adverse events was similar for manual therapy and exercise treatments, and for sham/passive/control interventions.

 

A patient-centered holistic and collaborative view of the needs of the patient with pain and disability is encouraged. 108,109 Although chiropractors are not responsible for pharmacologic management, they should have sufficient knowledge about pharmacologic agents and their adverse events. One eligible RCT22 found home exercises and advice to be as effective as medication (acetaminophen, NSAIDs, muscle relaxant, and opioid analgesic) in reducing pain and disability at short term for patients with acute or subacute neck pain grades I to II. However, medication was associated with a higher risk for adverse events. Of interest, recent evidence suggests that acetaminophen is not effective for managing low back pain,110,111 and the effectiveness of long-term opioid therapy for improving chronic pain and function is uncertain.64 However, a dose-dependent risk for serious harms is associated with long-term use of opioid (increased risk for overdose, opioid abuse and dependence, fractures, myocardial infarction, and use of medications to treat sexual dysfunction).64 Risk of unintentional opioid overdose injury appears to be particularly important in the first 2 weeks after initiation of long-acting agents.112,113

 

Recommendations

 

I. Stakeholders

 

Choosing a Care Provider. A range of health care providers (chiropractors, general medical practitioners, physiothera- pists, registered massage therapists, and osteopaths) deliver care for NADs and WADs.108,114 Considering the level of skills required to deliver manual therapy, including spinal manipulative therapy and other forms of therapies (eg, prescription of specific exercise) and based on individual patient preference, cervical spine manipulation as part of multimodal care should be delivered by properly trained licensed professionals. 115

 

II. Practitioners

 

Best Practice Recommendations-Initial Assessment and Monitoring.

 

This guideline specifically addresses the treatment of NAD and WAD grades I to III. Importantly, our panel supports�the following 5 best practice recommendations on patients care outlined in the OPTIMa guideline27: Clinicians should1 rule out major structural or other pathologic conditions as the cause of neck pain�associated disorders before classifying as grade I, II, or III2; assess prognostic factors for delayed recovery3; educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I to III and the importance of maintaining�activity and movement4; refer patients with worsening symptoms and those who develop new physical or psychological symptoms for further evaluation at any time during their care; and5 reassess the patient at every visit to determine whether additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged. Similar recommendations were formulated by the Neck Pain Task Force116 and in prior practitioner guides on the management of WAD and NAD by chiropractors.24,25

 

Benefits of Physical Activity and Self-management. Educating patients about the benefits of being physically active and participating in their care has become the standard of care internationally. Despite the benefits of therapeutic exercise for managing chronic neck pain and the strong evidence favoring regular physical activity to reduce related comorbidities, care providers fail to routinely prescribe these to patients.117-120 When prescribed, the amount of supervision and types of exercises do not follow practice guidelines and are not linked to the degree of patient impairment.118,121 On the patient side, adherence to prescribed exercise programs is often low. 122

 

The promotion of physical activity, including exercise, is a first-line treatment considered important in the prevention and treatment of musculoskeletal pain and its related comorbidities (eg, coronary heart disease, type 2 diabetes, and depression).123-126 For a minority of patients with chronic spine pain, clinician-delivered interventions and pharmacologic treatments are appropriate; and in fewer cases, multidisciplinary pain management or surgery may be indicated. 118

 

People with musculoskeletal pain will often adopt an inactive lifestyle. Unfortunately, physical inactivity is associated with important adverse health effects, including increased risks of coronary heart disease, type 2 diabetes, and breast and colon cancers, and shorter life expectancy in general.127 The World Health Organization128 provided clear guidance on physical activity for health for children, adults, and elders. In addition, recent research suggests that WAD patients with high levels of passive coping�strategies have slower pain and disability recovery.129 Self-management support (SMS) strategies aimed at increasing physical activity and active coping strategies are key to effectively managing spinal pain and related comorbidities. 124,125,130-134 The CCGI developed a theory-based knowledge translation (KT) intervention targeting identified barriers to professional behavior change to increase the uptake of SMS strategies among Canadian chiropractors.135 Interviews of clinicians identified 9 theoretical domains as likely relevant (ie, factors perceived to influence the use of multimodal care to manage nonspecific neck pain).135 The intervention, comprising a webinar and a learning module on Brief Action Planning, is a highly structured SMS strategy that allows patient- centered goals136 and is being pilot-tested among Canadian chiropractors (ongoing pilot trial).137 Care providers are encouraged to perform periodic clinical revaluations and to monitor patient progression of self-management strategies while discouraging dependence on passive treatment.

 

Figure 6 Algorithm of Recommendations for Managing NAD

 

Figure 7 Algorithm of CCGI Recommendations for WAD

 

Figure 8 CCGI Patient Information Sheet

 

III. Research

 

Overall, the quality of the research on conservative management of NADs and WADs remains low, partly explaining that only weak recommendations could be formulated for clinical practice. Further, the reporting of RCTs remains suboptimal. 138 Past recommendations for improving the quality of the research still apply.24,25 Future research should aim to clarify the role of spinal manipulation therapy alone or as part of multimodal care for the management of recent neck pain and have adequate frequency and length of follow-up. For instance, a large number of patient visits to the emergency departments each year are for acute neck and arm pain resulting from WADs.14,139 A small RCT suggested that cervical spine manipulation is a reasonable alternative to intramuscular NSAID for immediate pain relief in these patients.63 However, the small sample size, comparison of a single session of spinal manipulation to an NSAID injection, and a 1-day follow-up was not representative of clinical practice.

 

Few recent adequately controlled high-quality research studies of chiropractic care for NADs have been published. In addition, studies included in the reviews did not estimate the maximum therapeutic benefits (ie, best dosage for treatment under evaluation). Well-designed clinical trials with sufficient numbers of participants, longer-term treatments, and follow-up periods are needed to increase the confidence in the recommendations and to advance our understanding of effective and cost-effective conservative care, and spinal manipulation, for the management of patients with NADs and WADs.

 

Dissemination and Implementation Plan. Evidence-based practice aims to improve clinical decision making and patient care.140,141 When followed, CPGs have the potential to improve health outcomes and the efficiency of the health care system.142-144 However, low adherence to CPGs has been noted across health care sectors145 and in the management of musculoskeletal conditions, including NADs and WADs.77,101,102 Such gaps contribute to wide geographic variations in the use and quality of health care services. 146

 

Efforts to bridge the �research-practice gap� have led to a growing interest in KT.145,147 Knowledge translation is defined as the exchange, synthesis, and ethically sound application of knowledge to improve health and provide more effective health services. 148 Knowledge translation aims to bridge the research-practice gap and improve patient outcomes by promoting the integration and exchange of research and evidence-based knowledge into clinical practice.

 

To prepare for guideline implementation, we considered the Guideline Implementation Planning Checklist 149 and�available strategies and supporting evidence141,150 to increase guideline uptake. Although effects of KT inter- ventions tend to be modest, they are likely important at a population health level.37

 

To raise awareness, chiropractic professional organiza- tions are encouraged to inform their members of new CCGI guidelines and tools easily accessible on our website (www. chiroguidelines.org). The guideline implementation tools framework was used to clarify the objectives of the tools; identify end users and the context and setting where tools will be used; provide instructions for use; and describe methods to develop the tools and related evidence and to evaluate the tools.151 Implementation tools designed to increase guideline uptake include practitioner and patients� handouts (Fig. 8, Appendix 7); algorithms (Figs. 6 and 7), webinars, videos, and learning modules (http://www.cmcc. ca/CE); point-of-care checklists; and health status reminders.152-154 The CCGI has established a network of opinion leaders across Canada (www.chiroguidelines.org). Based on successful efforts to implement a WAD guideline in Australia using opinion leaders among regulated physiotherapists, chiropractors, and osteopaths, 155 the CCGI is planning a series of implementation studies among Canadian chiropractors.137 We will also pilot within chiropractic practice-based research networks.156 Monitor- ing guideline use in chiropractic is challenging because the use of electronic health records to routinely collect clinical practice information is not common in Canada and those using electronic health records often collect different indicators. 157 Nonetheless, the frequency of downloads (posting of the open access guideline on the CCGI website) and number of registering participants and completion of educational online material (webinar, video, and learning module) will be monitored monthly as proxy measures of guideline uptake.

 

Guideline Update

 

The methods for updating the guideline will be as follows: 1) Monitoring changes in evidence, available interventions, importance and value of outcomes, resources available or relevance of the recommendations to clinicians (limited systematic literature searches each year for 3-5 years and survey to experts in the field annually): 2) assessing the need to update (relevance of the new evidence or other changes, type and scope of the update); and 3) communi- cating the process, resources, and timeline to the Guideline Advisory Committee of the CCGI, who will submit a recommendation to the Guideline Steering Committee to make a decision to update and schedule the process.158-163

 

Strengths and Limitations

 

Shortcomings for this guideline include the low quantity and quality of supporting evidence found during the searches. Most of the downgrading of evidence supporting the outcomes occurred because of imprecision. In addition, our updated search of the published reports included 2 databases (Medline and Cochrane Central Register of Controlled Trials) but was limited to the English published reports, which possibly excluded some relevant studies. This, however, is an unlikely source of bias.164,165 Qualitative studies that explored the lived experience of patients were not included. Thus, this review cannot comment on how patients valued and experi- enced their exposure to manual therapies or passive physical modalities. Although the composition of the guideline panel was diverse, with experienced methodologists, expert clini- cians, and stakeholder and patient representatives, only 1 member was from another health discipline (physiotherapist). The scope of this guideline focused on selected outcomes such as pain and disability, although included studies assessed several additional outcomes.

 

Conclusion

 

This CPG supersedes the original (2005) and revised (2014) neck pain guideline as well as the 2010 whiplash-associated guidelines produced by the Canadian Chiropractic Association (CCA); Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (CFCREAB).

 

People should receive care based on evidence-based therapeutic options. Based on patient preference and resources available, a mixed multimodal approach includ- ing manual therapy and advice about self-management and exercise (supervised/unsupervised or at home) may be an effective treatment strategy for recent-onset and persistent NAD and WAD grades I to III. Progress should be regularly monitored for evidence of benefit, in particular on the basis of pain alleviation and reduction of disability.

 

Funding Sources and Conflicts of Interest

 

Funds provided by the Canadian Chiropractic Research Foundation. The views of the funding body have not influenced the content of the guideline. No conflicts of interest were reported for this study.

 

Guideline Disclaimer

 

The evidence-based practice guidelines published by the CCGI include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.21 Guidelines are intended to inform clinical decision making, are not prescriptive in nature, and do not replace professional chiropractic care or advice, which always should be sought for any specific condition. Furthermore, guidelines may not be complete or�accurate because new studies that have been published too late in the process of guideline development or after publication are not incorporated into any particular guideline before it is disseminated. CCGI and its working group members, executive committee, and stakeholders (the �CCGI Parties�) disclaim all liability for the accuracy or completeness of a guideline, and disclaim all warranties, expressed or implied. Guideline users are urged to seek out newer information that might impact the diagnostic and/or treatment recommendations contained within a guideline. The CCGI Parties further disclaim all liability for any damages whatsoever (including, without limitation, direct, indirect, incidental, punitive, or consequential damages) arising out of the use, inability to use, or the results of use of a guideline, any references used in a guideline, or the materials, information, or procedures contained in a guideline, based on any legal theory whatsoever and whether or not there was advice of the possibility of such damages.

 

Through a comprehensive and systematic literature review, CCGI evidence-based CPGs incorporate data from the existing peer-reviewed literature. This literature meets the prespecified inclusion criteria for the clinical research question, which CCGI considers, at the time of publication, to be the best evidence available for general clinical information purposes. This evidence is of varying quality from original studies of varying methodological rigor. CCGI recommends that performance measures for quality improvement, performance-based reimbursement, and public reporting purposes should be based on rigorously developed guideline recommendations.

 

Contributorship Information

 

Ncbi.nlm.nih.gov/pubmed/27836071

 

Practical Applications

 

  • A multimodal approach including manual therapy, self-management advice, and exercise can be an effective treatment strategy for recent-onset and persistent neck pain and whiplash-associated disorders.

 

Acknowledgements

 

We thank the following people for their contributions to this paper: Dr. John Riva, DC, observer; Heather Owens, Research Coordinator, proofreading; Cameron McAlpine (Director of Communication & Marketing, Ontario Chiro- practic Association), for assistance in producing the companion document intended for patients with NAD; members of the guideline panel who served on the Delphi consensus panel, who made this project possible by generously donating their expertise and clinical judgment.

 

Appendixes and Other Information

 

Ncbi.nlm.nih.gov/pubmed/27836071

 

In conclusion, whiplash-associated disorders can cause damage to the complex structures of the cervical spine, or neck, because the sheer force of an impact can extend the soft tissues beyond their natural range of motion. Many healthcare professionals can safely and effectively treat whiplash as well as other automobile accident injuries. The results of the article above demonstrate that a multimodal approach, including manual therapy, self-management advice and exercise can be an efficient treatment strategy for both recent-onset and persistent neck pain caused by whiplash-associated disorders.�Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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

 

Additional Topics: 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:�Neck Pain Treatment El Paso, TX Chiropractor

 

 

MORE TOPICS: EXTRA EXTRA: El Paso, Tx | Athletes

 

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Migraine Education Improves Headache Treatment in El Paso, TX

Migraine Education Improves Headache Treatment in El Paso, TX

Migraine symptoms are painful and debilitating, often affecting the quality of life of many migraine sufferers around the globe. Although headache pain is one of the most prevalent reasons for doctor office visits each year, migraines are considered to be one of the most underdiagnosed and undertreated diseases in the medical field. Furthermore, the emotional distress caused by the unresolved physical symptoms of migraines can create a number of mental health issues which can lead to worsened symptoms.�As a result, migraine education efforts have been implemented as a part of many headache treatment options, including chiropractic care. The purpose of the following article is to demonstrate the benefits of a primary care migraine education program, known as the Mercy Migraine Management Program or MMMP, on headache impact and quality of life.

 

A Primary Care Migraine Education Program has Benefit on Headache Impact and Quality of Life: Results from the Mercy Migraine Management Program

 

Abstract

 

  • Objective: The objective of this study was to evaluate the effectiveness of the Mercy Migraine Management Program (MMMP), an educational program for physicians and patients. The primary outcome was change in headache days from baseline at 3, 6, and 12 months. Secondary outcomes were changes in migraine-related disability and quality of life, worry about headaches, self-efficacy for managing migraines, ER visits for headache, and satisfaction with headache care.
  • Background: Despite progress in the understanding of the pathophysiology of migraine and development of effective therapeutic agents, many practitioners and patients continue to lack the knowledge and skills to effectively manage migraine. Educational efforts have been helpful in improving the quality of care and quality of life for migraine sufferers. However, little work has been done to evaluate these changes over a longer period of time. Also, there is a paucity of published research evaluating the influence of education about migraine management on cognitive and emotional factors (e.g., self-efficacy for managing headaches, worry about headaches).
  • Methods: In this open-label, prospective study, 284 individuals with migraine (92% female, mean age = 41.6) participated in the MMMP, an educational and skills based program. Of the 284 who participated in the program, 228 (80%) provided data about their headache frequency, headache-related disability (as measured by the Headache Impact Test-6 (HIT-6), migraine-specific quality of life (MSQ), worry about headaches, self-efficacy for managing headaches, ER visits for headaches, and satisfaction with care at four time points over 12 months (baseline, 3 months, 6 months, 12 months).
  • Results: Overall, 46% (106) of subjects reported a 50% or greater reduction in headache frequency. Over 12 months, patients reported fewer headaches and improvement on the HIT-6 and MSQ (all p < .001). The improvement in headache impact and quality of life was greater among those who had more worry about their headaches at baseline. There were also significant improvements in �worry about headaches�, �self-efficacy for managing headaches�, and �satisfaction with headache care�.
  • Conclusion: The findings demonstrate that patients participating in the MMMP reported improvements in their headache frequency as well as the cognitive and emotional aspects of headache management. This program was especially helpful among those with high amounts of worry about their headaches at the beginning of the program. The findings from this study are impetus for further research that will more clearly, through evaluate the effects of education and skill development not only on headache but also emotional and cognitive influences.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Migraine headache pain is characterized as a disabling symptom which can tremendously impact an individual’s quality of life. Plus, the stress created by the worry of an imminent migraine can result in a variety of mental health issues. Many healthcare professionals and migraine sufferers lack the proper knowledge and skills on how to effectively manage migraine symptoms. Fortunately, migraine education programs, like the Mercy Migraine Management Program (MMMP), were designed to teach patients how to improve their quality of care and quality of life. Migraine education programs such as these have been demonstrated to especially benefit migraineurs with higher levels of stress. Aside from providing spinal adjustments and manual manipulations to correct the alignment of the spine, chiropractic care focuses on the treatment of the body as a whole, making sure patients are educated regarding their migraine symptoms.

 

Introduction

 

Migraine headache is a highly prevalent, painful, disabling and costly disease. The evaluation, treatment and management of migraine have been estimated to involve 5 to 9 million office visits per year to primary care physicians in the United States.[1,2] Migraine is one of the most common reason for an outpatient office visit.[3] Numerous studies have reported that patients with migraines have significantly higher pharmacy and medical claims than those without migraine.[4�7] Migraine also has high indirect costs; it has been estimated to cost US employers between 17 and 20 billion dollars annually in lost work productivity.[8,9]

 

Despite its prevalence and high cost, migraine remains an underdiagnosed and undertreated disease.[10�14] Given the availability of migraine-specific therapeutic agents, it is vital that physicians be able to accurately diagnose migraine. Moreover, it is important for physicians to recognize the benefits of treating migraine as a specific condition as opposed to simply �head pain�. Unfortunately recent findings concerning the accurate diagnosis and treatment of migraine suggest that most patients with migraine are not accurately diagnosed or treated.[10�12,14]

 

Migraine is currently conceptualized as a chronic neurologic disease characterized by intermittent episodes of acute pain.[15�17] Current guidelines for managing chronic diseases emphasize the importance of self-management.[18�22] In self-management, the emphasis is on both the patient and the provider actively treating the disease, with the patient managing the disease outside the clinical setting. Self-management (or self-care) requires that the provider afford the patient the opportunity to take the right dose of the right medication at the right time, is educated about migraine and its management, and is equipped with tools to minimize the frequency and deleterious effects of migraine attacks.

 

Most migraine sufferers experience some disability from headache pain and the associated symptoms of migraine.[23�26] It is often the disability emanating from migraine attacks that compromises quality of life, thus making migraine both a pain problem and a life problem. For many patients, recurrent disability combined with a lack of effective coping tools and medications that are not always effective can create uneasiness, worry and anxiety between attacks as well as when an impending attack seems imminent. This worry and anxiety may be related to low self-efficacy, a cognitive variable that involves an individual�s belief that she or he is able to successfully manage a situation.[27�29] Self-efficacy has been theorized as a potent influence of how well one manages migraines.[29�33] Recent development of new therapeutic agents and the advent of improved educational efforts have been helpful in validating migraine and improving the quality of care for migraine sufferers. However, demonstrating the overall value of a primary care based educational program for migraine is difficult. Previously published articles evaluating the benefits of migraine education have reported successful results.[34�39] However, these programs mainly involved referral of patients into a specialized clinic or educational facility for instruction from specialist practitioners or educators and followed outcomes of the patients after enrollment. Unfortunately, few communities have access to such headache specialty clinics. Accordingly, most patients rely on their primary care clinicians for educational content and counseling regarding headache care. With these concepts in mind, the Mercy Migraine Management Program (MMMP), a multi-center, targeted enrollment study was undertaken to demonstrate the overall value of a migraine educational program through a provider-group setting. Given the paucity of programs whereby the physicians and participants are provided a one-time educational program, the decision was made to evaluate whether a program of this nature was feasible and suggestive of efficacy. If so, then this would allow for further investigation using a more elegant design.

 

The current study was an open trial looking at the effects of the MMMP. The effect of participation in the educational program on headache frequency, headache-related quality of life, headache-related worry, self-efficacy, treatment satisfaction, and emergency room visits for headache was assessed.

 

Methods

 

Participants

 

The research was conducted within a 120-clinician primary care group practice caring for more than 200,000 patients (St. Johns Mercy Medical Group in St. Louis, Missouri). A total of 31 physicians and three nurse practitioners from 14 of the group�s practice sites agreed to participate. From these sites, a total of 284 patients with migraine were identified and recruited by the clinicians and agreed to participate. Among participants 92% (n = 260) were female and the mean age was 42 (SD = 12.45). In order to be eligible, patients were required to have one or more of the following: (a) ICD-9-CM code for migraine/headache diagnosis in the previous six months; (b) one or more claims for acute migraine/headache medications in the previous six months; or (c) patients with one or more ER or urgent care center visits in the previous six months coded for migraine/headache or headache NOS and at least one migraine medication. In addition, patients who presented to the primary care office for evaluation of headache were eligible for enrollment in the program if they were given an ICD-9-CM code for migraine/headache diagnosis at that time.

 

Procedures

 

Provider Education and Training

 

Clinicians who expressed interest in participating attended a two-hour continuing medical education program on migraine. The program covered four key concepts: (1) impact recognition diagnosis of headache (office recognition of migraine based on headache repercussions and disability rather than the characteristics of pain alone), (2) the benefits of early abortive intervention, especially with migraine-specific medications, (3) effective preventive regimens, and (4) non-pharmacologic management. The overarching goal of the program was to educate providers about how to equip the patient with tools they can use to manage their migraines on a daily basis. Participating clinicians and their staff were provided printed educational materials. A majority of the materials were developed or selected for use by the first author. These were supplemented by standardized educational materials which included: (a) Patient Centered Strategies for Effective Management of Migraine[40]; (b) The Migraineur�s Guide to Migraine[41]; and (c) Provider and Patient Tipsheets from the Migraine Matrix� education program[41], a comprehensive migraine management program for providers.

 

Following their participation in the educational session, physicians from the practice sites sent IRB approved notices to potentially eligible patients, identified from claims data, informing them of the study or spoke with them directly during routine office visits for headache treatment. Interested individuals who responded to the mailed invitations then came to the practice site where their migraine diagnoses were confirmed and informed consent for participation was provided, as approved by the local IRB. The subjects subsequently completed study related questionnaires. Subjects recruited at the time of an office encounter were invited to participate at the time of said visit, provided informed consent in like-manner to those described above, and completed the baseline questonnaire.

 

After the questionnaires were completed, the clinician provided medication or other treatment recommendations based on their knowledge attained from the educational seminar and print materials previously provided to them. No mandatory interventions were required on the part of the provider. They were to make medication and other management decisions as they saw fit for each individual participant according to their own knowledge, understanding, and preferences. They were however required to provide the educational information from the study to the individual subjects enrolled in the trial. The clinician or a member of the health care team provided the patient with the educational materials and instructed them on how to use them. The patients were encouraged to use the materials as best fit their individual situation. The materials were designed to give the patient tools to self-manage their migraines in conjunction with ongoing care from their health care team. These materials included: (a) The Migraineur�s Guide to Migraine[41]; (b) a headache diary; (c) Patient Tipsheets from the Migraine Matrix� education program[42]; (d) educational materials on diet recommendations from the National Headache Foundation; (e) written and visual instruction on how to do cervical range of motion and stretching exercises from the physical therapy department that is associated with the St John�s Mercy Medical Group; (f) biofeedback tapes developed by the Primary Care Network; and (g) Managing Your Migraine Headaches.

 

The patients took the materials home with instructions to be as consistent as possible with adherence to the concepts proscribed by the educational packet. After 3-months, assessments were mailed to the participants with a self-addressed stamped envelope to return. The same assessments were mailed at 6-months and 12-months post-baseline as well.

 

Measures

 

The measures below were self-administered at baseline, 3-months, 6-months, and 12-months post-baseline.

 

Headache Days. Individuals reported the number of days they experienced headaches over the previous 90 days. This was a primary outcome of interest.

 

Disability/Quality of Life

 

Headache Impact Test-6 (HIT-6). The HIT-6 is a six-item measure that is a reliable and valid measure assessing the impact of headache on patients� lives.[43�44] Scores for the HIT-6 are derived by summing the responses to all the items. Higher scores reflect higher levels of headache impact (i.e., poorer quality of life). This was a primary outcome of interest.

 

Migraine Specific Quality of life (MSQ). The MSQ is a 14-item measure designed to assess the effects of migraine on an individual�s quality of life.[45�46] There are three MSQ subscales, Emotional (MSQ-E), restrictive (MSQ-R), and preventive (MSQ-P). The MSQ has been shown to be an internally consistent, valid measure. The MSQ was not done at 3 months. This was a primary outcome of interest.

 

Worry about headaches. Individuals indicated the extent to which they worried about headaches disrupting their life using a 4-point scale with options of �rarely�, �sometimes�, �often�, and �almost always�. For purposes of the current study, dichotomous groups were created. Individuals who answered �rarely� or �sometimes� were labeled Low Worry. Those who answered �often� or �almost always� were labeled High Worry.

 

Self-efficacy for controlling headaches. Individuals indicated the extent to which they were confident in their ability to do things to help control their headaches using a 4-point scale with options of �not confident�, �a little confident�, �fairly confident�, and �very confident�. Individuals who answered �not confident� or �a little confident� were labeled Low Self-Efficacy. Those who answered �fairly confident� or �very confident� were labeled High Self-Efficacy.

 

Satisfaction with headache care. Individuals indicated (Yes/No) whether they were satisfied with the headache care they were receiving.

 

ER visits. Individuals indicated the number of times they had been to the ER for headaches during the previous 3 months. For purposes of the current study a dichotomous yes/no variable was created in order to create a percentage of individuals who had visited the ER during the previous 90 days.

 

Statistical Analyses

 

All analyses were conducted using SPSS v. 15.[47] Prior to analysis, data were checked for the fit between scale distribution and the assumptions of normality. Headache frequency violated normality assumptions and was transformed (although the transformed variables were used in the model, the original data is used in the figures for ease of understanding for the reader).

 

A linear random mixed model (treating subjects as random effects) was used to model the change in headache frequency at the four time points over 12 months (baseline, 3 months, 6 months, 12 months). The same was done for the HIT-6 (measured at baseline, 3-months, 6-months and 12-months) and the MSQ subscales (measured at baseline, 6-months and 12-months). In order to determine whether baseline worry and confidence influenced changes in headache and quality of life, these variables were included in the models. Although the potential existed to investigate 3-way interactions (time � worry � confidence), doing so created cells with extremely low n and thus 2-way interactions were the higher order interactions analyzed. For all comparisons, Bonferroni adjustments were made.

 

In order to evaluate whether there were significant changes over time for worry, efficacy, patient�s satisfaction with their headache care, or ER visits, McNemar�s test was conducted. To account for multiple comparisons, the significance level for each set of comparisons was adjusted to p<.008.

 

The protocol and procedures for this study were approved by the local Institutional Review Board.

 

Results

 

Headache Frequency Change Over Time

 

Results indicated that overall, at 3 months, 34% (n = 77/228) reported at least a 50% reduction in headache frequency from baseline. This increased to 38% (N=86) at 6 months and 46% (N=106) at 12 months.

 

Results indicated that the main effect for reduction in headache frequency was significant (F [3, 691] = 27.89, p < .001). Figure 1 shows headache frequency per month at each time point. Table 1 shows that there was a significant reduction in headache frequency from baseline to each subsequent time point (p < .001). Also, headache frequency at month 12 was significantly lower than at month 3 and 6 (p<.001). The main effect for worry was also significant (F [1, 308] = 12.03, p < .001). Those who were labeled as having High Worry had significantly more headaches (M = 8.00, SE = .63) across the time frames than did those who were labeled as having Low Worry (M = 5.89, SE = .46) (95% CID = .62�3.68). The main effect for confidence, the time X worry interaction, and the time X confidence were all non-significant.

 

Figure 1 Headache Days per Month at Baseline, 3 Months, 6 Months, and 12 Months

Figure 1: Headache days per month at baseline, 3 months, 6 months, and 12 months.

 

Table 1 Comparisons of Change in Headache Frequency

 

Quality of Life Disability

 

HIT-6. Results indicate that the time X worry interaction was significant (F [2, 464] = 4.54, p < .01). Figure 2 shows HIT-6 scores for each time point by level of worry. Simple effects analysis showed that the degree of reduction in headache impact was greater at 3 months among those with High Worry than among those with Low Worry. Also, those with Low Worry showed a significant reduction in headache impact comparing baseline to 3 months and 6 months, and from 3 months to 6 months, whereas those with High Worry had a significant reduction in headache impact from baseline to 3 months but not from 3 months 6 months. The main effect for confidence was significant (F [1, 292] = 4.54, p < .001) such that those with High Self-Efficacy (M = 59.60, SE = .52) had less headache impact than those with Low Self-Efficacy (M = 61.72, SD = .70) (CID = .79�3.45). Neither the time X self-efficacy or worry X self-efficacy interaction was not significant.

 

Figure 2 HIT-6 at Each Time Point by Worry

Figure 2: HIT-6 at each time point by worry.

 

MSQ-E. Results indicate that the time X worry interaction was significant (F [2, 468] = 5.18, p < .01). Figure 3 shows MSQ-E scores for each time point by level of worry. Simple effects analysis showed that the degree of improvement in MSQ-E was greater at 3 months among those with High Worry than among those with Low Worry. The main effect for confidence was significant (F [1, 292] = 4.54, p < .001) such that those with High Self-Efficacy (M = 59.60, SD = 1.74) had better quality of life than those with Low Self-Efficacy (M = 61.72, SD = 1.87) (CID = .79�3.45). The main effect for self-efficacy, the time X self-efficacy interaction, and the worry X self-efficacy interaction were not significant.

 

Figure 3 MSQ-E at Each Time Point by Worry

Figure 3: MSQ-E at each time point by worry.

 

MSQ-R. Results indicate that the main effect for time was significant (F [2, 472] = 47.60, p < .001). Figure 4 shows MSQ-R for each time point by level of worry. Relative to baseline (M = 53.67, SD = 1.23), MSQ-R was significantly improved at 6 months (M = 66.02, SD = 1.35) (CID = 8.96�13.75) and at 12 months (M = 68.05, SD = 1.38) (CID = 10.34�18.42). No difference was found comparing 6 month and 12 month MSQ-R scores. The main effect for worry was significant (F [1, 281] = 34.86, p < .001) such that those with High Worry had significantly lower quality of life (M = 56.75, SD = 1.17) than those with Low Worry (M = 68.41, SD = 1.60) (CID = 7.78�15.57). The main effect for self-efficacy was significant (F [1, 281] = 7.89, p < .01) such that those with Low Self-Efficacy had significantly lower quality of life (M = 59.81, SD = 1.35) than those with Low Worry (M = 65.36, SD = 1.45) (CID = 1.67�9.44). Neither the main effect for self-efficacy or the time X confidence interaction was significant.

 

Figure 4 MSQ-R at Each Time Point by Worry

Figure 4: MSQ-R at each time point by worry.

 

MSQ-P. Results indicate that the time X worry interaction was significant (F [2, 449] = 4.01, p < .05). Figure 5 shows MSQ-P scores for each time point by level of worry. Simple effects analysis showed that those with High Worry showed significant improvement comparing baseline to 6 months and 12 months, and from 6 month to 12 months, while those with Low Worry showed significant improvement comparing baseline to 6 months and 12 months, but no significant improvement from 6 months to 12 months. The main effect for confidence was significant (F [1, 272] = 4.11, p < .05) such that those with Low Self-Efficacy (M = 75.08, SD = 1.48) had lower quality of life than those with High Self-Efficacy (M = 79.47, SD = 1.58) (CID = .13�8.65). The time X self-efficacy interaction and the worry X self-efficacy interaction were not significant.

 

Figure 5 MSQ-P at Each Time Point

Figure 5: MSQ-P at each time point.

 

Worry about headaches. Figure 6 shows the percentage of individuals with High Worry at baseline, 3 months, 6 months, and 12 months. Results indicated that when compared to baseline, the percentage of individuals with High Worry was significantly less at 3 months (?2 [223] = 20.42, p < .001), 6 months (?2 [223] = 29.98, p < .001), and 12 months (?2 [223] = 29.82, p < .001). No other significant differences were found.

 

Figure 6 Percentage of Individuals with High Worry and High Self-Efficacy at Each Time Point

Figure 6: Percentage of individuals with high worry and high self-efficacy at each time point.

 

Self-Efficacy for managing headaches. Figure 6 shows the percentage of individuals with High Self-Efficacy at baseline, 3 months, 6 months, and 12 months. Results indicated that the percentage of individuals with High Self-Efficacy at 12 months was significantly more than at baseline (?2 [223] = 10.92, p < .001) and 3 months (?2 [223] = 8.02, p < .001). No other significant differences were found.

 

Satisfaction. Figure 7 shows the percentage of individuals who were satisfied with their headache care. Results indicated that when compared to baseline, the percentage of individuals who were satisfied with their headache care was significantly higher at 3 months (?2 [223] = 66.39, p < .001), 6 months (?2 [223] = 75.87, p < .001), and 12 months (?2 [223] = 100.99, p < .001). Also, the percentage of individuals who were satisfied with their headache care at 12 months was significantly higher than at 3 months (?2 [223] = 16.25, p < .001) and 6 months (?2 [223] = 9.80, p < .001). No other significant differences were found.

 

Figure 7 Satisfaction with Headache Care

Figure 7: Satisfaction with headache care.

 

ER visits. Results indicated that at baseline, 8.33% (n=19) has gone to the ER for headache in the previous 3 months. Although there was a decrease in ER visits at 3 months (3.08%; n= 7), 6 months (3.95%; n = 9), and 12 months (5.26%; n = 12), these reductions were not significant.

 

Discussion

 

The primary outcome was the impact that the MMMP would have on headache frequency. Almost half (46%) of all participants reported a 50% or greater reduction in headache frequency at 12 months. It is notable that the percentage of participants experiencing a >50% reduction in headache frequency increased steadily over the 12 months, showing a lasting effect of the educational intervention. The degree of change was not significantly greater in either High Worry or Low Worry groups. However, the reduction in HIT-6 scores was significantly greater for those with High Worry compared to those with Low Worry at 3 months after baseline. In a related finding, participants with Low Self-Efficacy at baseline reported significantly greater reduction in headache impact than those with High Self-Efficacy. It is likely that this was due to participants gaining greater confidence in their own ability to manage their headaches through the education and headache management skills provided in the MMMP. This hypothesis is supported by the increasing percentage of participants with High Self-Efficacy scores and declining percentage of subjects with High Worry over the 12 month study period.

 

Participants reported that headache-related disability decreased and quality of life improved during the course of the study. This is an encouraging finding given that most patients seek treatment for headaches due to the disability and burden of disease. It is notable that this improvement was achieved through a low-cost, easy to administer educational program. The results also showed that patients worried less about their headaches. It has been well established among chronic pain patients that anxiety and worry about impending pain can significantly increase pain and inhibit efficacy of analgesic therapies.[48�49] To date, however, little research has looked at these phenomena among those with migraine. What research has been conducted has found that worry and anxiety appear to be a significant issue in migraine.[50�54]

 

It is interesting to note the interactions of worry with disability and quality of life. The focus of the current intervention was solely on education. Not enough research has been published to fully establish the importance of education in changing disease outcomes, particularly as it relates to headache pain. Perhaps the education and basic headache management skills provided in the education program equipped patients with enough knowledge and basic skills that worry and anxiety about headaches were reduced. This idea is supported by the finding that those with high worry at the beginning of the study reported the greatest amount of improvement on ratings of disability and quality of life.

 

The finding that satisfaction was higher serves as an encouragement that an intervention that is low cost and easy to administer can have a positive impact on patients� perception of care. There are a number of possibilities as to why this may have occurred. It could be that as a result of their education the health care providers were able to better answer patients� questions about migraine and its management. It is possible that the educational materials distributed to the patients resulted in their becoming more knowledgeable about migraine and, in turn, more satisfied with their care. It is also possible that the greater satisfaction came from having fewer headaches and headaches that were less disabling. The current study was not designed to answer these mechanistic questions, thus it is difficult to determine the influence of each of these variables on patient satisfaction. In regards to ER visits; although there was a decrease in ER visits at each time point, the percentage of individuals who had gone to the ER at baseline (8.33%) was low enough that there was little chance to see significant decline.

 

The results of this study imply that increased knowledge about migraine and management skills can lessen the burden of disease. This is congruent with research in other chronic disease areas (e.g., diabetes, asthma, cardiovascular disease) where providing patients with education about their disease state has been demonstrated to reduce disease burden and reduce worry and anxiety.

 

Although the current study is encouraging in its findings and raises the specter of future research into the disease management benefits of migraine education, there are limitations to the current study. Likely the greatest limitation to the study was the lack of a parallel condition. Not including such a condition did not allow us to evaluate the possibility that the results emanated from a positive bias or even a �self-fulfilling� outcome whereby decreases in headache were a function of participants� expectations. However, in the current study, the issue of positive bias may have been lessened by the fact the participants had no regular direct interaction with the researchers, and what interaction occurred did so at 3 or more month intervals. At the same time, with a lack of a control condition, this possibility cannot be discounted. This study was undertaken in an effort to see whether an approach that involved a one-time contact would have any impact on headache and associated outcomes. As a result, the conclusions that can be drawn from the current study are limited.

 

There was no formal oversight of prophylactic prescription patterns, so it is possible that the improvements seen in the participants was due to the 15% increase in the number of individuals prescribed migraine prophylaxis. However, a regression analysis was conducted to evaluate the possibility that starting migraine prophylaxis predicted improvement on the various outcomes (headache frequency, disability, quality of life, worry, satisfaction with care) at each time point. Starting migraine prophylaxis predicted a decrease in headache frequency at 3 months, but had no significant influence on any other domains at any time point. Another limitation was the lack of a parallel comparison group that did not receive the educational intervention. It is possible that the reported improvements in all these domains is a result of positive response bias. Another area of concern is that the scales and questionnaires were based on patient recall rather than diaries, allowing for recall bias. It is also possible that the physicians who participated in the educational seminar tend to have a more interactive communication approach with their patients which can have a positive influence on patient management.[50]

 

In summary, the purpose of the current study was to evaluate the efficacy of the MMMP which provided education about migraine and its management to health care providers and persons with migraine. In this open-label trial that utilized a linear random mixed model to evaluate change over a 12-month period, patients who participated reported fewer headaches, less disability, and improved quality of life. Also, a significant proportion of the patients reported having less worry, increased self-efficacy, and greater satisfaction with their migraine treatment. It is also worthwhile to note that the increased satisfaction, decreased worry and improved quality of life scores demonstrated in this program were achieved through a low-cost, easy to administer educational program.

 

Acknowledgments

 

The authors would like to thank Ms. Mitzi Corzine and Ms. Sally Kane at St. John�s Mercy Health Research (for managing the project), the health care providers and practices in the St. John�s Mercy Medical Group who participated, and Dr. Timothy Houle (statistical assistance). This project was funded by small unrestricted grants provided by the Primary Care Network, GlaxoSmithKline Pharmaceuticals, and Abbott Laboratories. The manuscript was prepared while the second author was funded by the National Institutes of Health (NINDS #K23NS048288).

 

In conclusion,�despite the fact that headache is one of the most prevalent reasons for doctor office visits each year, migraine still continues to be one of the most underdiagnosed and undertreated diseases in the medical field, impacting the overall health as wellness of migraine sufferers around the world. According to the findings of the article above, patients who participated in the Mercy Migraine Management Program, or MMMP, reported improvements in their migraine symptoms. Furthermore, migraineurs demonstrated additional improvements in a variety of other headache treatment options. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Back Pain

 

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

 

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EXTRA IMPORTANT TOPIC: Migraine Pain Treatment

 

 

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15.�Hazard E, Munakata J, Bigal ME, Rupnow MFT, Lipton RB. The burden of migraine in the United States: Current and emerging perspectives on disease management and economic analysis.�Value Health�[PubMed]
16.�Lipton RB, Pan J. Is migraine a progressive brain disease?�JAMA.�2004;291:493�494.�[PubMed]
17.�Scher AI, Stewart WF, Ricci JA, Lipton RB. Factors associated with the onset and remission of chronic daily headache in a population-based study.�Pain.�2003;106:81�89.�[PubMed]
18.�Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care.�JAMA.�2002;288:2469�2475.�[PubMed]
19.�Chodosh J, Morton SC, Mojica W. Meta-analysis: Chronic disease self-management programs for older adults.�Ann Intern Med.�2005;143:427�438.�[PubMed]
20.�Lorig KR, Holmon H. Self-management education: history, definition, outcomes, and mechanisms.�Ann Behav Med.�2003 Aug;26(1):1�7.�[PubMed]
21.�Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs.�Arthritis Rheum.�1993;36:439�446.�[PubMed]
22.�Lorig KR, Sobel DS, Stewart AL, Brown BW, Jr, Bandura A, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial.�Med Care.�1999;37:5�14.�[PubMed]
23.�Ferrari MD. The economic burden of migraine to society.�Pharmacoeconomics.�1998;13:667�676.[PubMed]
24.�Ford S, Calhoun A, Kahn K, Mann J, Finkel A. Predictors of disability in migraineurs referred to a tertiary clinic: Neck pain, headache characteristics, and coping behaviors.�Headache.�2008;48:523�528.[PubMed]
25.�Jelinski SE, Becker WJ, Christie SN, Giammarco R, Mackie GF, Gawel MJ, Eloff AG, Magnusson JE. Demographics and clinical features of patients referred to headache specialists.�Can J Neurol Sci.�2006;33:228�234.�[PubMed]
26.�Stewart WF, Lipton RB, Simon D. Work-related disability: results from the American Migraine study.�Cephalalgia.�1996;16:231�238.�[PubMed]
27.�Bandura A, O�Leary A, Taylor C, Gauthier J, Gossard D. Perceived self-efficacy and pain control: Opioid and nonopioid mechanisms.�J Personal Social Psychol.�1987;53:563�571.�[PubMed]
28.�Bandura A.�Self-efficacy: The Exercise of Control.�New York: W.H. Freeman and Company; 1997.
29.�Nicholson RA, Houle TT, Rhudy JL, Norton PJ. Psychological risk factors in headache.�Headache.�2007;47:413�426.�[PMC free article][PubMed]
30.�Lake AI. Behavioral and nonpharmacologic treatments of headache.�Med Clin North Am.�2001;85:1055�1075.�[PubMed]
31.�Maizels M. Why should physicians care about behavioral research?�Headache.�2005;45:411�413.[PubMed]
32.�Nicholson RA, Hursey KG, Nash J. Moderators and mediators of behavioral treatment for headache.�Headache.�2005;45:513�519.�[PubMed]
33.�Penzien D, Rains J, Lipchik G, Nicholson R, Lake A, Hursey K. Future directions in behavioral headache research: Applications for an evolving health care environment.�Headache.�2005;45:526�534.[PubMed]
34.�Blumenfeld A, Tischio M. Center of excellence for headache care: Group model at Kaiser Permanente.�Headache.�2003;43:431�440.�[PubMed]
35.�Cady R, Farmer K, Beach ME, Tarrasch T. Nurse-based education: An office-based comparative model for education of migraine patients.�Headache.�2008;48:564�569.�[PubMed]
36.�Kwong WJ, Landy SH, Braverman-Panza J, Rosen JH, Hutchinson S, Burch SP. A migraine disease management program in the primary care setting: impact on patient quality of life and productivity loss.�J Clin Outcomes Manage.�2007 Jun;14(6):332�338.
37.�Maizels M, Saenz V, Wirjo J. Impact of a group-based model of disease management for headache.�Headache.�2003;43:621�627.�[PubMed]
38.�Rothrock JF, Parada VA, Sims C, Key K, Walters NS, Zweifler RM. The impact of intensive patient education on clinical outcome in a clinic-based migraine population.�Headache.�2006;46:726�731.[PubMed]
39.�Harpole L, Samsa G, Jurgelski A, et al. Headache management program improves outcome for chronic headache.�Headache.�2003;43:715�724.�[PubMed]
40.�Primary Care Network.�Patient Centered Strategies for Effective Management of Migraine.�2000.
41.�Primary Care Network.�The Migraineur�s Guide to Migraine.�1998.
42.�GlaxoSmithKline.�Migraine Matrix�.�2001.
43.�Kosinski M, Bayliss MS, Bjorner JB, et al. A six-item short-form survey for measuring headache impact: The HIT-6.�Qual Life Res.�2003;12:963�974.�[PubMed]
44.�Nachit-Ouinekh F, Dartigues JF, Henry P, et al. Use of the headache impact test (HIT-6) in general practice: Relationship with quality of life and severity.�Eur J Neurol.�2005;12:189�193.�[PubMed]
45.�Jhingran P, Osterhaus JT, Miller DW, et al. Development and validation of the Migraine-Specific Quality of Life Questionnaire.�Headache.�1998;38:295�302.�[PubMed]
46.�Jhingran P, Davis SM, LaVange LM, et al.�Migraine-Specific Quality of Life Questionnaire: Further investigation of the factor structure.[PubMed]
47.�Statistical Packages for the Social Sciences (SPSS) [computer program]. Version 14.0.�Chicago: SPSS Inc; 2006.
48.�Asmundson GJG, Norton PJ, Norton GR. Beyond pain: The role of fear and avoidance in chronicity.�Clin Psych Rev.�1999;19:97�119.�[PubMed]
49.�McCracken LM, Gross RT. Does anxiety affect coping with chronic pain?�Clin J Pain.�1993;9:253�259.[PubMed]
50.�Bishop KL, Holm JA, Borowiak DM, Wilson BA. Perceptions of pain in women with headache: a laboratory investigation of the influence of pain-related anxiety and fear.�Headache.�2001;41:494�9.[PubMed]
51.�Lanteri-Minet M, Radat F, Chautard MH, Lucas C. Anxiety and depression associated with migraine: Influence on migraine subjects� disability and quality of life, and acute migraine management.�Pain.�2005;118:319�26.�[PubMed]
52.�Radat F, Mekies C, Geraud G, Valade D, Vives E, Lucas C. Anxiety, stress, and coping behaviours in primary care migraine patients: results of the SMILE study.�Cephalagia.�2008;28:1115�25.�[PubMed]
53.�Smith T, Nicholson R. Are changes in cognitive and emotional factors important in improving headache impact and quality of life?�Headache.�2006;46:878.
54.�White KD, Farrell AD. Anxiety and psychosocial stress as predictors of headache and abdominal pain in urban early adolescents.�J Ped Psych.�2006;31:582�96.�[PubMed]
55.�Hahn SR, Cady RK, Nelson MR. Improving healthcare professional-patient communication to promote more effective assessment of migraine impairment during and between attacks: results of the American Migraine Communication Study (AMCS) Phase II. Presented at: the Diamond Headache Clinic�s 20th Annual Practicing Physician�s Approach to the Difficult Headache Patient; February 12�15, 2007; California: Rancho Mirage;
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Migraine Pain Treatment El Paso, TX | Video

Migraine Pain Treatment El Paso, TX | Video

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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Chiropractic Clinic News Extra: Headache Treatment

Chiropractic Headache Treatment Guidelines in El Paso, TX

Chiropractic Headache Treatment Guidelines in El Paso, TX

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

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

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

 

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Additional Topics: Back Pain

 

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

 

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

 

 

MORE TOPICS: EXTRA EXTRA: El Paso, Tx | Athletes

 

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Migraine Headache Pain Chiropractic Therapy in El Paso, TX

Migraine Headache Pain Chiropractic Therapy in El Paso, TX

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

 

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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

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

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

 

Table 3 Means and SD

 

Table 4 Mean SD Doses of Medications

 

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

 

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Additional Topics: Back Pain

 

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

 

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

 

 

MORE TOPICS: EXTRA EXTRA: El Paso, Tx | Athletes

 

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References
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Chiropractic Treatment for Migraine Pain in El Paso, TX

Chiropractic Treatment for Migraine Pain in El Paso, TX

Migraine headache pain can be characterized as a throbbing pain or a pulsing sensation of varying intensity, which is generally accompanied by nausea as well as extreme sensitivity to light and sound. According to the American Migraine Association, migraines affect about 36 million Americans, or approximately 12 percent of the population in the United States. Because the symptoms can often become very debilitating, many migraine sufferers will have tried everything to attempt to relieve their headache pain, including avoiding triggers and using drugs and/or medications to reduce the symptoms. However, research studies have found that one alternative treatment option can greatly benefit migraineurs: chiropractic care.

 

Chiropractor Treating Migraine Pain

 

Chiropractic care is a safe and effective alternative treatment option which focuses on the diagnosis, treatment and prevention of a variety of injuries and/or conditions associated with the musculoskeletal and nervous system. A doctor of chiropractic, or chiropractor, will commonly utilize a series of chiropractic methods and techniques, including spinal adjustments and manual manipulations, to carefully correct any spinal misalignment, or subluxation, located along the length of the spine. Although the true source of migraines is still misunderstood today, healthcare professionals believe that a misalignment of the cervical spine, or neck, may trigger migraine symptoms. By correcting the alignment of the spine, a chiropractor can release the pressure being placed against the spinal column which may be irritating and/or compressing the complex structures surrounding the spine, manifesting the well-known symptoms of migraines. Furthermore, chiropractic care can decrease muscle tension and increase circulation, eliminating stress in the body which is also known to be a factor behind migraines, promoting further relief.

 

Dr. Alex Jimenez chiropractor treating migraine pain.

 

Dr. Jimenez using chiropractic treatment to release pressure on a patient's neck

 

The Efficacy of Chiropractic Spinal Manipulative Therapy (SMT) in the Treatment of Migraine

 

Abstract

 

  • Objective: To test the efficacy of Chiropractic spinal manipulative therapy (SMT) in the treatment of migraine, using an uncontrolled clinical trial.
  • Design: A clinical trial of six months duration. The trial consisted of 3 stages: two months of pre-treatment, two months of treatment, and two months post treatment. Comparison was made to initial baseline episodes of migraine preceding commencement of SMT.
  • Setting: Chiropractic Research Centre of Macquarie University
  • Participants: Thirty two volunteers, between the ages of 23 to 60 were recruited through media advertising. The diagnosis of migraine based on a detailed questionnaire, regarding self reported symptoms or signs, with minimum of one migraine with aura per month.
  • Interventions: Two months of SMT provided by an experienced chiropractor at a university clinic.
  • Main Outcome Measures: Participants completed diaries during the entire trial noting the frequency, intensity, duration, disability, associated symptoms and use of medication for each migraine episode. In addition, clinic records were compared to their diary entries of migraine episodes.
  • Results: A total of fifty nine participants responded to the advertising, with twenty five being excluded or deciding not to continue in the trial. Two participants (5.9%) withdrew during the trial, one due to alteration in work situation and one following soreness after SMT. The Chiropractic SMT group showed statistically significant improvement (p < 0.05) in migraine frequency and duration, when compared to initial baseline levels. Only one participant (3.1%) reported that the migraine episodes were worse after the two months of SMT, and this was not sustained at the two month post treatment follow up period.
  • Conclusion: The results of this study suggest that Chiropractic SMT is an effective treatment for migraine with aura. However, due to the cyclical nature of migraine with aura, and the finding that episodes usually reduce following any intervention, further research is required. A prospective randomised controlled trial utilising detuned EPT (interferential), a sham manipulation group and an SMT group is nearing conclusion. It is anticipated this trial will provide further information of the efficacy of Chiropractic SMT in the treatment of migraine with aura.
  • Key Indexing Terms (MeSH): Migraine, chiropractic, spinal manipulation, clinical trial.

 

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Dr. Alex Jimenez’s Insight

According to the American Chiropractic Association, a 2011 report published in the Journal of Manipulative and Physiological Therapeutics, or JMPT, found that chiropractic care, including spinal adjustments and manual manipulations, can improve migraine and cervicogenic headache symptoms. Healthcare professionals have associated primary headaches with stress and muscle tension. Chiropractic care can help decrease the frequency of migraines and manage its symptoms by carefully correcting any spinal misalignment, or subluxation, found along the spine. By restoring the proper alignment of the spine, chiropractic care can improve overall spinal function by alleviating pressure on the nervous system, increasing circulation and reducing muscle tension and stress which causes migraine pain.

 

Introduction

 

Some studies appear to have demonstrated significant reduction in migraines following chiropractic intervention (1-8). However, this reduction may in part have been due to inaccurate diagnosis or overlapping symptoms (4,9,10). Many different conditions of the cervical spine, including mechanical and joint pathology, have been reported to cause headache (10-16). Sjaastad (17) used the term �cervicogenic headache� to describe a type of the chronic paroxysmal unilateral headache, which is accompanied by autonomic symptoms and provacated by movements of the head and neck. Sjaastad proposed that entrapment of the occipital nerve or a C2-C3 rhizopathy may produce this headache (18).

 

There are a number of aetiologies of migraines proposed in the literature. These include: vascular (19-21); autonomic (22); biochemical/cellular/immunological (23- 27); psychophysiological (28,29); neurogenic (9,15,25,30) and somatic (1-9,31,32). This has made a common treatment regime difficult. One early medical model was vascular cause of migraine, where a migrainous attack is initiated by a decreased blood flow to the cerebral vasculature or a cerebrovascular spasm, but characterized by extracranial vasodilation during the headache phase (19,20). However, later aetiological models have demonstrated more complex vascular changes with associated neurological changes (9).

 

Many practitioners involved in the treatment of migraine would, however, accept that a number of aetiological factors are involved and that there is substantial overlap in both aetiology or diagnosis (9,15,26,33,34). In addition, no single model appears to explain all the possible symptoms associated with migraine.

 

One possible aetiological factor is cervical spondylosis with associated neck pain and stiffness (34). Anthony states �when this is recognised, appropriate treatment can give impressive results…the aim is to relieve pressure on nerve roots in the upper neck thereby reducing activation of the spinal tract of the trigeminal nerve, which is part of the pain centre in the head and neck� (34). Surgical decompression of the lower cervical nerve�roots as carried out by Ghavamian (36) showed relief of migraine symptoms. He proposed that irritation and compression of the deep sympathetic fibres incited such symptomatology.

 

Vernon (7), proposed a vertebrogenic model which involves components from the different categories previously stated. One part involves lesions in the low cervical/upper thoracic spine and the upper cervical spine. The low cervical spine/upper thoracic spine (C7-T4) model proposed that dysfunction (i.e. somatic dysfunction) at these vertebral levels causes joint fixation and pain. This pain alters the neural messages received, and therefore sent, by the Central Nervous System (CNS). The Autonomic Nervous System which controls, amongst other functions, blood supply, is thus also affected. It is proposed that when certain threshold levels of transient cerebral ischaemia (due to vasoconstriction caused by the above mechanism) are reached, a migraine cascade of symptomatology may be precipitated.

 

A second part involves somatic dysfunction in the upper cervical spine (Occiput-C2), which produces local pain and fixation leading to increased neural input to the CNS. This results in a reduction in descending pain-inhibiting impulses from the CNS and consequently increases activity within the spinal trigeminal tract (which transmits the majority of sensory afferents and pain signals from the upper cervical region to the brain). Having exceeded a threshold level, this excessive afferent input to the CNS will trigger focal, and spreading vasoconstriction within the intracerebral vasculature. This will in turn promote extra-carotid vasodilation and cranial pain which is mediated by the ipsilateral trigeminal nerve (7).

 

Another model contends that irritation of the vertebral nerve by cervical lesions can produce a sympathetic syndrome, giving symptoms of headache, vertigo, visual disturbances and tinnitus. However, this model has not been well substantiated and appears more likely a cause of vascular headache as opposed to migraine (11). The source of pain in migraines is found in the intra- and extracranial blood vessels. The blood vessel walls are pain sensitive to distension, traction or displacement. The idiopathic dilation of cranial blood vessels, together with an increase in a pain threshold lowering substance, result in headache of migraine type (26).

 

Migraine has a well established symptomatology that has been outlined in various studies (4,12,15). The debilitating and frequent nature of symptoms that include head pain, nausea, vomiting, phonophobia, and photophobia, costs our society both socially and economically (4,12,15,20). As such, effective treatment has long been sought, therefore justifying study in this area. However, there is substantial overlap of symptoms between migraine and cervicogenic�headache, and some authors believe elements of the migraine headache continuum involve cervical headache (9,10).

 

The Headache Classification Committee of the International Headaches Society, has discarded the former terms classical migraine and common migraine in favour of migraine with aura and migraine without aura. In migraine with aura (MA), this condition is defined as recurrent, periodic, unilateral headache which is preceded or accompanied by transient visual, sensory, motor, or other focal neurological symptoms which localise to the cerebral cortex or brainstem. Migraine without aura, (MWA) is defined as a vascular headache without striking prodromal or associated symptoms of cerebral dysfunction (37).

 

The incidence of migraine in Australia is estimated at 12%, with the cost to industry an estimated $250 million (38). In the USA approximately 8% of headaches diagnosed by medical practitioners are called migraine headaches (39). Migraine, in its various forms, affects an estimated 5-20% of people throughout the world (40).

 

A review of the literature appears to indicate that migraine is an associated feature of cervical dysfunction. This paper will evaluate chiropractic spinal manipulative treatment directed towards improving vertebral function, and its role in the management of the migraines.

 

Methodology

 

Chiropractic spinal manipulative therapy (SMT) is defined as a passive manual manoeuvre during which the three joint complex is carried beyond the normal physiological range of movement without exceeding the boundaries of anatomical integrity (41). SMT requires a dynamic force in a specific direction, usually with a short amplitude, to correct a problem of reduced vertebral motion or positional fault.

 

The study design was based on a previous study which involved 82 subjects who received either chiropractic SMT, physiotherapy manipulation, or a control treatment of medical mobilization (1). Parker et al, concluded that manipulation was not found to be more effective than mobilisation, and chiropractic treatment not more effective than the other two groups (3). However, much criticism was received over the study, especially the statistical analysis (42).

 

People with migraines were advertised for participation in the study via the radio and newspapers within a local region of Sydney. All applicants completed a questionnaire, developed from Vernon (12), which contains over 25 sections, including details of the initial�history, frequency, severity, location and reaction to the pain, associated symptoms, precipitating or aggravating factors, relieving factors, past treatment for migraines, medical history including medications and other diagnostic tests.

 

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

 

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

 

Participants were informed that they were involved in a trial of manipulative therapy for migraine, and that they may be randomly assigned to a control group which would receive a placebo (non effective) treatment, or to an intervention group which would receive Chiropractic SMT. However, because of the small numbers of participants that were involved in the trial, a control group was not used. Participants were also informed that a thorough physical examination would be performed prior to commencement of treatment to assess any physical problems precluding them receiving SMT. Patients were blinded, by believing that they may or may not receive an effective treatment. In addition, practitioners were not aware of ongoing treatment results, therefore they were also �blinded� to the stage of progress of the patients condition or response to treatment.

 

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

 

Patients were instructed at the beginning of the study on the use of the diary and were given an instruction sheet to use throughout the course of the trial. The diary consisted of a table for entries of each of the outcome measures. This included noting the date of each episode, a number representing a visual analogue score, letters denoting associated symptoms, the length (in hours) of each migraine, the time (in hours) before the person could return to normal duties, type and use of medications and the overall relief from the medication. The diaries were modified from standard diaries used by the Brain Foundation of Australia.

 

A detailed history of the patient’s subjective pain features was taken during the initial consultation. This included the type of pain, duration, onset, severity, radiation, aggravating and relieving factors. The history also included medical features, a systems review for potential pathologies, previous treatments and its effects.

 

Factors for assessing subluxation included: orthopaedic and neurological testing, segmental springing, mobility measures such as visual estimation of range of motion, assessment of previous radiographs, specific chiropractic vertebral testing procedures, as well as response of the patient to SMT.

 

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

 

During the treatment period, the subjects continued to record migraine episodes in their diary, and receive telephone calls from the authors. Treatment consisted of short amplitude, high velocity spinal manipulative thrusts, or areas of fixation determined by the physical examination. Patients were allowed a maximum of sixteen treatments, and the frequency of treatment was dependent on the clinicians opinion of the severity of the vertebral dysfunction. The majority of patients received a minimum of twelve treatments.

 

Comparison was made to initial baseline episodes of migraine preceding commencement of SMT. Statistical analysis involved comparing the effects of the different treatment regimes on the incidence, intensity, and duration of migraines throughout the trial. Statistical tests employed were a students t test to test for significant difference between each group and a one way analysis of variance (ANOVA) to test for changes for all groups. Statistical calculations were performed via a computer software program Minitab for Macintosh.

 

Results

 

A total of fifty nine participants responded to the�advertising, with twenty five being excluded or deciding not to continue in the trial. These included: six cases of infrequent recurrence of the migraines (less than one per month); two cases of contraindications to SMT; one case of cluster headache; one case of motor vehicle accident during pre treatment; one case of fear of SMT; fourteen cases where the university clinic was inconvenient or time constraints were too difficult for participants. Two participants (5.9%) withdrew during the trial, one due to alteration in work situation and one following soreness after SMT.

 

Thirty two participants, between the ages of 23 to 60, joined the study with there being 14 males and 18 females. Table 1 gives the comparative descriptive statistics for the group.

 

Table 1 Comparative Descriptive Statistics

 

The Chiropractic SMT group showed statistically significant improvement (p < 0.05) in migraine severity (Figure 1), duration (Figure 2) and disability (Figure 3), when compared to initial baseline levels. Only one participant (3.1%) reported that their migraine episodes were worse after the two months of SMT, but this was not sustained at the two month post treatment follow up period. Table 2 demonstrates variate scores in each of the six diary categories for the three phases of the trial.

 

Table 2 Variate Scores for the Three Phases of the Trial

 

The greatest area for improvement was with disability scores (p < 0.01), where participants were asked to rate the time that elapsed before they could return to normal activities (Table 3). In addition, the duration of the migraine and the use of medication, reduced significantly following the SMT intervention (p < 0.05). Table 3 shows mean variate scores for the three phases of the trial�and statistical significance by analysis of variance (ANOVA).

 

Table 3 Mean Variate Scores

 

There was no apparent difference in the number of associated symptoms and the time taken for treatment to give relief of each migraine episode (Table 3). In addition, self reported possible trigger factors demonstrated no significant findings, predominantly due to the small sample size. Common trigger factors that were cited included stress, lack of sleep, work changes, or family situations. Most participants could not state a particular trigger factor.

 

Discussion

 

The majority of people who participated in this trial had chronic migraines that were severe and debilitating. However, the results have demonstrated a significant (p< 0.05) reduction in their�migraine episodes and their associated disability. The mean number of migraine per month reduced from 7.6 to 4.9 episodes.

 

This trial was conducted using a similar design to a previous study which demonstrated significant improvement in migraines following chiropractic SMT (1,3). The initial trial had limitations due to an inadequate control group, and this could also be a limitation with this study(2). However, the use of self reported, non treatment period as a control, allows flexibility regarding use of medication and any alteration during the trial.

 

Figure 1 Comparison of Visual Analogue Scores

Figure 1: Comparison of visual analogue scores for pre-treatment, treatment and post-treatment group means.

 

Figure 2 Comparison of Duration Time of Migraine Hours

Figure 2: Comparison of duration time of migraine (hours) for pre-treatment, treatment and post-treatment group means.

 

Figure 3 Comparison of Disability Time of Migraine Hours

Figure 3: Comparison of disability time of migraine (hours) for pre-treatment, treatment and post-treatment group means.

 

A similar design to this study has also been used in a study of headache and SMT (14). The Boline study was a randomised controlled trial using two parallel groups, with a two week baseline, a six week treatment period and a four week post treatment period. The results of this study show that SMT was an effective method of treatment for tension type headaches, and that the benefit was sustained for the four weeks after cessation of the treatment.

 

The present study was conducted over a six month period which gives the results substantial significance because early criticisms of studies were that the length of the trial was too short to allow for the cyclical nature of migraines. However, the study is limited in the sample size and the fact that the trial was a pragmatic study which did not consider what aspects of chiropractic SMT had contributed to the improvement in the migraine episodes.

 

In addition, the study is limited due to the lack of a control group. However, the fact that the trial was conducted over a six month period, with two months pre-treatment, it could be argued that participants acted as their own form of control.

 

A further limitation of this study, as with other studies of migraine or headaches is that there is substantial overlap in diagnosis and classification of migraines. The questionnaire used in this study proved to have good reliability, however, there is strong suggestion that many headache sufferers may have more than one type of headache (12). An advantage with the design of this study is that regardless of the exact �diagnosis� of the migraine, self reported, non-treatment controls still allow assessment of the therapy in question.

 

The measurement used for relief scores proved to be poor, which was probably due in part to the small scale for response that participants were given. Future studies should address this issue. In addition, associated symptoms did not give a clear result because the study only measured the total number of associated symptoms, and the sample size was too small for a significant percentage breakdown. Future studies should also address this issue.

 

Conclusion

 

The results of this study suggest that Chiropractic SMT may be an effective treatment for migraine. However, due to the cyclical nature of migraine, and the finding that episodes usually reduce following any intervention, further research is required. A prospective randomised controlled trial utilising detuned EPT (interferential), a sham manipulation group and an SMT group is nearing�conclusion. It is anticipated this trial will provide further information of the efficacy of Chiropractic SMT in the treatment of migraine.

 

In conclusion,�chiropractic care is a safe and effective alternative treatment option which can be used to improve migraine symptoms as well as decrease their frequency. A chiropractor will utilize spinal adjustments and manual manipulations to correct spinal misalignments, or subluxations, releasing pressure being placed against the complex structures surrounding the spine, decreasing muscle tension and improving circulation to eliminate stress, ultimately benefitting migraine sufferers. Finally, the purpose of the article above was to demonstrate the efficacy of chiropractic spinal manipulative therapy, or SMT, in the treatment of 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

 

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Additional Topics: Back Pain

 

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

 

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