Body To Balance: /Chiro /Research

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Research

Chiropractic Care

Neil M. Paige, MD, MSHS, Isomi M. Miake-Lye, BA, Marika Suttorp Booth, MS et al: Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460. doi:10.1001/jama.2017.3086. Conclusions and Relevance: Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

 

Schneider M, Murphy D, Hartvigsen J: Spine Care as a Framework for the Chiropractic Identity. J. Chiropractic Humanit. 2016 Nov 4;23(1):14-21. eCollection 2016. Discussion: Surveys of the general public and chiropractors indicate that the majority of patients seek chiropractic services for back and neck pain. Insurance company utilization data confirm these findings. Regulatory and legal language found in chiropractic practice acts reveals that most jurisdictions define the chiropractic scope of practice as based on a foundation of spine care. Educational accrediting and testing organizations have been shaped around a chiropractic education that produces graduates who focus on the diagnosis and treatment of spine and musculoskeletal disorders. Spine care is thus the common denominator and theme throughout all aspects of chiropractic practice, legislation, and education globally. Conclusion: Although the chiropractic profession may debate internally about its professional identity, the chiropractic identity seems to have already been established by society, practice, legislation, and education as a profession of health care providers whose area of expertise is spine care.

 

Christine M. Goertz, DC, PhD, Cynthia R. Long, PhD, Maria, A. Hondras, DC, MPH, Richard Petri, MD, Roxana Delgado, MS, Dana J. Lawrence, DC, MMedEd, MA, Edward F. Owens, Jr, MS, DC,  William C. Meeker, DC, MPH: Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study. Spine 2013 Apr 15;38(8):627-34. The results of this trial suggest that chiropractic manipulative therapy in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute low back pain.

 

Gary Globe, PhD, MBA, DCl, Ronald J. Farabaugh, DC, Cheryl Hawk, DC, PhD, Craig E. Morris, DC, Greg Baker, DC, Wayne M. Whalen, DC, Sheryl Walters, MLS, Martha Kaeser, DC, MA, Mark Dehen, DC, Thomas Augat, DC: Clinical Practice Guideline: Chiropractic Care for Low Back Pain, JMPT 2016: 39(1). The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain disorders.

 

Gilles LGF: A randomized clinical trial comparing medication, acupuncture and spinal manipulation. Spine 2003; 28(14). Manipulation is superior to acupuncture or NSAIDS for chronic spinal pain.

 

McNaughton H: Managing acute low back pain. New Zealand Med J 1996: 109. Chiropractic reduces severe pain in the first 4 weeks of acute low back pain.

 

Green BN1, Johnson CD2, Daniels CJ3, Napuli JG4, Gliedt JA5, Paris DJ6. Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature. J Evid Based Complementary Altern Med. 2015 Dec 16. pii: 2156587215621461. DOCTORS OF CHIROPRACTIC THAT ARE INTEGRATED WITHIN MILITARY AND VETERAN HEALTH CARE FACILITIES. PATIENT SATISFACTION WITH CHIROPRACTIC SERVICES IS HIGH. PRELIMINARY FINDINGS SHOW THAT CHIROPRACTIC MANAGEMENT OF COMMON CONDITIONS SHOWS SIGNIFICANT IMPROVEMENT.

 

Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T. Chiropractic as spine care: a model for the profession. Chiropr Osteopat. 2005 Jul 6;13:9. The continued failure by the chiropractic profession to remedy this state of affairs will pose a distinct threat to the future viability of the profession. Three specific characteristics of the profession are identified as impediments to the creation of a credible definition of chiropractic: Departures from accepted standards of professional ethics; reliance upon obsolete principles of chiropractic philosophy; and the promotion of chiropractors as primary care providers. A chiropractic professional identity should be based on spinal care as the defining clinical purpose of chiropractic, chiropractic as an integrated part of the healthcare mainstream, the rigorous implementation of accepted standards of professional ethics, chiropractors as portal-of-entry providers, the acceptance and promotion of evidence-based health care, and a conservative clinical approach. This paper presents the spine care model as a means of developing chiropractic cultural authority and relevancy. The model is based on principles that would help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession.

 

W. Mark Erwin, DC, PhD, A. Pauliina Korpela, BSc, Robert C. Jones, DC: Chiropractors as Primary Spine Care Providers: precedents and essential measures. J Can Chiropr Assoc 2013; 57(4). It has been stated that the chiropractic status quo threatens the future of the profession. What happens if chiropractic fails to reform? As other health care professions adapt according to evolving evidence to best meet societal needs, is it possible that chiropractic could lose its relevance? Podiatry, optometry, chiropody and naturopathy have made significant efforts in professional reform and modernization and as a consequence have made significant gains in their respective scopes of practice and legislation. If chiropractic aspires to become the primary spine care provider of the present and future, it need not reinvent the wheel; it needs only to look as far as its own front door.

 

Effectiveness of Pharmacological Therapies and Non Pharmacological Therapies for Low Back Pain

Roger Chou, MD; Richard Deyo, MD, MPH; Janna Friedly, MD; Andrea Skelly, PhD, MPH; Melissa Weimer, DO, MCR; Rochelle Fu, PhD; Tracy Dana, MLS; Paul Kraegel, MSW; Jessica Griffin, MS; Sara Grusing, BA: Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline, Annals of Internal Medicine 2017. Several systemic medications for low back pain are associated with small to moderate, primarily short-term effects on pain. New evidence suggests that acetaminophen is ineffective for acute low back pain, and duloxetine is associated with modest effects for chronic low back pain.

 

Roger Chou, MD; Richard Deyo, MD, MPH; Janna Friedly, MD; Andrea Skelly, PhD, MPH; Robin Hashimoto, PhD; Melissa Weimer, DO, MCR; Rochelle Fu, PhD; Tracy Dana, MLS; Paul Kraegel, MSW; Jessica Griffin, MS; Sara Grusing, BA; Erika D. Brodt, BS: Non Pharmacologic Therapies for Low Back Pain: A systematic review for an Americal College of Physicians Clinical Practice Guidline, Annals of Internal Medicine 2017. Several non pharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain; findings include new evidence on mind–body interventions.

 

Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH; Robert M. McLean, MD; Mary Ann Forciea, MD; for the Clinical Guidelines Committee of the American College of Physicians: Non invasive treatments for acute, subacture, and chronic low back pain: A clinical practice guideline from the American College of Physicians: Annals of Internal Medicine 2017. 

Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation). 

Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select non pharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation). 

Recommendation 3: In patients with chronic low back pain who have had an inadequate response to non pharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

 

Gustavo C Machado,1 Chris G Maher,1 Paulo H Ferreira,2 Richard O Day,3 Marina B Pinheiro,2 Manuela L Ferreira: Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis, Ann Rheum Dis 2017;0:1–10. doi:10.1136/annrheumdis-2016-210597. NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition.

 

 Safety of Chiropractic Care

James M. Whedon DC, Yunjie Song PhD, Todd A. Mackenzie PhD, Reed B. Phillips PhD, Timothy G. Lukovits MD, and Jon D. Lurie MD, MS: Risk of Stroke after Chiropractic Spinal Manipulation In Medicare B Beneficiaries Aged 66 To 99 Years With Neck Pain, JMPT 2015: 38(2). Among Medicare B Beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.

  

Flexion Distraction Therapy Spinal Decompression Manipulation

Cox, JM, Feller JA, Cox JA: Distraction Chiropractic Adjusting: Clinical Application, Treatment Algorithms, and Clinical Outcomes of 1000 Cases Studied. Topics in Clinical Chiropractic 1996; (3)3:45-59, 79-81. Data from 1000 flexion distraction cases were collected from 30 different clinics. The researchers reported a median 29 days and a median 12 visits for maximal improvement. Less than 9% of cases reached the chronic stage and less than 4% of cases were candidates for surgery after care. The results were separated by conditions to highlight that lumbar disc herniation generally requires more visits and days till maximum improvement than a lumbar sprain/ strain.

 

Murphy, DR; Hurwitz, EL; Gregory, AA; Clary, R. A non-surgical approach to the management of lumbar spinal stenosis: A prospective observation cohort study. BMC Musculoskeletal Disorders 2096; 7. Study of Cox distraction manipulation on the treatment of lumbar spine stenosis. Lumbar spinal stenosis improved by 76% and disability improved in 73%.

 

Maruti R. Gudavalli, PhD, Kurt Olding, DC, George Joachim, DC, James M. Cox, DC: Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Study Series. Journal of Chiropractic Medicine: June 2016 15 1 Number 2: 121-128. Greater than 50% pain relief following chiropractic distraction spinal manipulation was seen in 81% of postsurgical patients receiving a mean of 11 visits over a 49 day period of active care. At 24 month follow up, 79% continued with greater than 50% pain relief. The mean pain relief at the end of active care was 72% and at 24 months was 70%. 24 months after active care, 24 patients (43%) had not sought continued care while 32 required further care (chiropractic for 17 (53%), PT, exercise, injection, medication for 9(28%), surgery for 5 (16%).

 

Gudavalli R, Cambron J, McGregor M et al: A randomised clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. European Spine Journal 2006; 15: 1070-1082. Both groups improved significantly after treatment. Patients assigned to flexion distraction did better than active exercise. Patients with radiculopathy improved significantly better with flexion distraction therapy.

 

Cambron GA, Gudavalli MR, McGregor M et al: Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain. Osteopathy and Chiropractic 2006; 14:19. During a one-year follow-up, participants previously randomized to physical therapy attended significantly more healthcare visits  for low back pain than those participants who received chiropractic care. 38% of flexion–distraction patients sought care. 54% of physical therapy patients sought care.

 

Snow G: Chiropractic management of a patient with lumbar spinal stenosis. JMPT 2001; 24(4): 300-304

  • severe, multilevel central canal stenosis in a 78-year-old man
  • low back pain and severe bilateral leg pain
  • MRI - severe degenerative lumbar stenosis at L3-L4 and L4-L5 and at L2-L3 (less so)
  • Treatment - flexion-distraction manipulation of the lumbar spine
  • Outcome - decrease in the frequency and intensity of his leg symptoms and a resolution of his low back pain. These improvements were maintained at a 5-month follow-up visit.

 

Morris CE: Chiropractic rehabilitation of a patient with S1 radiculopathy associated with a large lumbar disk herniation. Journal of Manipulative and Physiological Therapeutics 1999; 22(1):38-44

  • 31 y/o man with severe lbp, plantar flexion weakness of left leg, absent Achilles reflex, hypesthesia S1 dermatome, MRI large L5-S1 HNP
  • Cox decompression distraction adjustment was part of the treatment resulting in RTW in 27 days.
  • Repeat MRI showed no change
  • 20 visits over 50 days with total remission. Absent Achilles maintained.

 

Hayden RA: Multilevel degenerative disc disease: a case study. Georgia Chiropractic Journal 1996; April: 6-7:34

  • 61-year-old female with low back, hip and sciatic pain
  • five years bedridden or restricted to the sofa
  • Onset of the pain was gradual and worsened recently, interfering with work, sleep and rest. Lying flat on her back helped. Pain radiated to both calves at time, left more than right. The physician diagnosed her as having multi-level disc degeneration and degenerative joint disease with significant subluxation of the thoracolumbar spine. She was most symptomatic of a large, medial, contained L5/S1 disc protrusion with S1 nerve root compression.
  • After four weeks of Cox® Distraction therapy, she reported no leg or back pain. She is able to walk and function again much to the delight of her family and the confusion of her friends.

 

Dry Needling/ Acupuncture

Tekin L, Akarsu S, Durmus O, Cakar E, Dincer U, Karalp MZ: The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol. 2013 Mar;32(3):309-15. doi: 10.1007/s10067-012-2112-3. Epub 2012 Nov 9. The objective of this study was to test the hypothesis that dry needling is more effective than sham dry needling in the treatment of myofascial pain syndrome (MPS). This was a prospective, double-blinded, randomized-controlled study conducted in an outpatient clinic. Thirty-nine subjects with established myofascial trigger points were randomized into two groups: study group (N = 22) and placebo group (N = 17). Dry needling was applied using acupuncture needles, and sham dry needling was applied in the placebo group. The treatment was composed of six sessions which were performed in 4 weeks; the first four sessions were performed twice a week (for 2 weeks) and the last two, once a week (for 2 weeks). The visual analog scale (VAS) and Short Form-36 (SF-36) were used. When compared with the initial values, VAS scores of the dry needling group following the first and sixth sessions were significantly lower (p = 0.000 and p < 0.000, respectively). When VAS scores were compared between the groups, the first assessment scores were found to be similar, but the second and third assessment scores were found to be significantly lower in the dry needling group (p = 0.034 and p < 0.001, respectively). When SF-36 scores of the groups were compared, both the physical and mental component scores were found to be significantly increased in the dry needling group, whereas only those of vitality scores were found to be increased significantly in the placebo (sham needling) group. The present study shows that the dry needling treatment is effective in relieving the pain and in improving the quality of life of patients with MPS.

 

Eric Gattie, Joshua A. Cleland, Suzanne Snodgrass: The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: A systematic Review and Meta-analysis. Journal of Orthoaedic & Sports Physical Therapy. Vol. 47: Issue 3: Pages 133-149, March 17. Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain threshold in patients presenting with musculoskeletal pain in the immediate to 12 week follow up period. Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling. However, no difference in functional outcomes exists when compared to other physical therapy treatments.

 

Lumbar Supports

Kang JI, Kwon HM, Jeong DK, Choi H, Moon YJ, Park JS: The effects of postural control and low back pain according to the types of orthoses in chronic low back pain patients.J Phys Ther Sci. 2016 Nov;28(11):3074-3077. Epub 2016 Nov 29. This study investigated how types of lumbosacral orthoses applied to patients with chronic lumbar pain affect postural control and low back pain. Ten subjects were randomly selected and allocated to each a group wearing soft lumbosacral orthoses and a group wearing rigid lumbosacral orthoses. They wore the lumbosacral orthoses for 4 weeks. Pain index and postural control were measured on the first day of wearing lumbosacral orthoses and 4 weeks later. Pain index was evaluated using a visual analogue scale, and postural control was measured using a Balance measurement system. The measurements examined included the overall balance index, anteroposterior balance index, and mediolateral balance index. [Results] There were statistically meaningful within-group differences in all variables, the visual analogue scale, overall balance index, anteroposterior balance index, and mediolateral balance index, in the group wearing soft lumbosacral orthoses. There were meaningful differences in visual analogue scale, overall balance index, and mediolateral balance index in the group wearing rigid lumbosacral orthoses. Furthermore, there was a meaningful difference in anteroposterior balance index between the group wearing soft lumbosacral orthoses and the group wearing rigid lumbosacral orthoses. Conclusion: The results of the present study showed that wearing soft lumbosacral orthoses was more effective than wearing rigid lumbosacral orthoses.

 

Surgical vs Conservative Spinal Treatment

Zaina F MD, Tomkins-Lane C PhD, Carragee E MD, Negrini S MD: Surgical versus non-surgical treatment for lumbar spinal stenosis, Spine: 15 July 2016 - Volume 41 - Issue 14 - p E857–E868. We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.

 

Weber: Spine Update: the natural history of disc herniation and the influence of intervention. Spine 19(19). 90% of patients with 4 months of sciatica respond to non surgical energetic non-operative care. 60% of surgical interventions are unnecessary.

 

Atlas S, Keller RB, Wu YA, Deyo RA, Singer DE. Spine 30(8) April 15, 2005: Long term outcomes of surgical and non surgical management of sciatica secondary to lumbar disc herniation: 10 year results from the Maine lumbar spine study. 400 patients with sciatica from a lumbar disc herniation treated surgically or non surgically were followed over a 10 year period. By 10 years, 25% of surgical patients had undergone at least one lumbar spine surgery. At 10 year follow up, 69% of surgically treated patients and 61% of those treated non surgically reported improvement in their predominant symptom of back or leg pain.

Long term outcomes of surgical and non surgical management of lumbar spinal stenosis: 8-10 year results from from the Maine lumbar spine study. 97 patients with low back and leg pain due to spinal stenosis were treated surgically and non surgically. After 8-10 years, 53% of surgically treated and 50% of non surgically treated patients reported that their predominant symptom of low back pain was improved. Both groups were satisfied with their current status in 55% of surgical and 49% of non surgically treated patients.

 

Gamache FW. Neurological Surgery, New York Presbyterian-Weill/ Cornell, New York, NY, USA. 26. The value of "another" opinion for spinal surgery: A prospective 14 month study of one surgeon's experience. Surg Neurol Int. 2012; 3(Suppl 5: S350-4. November 2012. Author recommended no surgery for 69 (44.5%) patients on second opinion.

 

Froholdt A; Reikeraas O; Holm I; Keller A; Brox JI. No difference in 9 year outcome in chronic low back pain patients treated with lumbar fusion versus cognitive intervention and exercises. European Spine Journal, Vol 21 Nov 12, 2012.

 

Albert, Hanne B. PT, MPH, MPH, PhD; Manniche, Claus MD, PhD, Med Sci. The efficacy of systematic active conservative treatment for patients with severe sciatica: A single-blind, randomized, clinical, controlled trial. Spine: 01 April 2012 - Volume 37 - Issue 7 - p 531-542. Paper shows non surgical care for surgical disc herniation patients is equal to surgery. 181 consecutive patients with radical are pain below the knee were examined at the baseline, at 8 weeks, and at 1 year after the treatment. All were surgical candidates for lumbar disc surgery.

 

Foulongne E, Derrey S, Ould Slimane M, Leveque S, Tobenas AC, Dujardin F, Freger P, Chassagne P, Proust F. Department of orthopaedics, Rouen University Hospital, 1, Rue de Germont, 76091 Rouen cedex, France. Lumbar spinal stenosis: Which predictive factors of favourable functional results after decompressive laminectomy? Neurochirurgie. 2012 Dec 13. pii: S0028-3770(12). The long term results of surgical treatment of lumbar spinal stenosis were moderate with an improved outcome in 49.5% of cases in this study.

 

Memo PA, Nadler S, Malanga G: Lumbar disc herniations: a review of surgical and non surgical indications and outcomes. J of Back and Musculoskeletal Rehabilitation. 2000; 14(3): 79-88. Non surgical treatment of radicular pain may be superior to surgery based on cost, morbidity, complications.

 

Millhouse PW1, Schroeder GD, Kurd MF, Kepler CK, Vaccaro AR, Savage JW. Microdiscectomy for a Paracentral Lumbar Herniated Disk. J Spinal Disord Tech. 2015 Dec 24. Patients with lumbar disc herniations causing radiculopathy often associated with leg pain see the vast majority improve with nonoperative care. Surgical intervention is reserved for patients who have significant pain that is refractory to at least 6 weeks of conservative care, patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction.

 

Choi J1, Lee S2, Jeon C3. Effects of flexion-distraction manipulation therapy on pain and disability in patients with lumbar spinal stenosis. J Phys Ther Sci. 2015 Jun;27(6):1937-9. doi: 10.1589/jpts.27.1937. Epub 2015 Jun 30. COX® FLEXION DISTRACTION EFFECT FOR TREATMENT OF SPINAL LUMBAR STENOSIS OVER OTHER CONSERVATIVE THERAPIES. THIS STUDY EXAMINED THE EFFECTS OF FLEXION-DISTRACTION MANIPULATION THERAPY ON PAIN AND DISABILITY IN PATIENTS WITH LUMBAR SPINAL STENOSIS. [SUBJECTS] THIRTY PATIENTS WITH LUMBAR SPINAL STENOSIS WERE DIVIDED INTO TWO GROUPS: A CONSERVATIVE TREATMENT GROUP (N=15) AND A FLEXION-DISTRACTION MANIPULATION GROUP (N=15). [METHODS] THE CONSERVATIVE TREATMENT GROUP RECEIVED CONSERVATIVE PHYSICAL THERAPY, AND THE FLEXION-DISTRACTION GROUP RECEIVED BOTH CONSERVATIVE PHYSICAL THERAPY AND FLEXION-DISTRACTION MANIPULATION THERAPY. BOTH GROUPS RECEIVED TREATMENT 3 TIMES A WEEK FOR 6 WEEKS. THE VISUAL ANALOG SCALE WAS USED TO MEASURE PAIN INTENSITY, AND THE OSWESTRY DISABILITY INDEX WAS USED TO EVALUATE THE LEVEL OF DISABILITY CAUSED BY THE PAIN. [RESULTS] THE VISUAL ANALOG SCALE SCORES FOR PAIN WERE SIGNIFICANTLY DECREASED IN BOTH GROUPS. IN THE BETWEEN-GROUP COMPARISON, THE DECREASE IN PAIN WAS MORE SIGNIFICANT IN THE FLEXION-DISTRACTION GROUP COMPARED TO PHYSICAL THERAPY. FLEXION-DISTRACTION MANIPULATION APPEARS TO BE AN EFFECTIVE INTERVENTION FOR PAIN AND DISABILITY AMONG PATIENTS WITH LUMBAR SPINAL STENOSIS.

 

Diagnostic Imaging

Webster BS et al: Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilisation outcomes, J Occup Environ Med. 2010. The majority of cases had no early MRI indications. Results suggest that iatragenic effects of early MRI are worse disability and increased medical costs and surgery, unrelated to severity.

 

Prevalence of Spinal Degeneration & Disc Bulges

Brinjikji W, Luetmer PH, Comstock B, Breshahan BW, Chen LE, Devo RA, Halabj S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG: Systematic literature review of imaging features of spinal in asymptomatic populations, Am Journal of Neuroradiology, 2015 Apr;36(4):811-6. Results: Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age. Conclusions: Imaging findings of spine are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient's clinical condition.

 

Nakashima, Hiroaki MD*; Yukawa, Yasutsugu MD†; Suda, Kota MD‡; Yamagata, Masatsune MD§; Ueta, Takayoshi MD¶; Kato, Fumihiko MD†. Cervical Disc Protrusion Correlates With the Severity of Cervical Disc Degeneration: A Cross-Sectional Study of 1211 Relatively Healthy Volunteers. Spine: 01 July 2015 - Volume 40 - Issue 13 - p E774–E779doi: 10.1097/BRS.0000000000000953. IN 1211 PEOPLE AGED 20 TO 70, PFIRRMANN CLASSIFICATION OF DISC DEGENERATION SHOWED THAT MILD DISC DEGENERATION WAS VERY COMMON, INCLUDING 98.0% OF BOTH SEXES IN THEIR 20'S. THE SEVERITY OF CERVICAL DISC DEGENERATION SIGNIFICANTLY INCREASED WITH AGE IN BOTH SEXES AT EVERY LEVEL. THE DISC DEGENERATION PREDOMINANTLY OCCURRED AT C5–C6 AND C6–C7.

 

Boos: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine 20(24). 76% of asymptomatic patients show MRI disc herniations. 96% of symptomatic patients show MRI disc herniations.

 

Economic Costs of LBP

 Rainville: Ortho Cl NA 27(4). Back injuries in USA have an annual cost of 86 billion.

 

Carey: Care seeking individuals with chronic low back pain. Spine 20(3). 25% of chronic low back pain patients absorb 95% of the cost.

 

Taimela S: The role of physical exercise and inactivity in pain recurrence and absenteeism from work after active outpatient rehabilitation for recurrent or chronic low back pain. A follow up study. Spine 2000; 25(14). Recurring persistent pain and work absenteeism is less among those who maintain regular exercise habits after an active treatment for recurrent chronic low back pain. Less favorable outcome in those who do not exercise.

 

Andronis, L., Kinghorn, P., Qiao, S. et al. Appl Health Econ Health Policy (2016). doi:10.1007/s40258-016-0268-8. Cost-effectiveness of non-invasive and non-pharmacological interventions for low back pain: a systematic literature review. The identified evidence suggests that combined physical and psychological treatments, medical yoga, information and education programs, spinal manipulation and acupuncture are likely to be cost-effective option for low back pain.

 

Prognosis of LBP

 Jayson MIV: Presidential Address: Why does acute back pain become chronic? Spine 22(10). At 3 months, prognosis is 27% completely better, 28% improved, 30% no change, 14% worse.

 

von Korff: Spine 21(24). 66-75% patients have pain at 1 month after treatment ends.

 

Mathews: Arth Rheum 39(9). 175 of 513 low back pain patients had pain 15 years after onset.

 

Yuen: Sciatic neuropathy: clinical and prognostic features in 73 patients. Neurology 44. Return of motor strength after damage of the sciatic nerve was 10% within 6 months, 30% by 1 year, 50% by 2 years and 75% by 3 years.

 

Epidural Injections for LBP

 Valat JP: Epidural corticosteroid injections for sciatica: a randomized, double blind controlled clinical trial. Annals of Rheumatic Diseases 2003: 62(7). 3 epidural injections of 2ml prednisolone acetate or saline were given to sciatica patients with herniated nucleus pulposus. Same relief with both.

 

Deplort et al: Archives of Physical Medicine and Rehabilitation 85(3), March 2004. Epidural steroid injections provide 32% of patients sustained pain relief.

 

Radiofrequency Neurotomy

Lopes Luis AI, Casimiro MV, Reizinho C. Efficacy of Radiofrequency Neurotomy for Lumbar Facet Syndrome and Sacroiliac Joint Pain Neurosurgery. 2015 Aug;62 Suppl 1, CLINICAL NEUROSURGERY:203-204. RADIOFREQUENCY NEUROTOMY WAS USEFUL FOR THE TREATMENT OF LUMBAR FACET SYNDROME AND SACROILIAC JOINT PAIN. DESPITE OF GRADUAL LOSS OF EFFICACY, AT 2 YEARS 40% OF PATIENTS MAINTAINED A 50% REDUCTION OF PAIN INTENSITY. THEREFORE THIS PROCEDURE COULD BE USED FOR TREATMENT OF CAREFULLY SELECTED PATIENTS WITH CHRONIC LBP.

 

Muscle De-conditioning in LBP

 Asian Spine J. 2016 Jun;10(3):516-21. doi: 10.4184/asj. 2016.10.3.516. Classification of Chronic Back Muscle Degeneration after Spinal Surgery and Its Relationship with Low Back Pain. Ohtori S1, Orita S1, Yamauchi K1, Eguchi Y1, Aoki Y1, Nakamura J1, Ishikawa T1, Miyagi M1, Kamoda H1, Suzuki M1, Kubota G1, Inage K1, Sainoh T1, Sato J1, Shiga Y1, Abe K1, Fujimoto K1, Kanamoto H1, Inoue G1, Takahashi K1. AFTER SPINE SURGERY, MRI REVEALED MUSCLE DEGENERATION IN ALL PATIENTS. MODIC CLASSIFICATION WAS USED TO DESCRIBE IT. AFTER SURGERY (TYPE 1, 6%; TYPE 2, 82%; AND TYPE 3, 12%).

 

Mitsutake T1, Sakamoto M, Chyuda Y, Oka S, Hirata H, Matsuo T, Oishi T, Horikawa E. Greater Cervical Muscle Fat Infiltration Evaluated by Magnetic Resonance Imaging is Associated with Poor Postural Stability in Patients with Cervical Spondylotic Radiculopathy. Spine (Phila Pa 1976). 2015 Oct 15.  FAT INFILTRATION WITHIN MUSCLE COULD LEAD TO INHIBITION OF NORMAL ACTIVITY OF MUSCULATURE. FAT WITHIN CERVICAL MULTIFIDUS MUSCLE COULD DIRECTLY CAUSE POSTURAL INSTABILITY IN STATIC STANDING, EVEN THOUGH THE PROPRIOCEPTIVE INFORMATION HAS NORMAL LOWER LIMBS. GREATER CERVICAL MUSCLE FAT INFILTRATION EVALUATED BY MAGNETIC RESONANCE IMAGING IS ASSOCIATED WITH POOR POSTURAL STABILITY IN PATIENTS WITH CERVICAL SPONDYLOTIC RADICULOPATHY.

 

Adolescent Idiopathic Scoliosis

Asian Spine J. 2016 Jun;10(3):570-81. doi: 10.4184/asj.2016.10.3.570. Epub 2016 Jun 16. Postural Rehabilitation for Adolescent Idiopathic Scoliosis during Growth. Weiss HR1, Moramarco MM2, Borysov M3, Ng SY4, Lee SG5, Nan X6, Moramarco KA2. LONG-TERM FOLLOW-UP OF UNTREATED PATIENTS WITH ADOLESCENT IDIOPATHIC SCOLIOSIS (AIS) INDICATES THAT, WITH THE EXCEPTION OF SOME EXTREMELY SEVERE CASES, AIS DOES NOT HAVE A SIGNIFICANT IMPACT ON QUALITY OF LIFE AND DOES NOT RESULT IN DIRE CONSEQUENCES. IN VIEW OF THE RELATIVELY BENIGN NATURE OF AIS AND THE LONG-TERM COMPLICATIONS OF SURGERY, THE INDICATIONS FOR TREATMENT SHOULD BE REVIEWED. FURTHERMORE, RECENT STUDIES HAVE SHOWN THAT SCOLIOSIS-SPECIFIC EXERCISES FOCUSING ON POSTURAL REHABILITATION CAN POSITIVELY INFLUENCE THE SPINAL CURVATURES IN GROWING ADOLESCENTS. THERE IS AT PRESENT LEVEL 1 EVIDENCE FOR THE EFFECTIVENESS OF SCHROTH SCOLIOSIS EXERCISES IN THE MANAGEMENT OF AIS.

 

McGill, Stuart. Low- Back Disorders: Evidence-Based Prevention and Rehabilitation, 2nd Ed.  Champaign: Human Kinetics Publishers, 2007. CONCLUSIONS: Supervised Schroth exercises provided added benefit to the standard of care by improving SRS-22r pain, self-image scores and BME. Given the high prevalence of ceiling effects on SRS-22r and SAQ questionnaires' domains, researchers hypothesize that in the AIS population receiving conservative treatments, different QOL questionnaires with adequate responsiveness are needed.

 

den Boer WA, Anderson PG, Limbeck JV, Kooijam MAP: Treatment of idiopathic scoliosis with side shift therapy: an initial comparison with a brace treatment historical cohort. Eur Spine J 1999:8;406-10. Exercise for scoliosis are for strengthening the convexside of thecurve and ensuring itsmobility, the same goals for adjusting scoliosis. We are not looking to necessarily correct the curve or reverse it, but rather ensure its mobility. Mehta Exercises are excellent tools the patient can do alone or, optimally, with a helper. 

 

Active correction by sideshift: an alternative treatment for early idiopathic scoliosis, In: Warner JO, Mehta MH. Scoliosis prevention. Proceedings of the P. Zorab scoliosis symposium 1983: Praeger, New York pp 126040. Side shift therapy should be considered as an additional treatment for idiopathic scoliosis in adolescents with an initial Cobb angle between 20 and 32 degrees.

 

Spondylolisthesis

Dunn A, Baylis S, Ryan D: Chiropractic management of mechanical low back pain secondary to multiple level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report. J Chiropractic Medicine. 2009 Sep; 8(3): 125-30. Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

 

Schneiderman: Spine 20(16): Cause of pain in spondylolisthesis. Pars interarticularis is source of pain in spondylolisthesis.

 

Synovial Cysts

Cox Jm: Chiropractic treatment of lumbar spine synovial cysts: a report of two cases. J Manipulative Physiol Ther. 2005 Feb;28(2):143-7. Chiropractic distraction manipulation and physiological therapeutic care relieved 2 patients with low back and radicular pain attributed to MRI-confirmed synovial cysts of the lumbar spine. This treatment may be an initial conservative treatment option for synovial cysts with careful patient monitoring for progressive neurologic deficit which would necessitate surgery. Distraction manipulation may be a safe and effective conservative treatment of synovial cyst causing radicular pain; further data collection of clinical outcomes is warranted.

 

Khan, AM; Girardi, F . Spinal lumbar synovial cysts. Diagnosis and management challenge. EUROPEAN SPINE JOURNAL 15 (8). AUG 2006. p.1176,1177-1182 SPRINGER, NEW YORK. STILL RECOMMENDING SURGERY FOR SYNOVIAL CYST?? Occur in females mostly in 6th decade of life. Incidence <0.5% of the general symptomatic population. Symptoms: radicular pain and neurological deficits. Level: commonly found at L4-5, the site of maximum mobility. Unilateral or bilateral and at one or multilevel. MRI is considered the tool of choice for its diagnosis. Etiology spinal instability, facet joint arthropathy and degenerative spondylolisthesis. Synovial cysts resistant to conservative therapy should be treated surgically. Resection and decompression with or without fusion and instrumentation remains an appropriate option. Synovial cysts may recur following surgery.

 

Tepe, S; Kara, M; Iplikcioglu, AC. Spontaneous Disappearance of Lumbar Synovial Cyst. JOURNAL OF NEUROLOGICAL SCIENCES-TURKISH 29 (1). 2012. p.154-158. CONSERVATIVE TREATMENT OF LUMBAR SYNOVIAL CYSTS IS RECOMMENDED DUE TO DISAPPEARANCE WITHOUT SURGERY.

 

Martha, JF; Swaim, B; Wang, DA; Kim, DH; Hill, J; Bode, R; Schwartz, CE. Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients. SPINE JOURNAL 9 (11). NOV 2009. p.899-904. LUMBAR FACET JOINT STEROID INJECTION WITH ATTEMPTED SYNOVIAL CYST RUPTURE IS CORRELATED WITH AVOIDING SUBSEQUENT SURGERY IN HALF OF 101 TREATED PATIENTS.

 

Bozzao A et al: Relapsing remitting bilateral synovial cysts of the lumbar spine. Neuroradiology 2001:43:1076-8. 33% of synovial cysts associated with degenerative spondylolisthesis and instability of the involved joint found in 61% of cases. Suggests that segmental joint play is a role in development of synovial cyst.

 

Chemical Inflammation & Neuropathic Pain

Eur Cell Mater. 2016 Jul 19;32:123-36. Reduced tissue osmolarity increases TRPV4 expression and pro-inflammatory cytokines in intervertebral disc cells. Walter BA1, Purmessur D, Moon A, Occhiogrosso J, Laudier DM, Hecht AC, Iatridis JC. REDUCED TISSUE OSMOLARITY, LIKELY FOLLOWING PROTEOGLYCAN DEGRADATION, CAN INCREASE TRPV4 SIGNALLING AND ENHANCE PRO-INFLAMMATORY CYTOKINE PRODUCTION, SUGGESTING CHANGES IN TRPV4 MEDIATED OSMO-SENSATION MAY CONTRIBUTE TO THE PROGRESSIVE MATRIX BREAKDOWN IN DISEASE.

 

 Ogon I1, Takebayashi T, Iwase T, Emori M, Tanimoto K. Sympathectomy and sympathetic blockade reduce pain behavior via alpha-2 adrenoceptor of the dorsal root ganglion neurons in a lumbar radiculopathy model. Spine (Phila Pa 1976). 2015 Jul 10. NEUROPATHIC PAIN IS DUE, AT LEAST IN PART, TO ENHANCED SYMPATHETIC NORADRENERGIC TRANSMISSION WITHIN THE DRG. SUPPRESSION OF SYMPATHETIC ACTIVITY BY REDUCING ADRENERGIC RELEASE IN THE DRG MAY RELIEVE NEUROPATHIC PAIN.

 

Wang J1, Wang XW2, Zhang Y3, Yin CP3,Yue SW3. Ca2+ influx mediates the TRPV4-NO pathway in neuropathic hyperalgesia following chronic compression of the dorsal root ganglion. Neurosci Lett. 2015 Jan 6. pii: S0304-3940(15)00015-4. doi:10.1016/j.neulet.2015.01.010. CHRONIC COMPRESSION OF THE DORSAL ROOT GANGLION (DRG) (CCD) IN RATS IS A TYPICAL MODEL OF NEUROPATHIC PAIN.

 

Wang J1, Wang XW2, Zhang Y3, Yin CP3,Yue SW3. Ca2+ influx mediates the TRPV4-NO pathway in neuropathic hyperalgesia following chronic compression of the dorsal root ganglion. Neurosci Lett. 2015 Jan 6. pii: S0304-3940(15)00015-4. doi: 10.1016/j.neulet.2015.01.010. CHRONIC COMPRESSION OF THE DORSAL ROOT GANGLION (DRG) (CCD) IN RATS IS A TYPICAL MODEL OF NEUROPATHIC PAIN. NEUROINFLAMMATION IS CAUSED BY LOCAL AND SYSTEMIC EXPRESSION OF PROFLAMMATORY CYTOKINES AS MEDIATORS OF PAIN. AMONG THESE CYTOKINES, TNF-Α, IL-1Β AND IL-6 ARE ESPECIALLY NOTABLE ATTRIBUTED TO THEIR HYPERALGESIC IMPACTS AFTER NERVE DAMAGE. THIS STUDY COMPARED THE TISSUE LEVELS OF INTERLEUKIN-1Β(IL-1Β), INTERLEUKIN-6 (IL-6), INTERLEUKIN-10 (IL-10) AND TUMOR NECROSIS FACTOR-Α (TNF-Α) IN SUBLIGAMENTOUS AND FREE FRAGMENT TYPES OF DEGENERATED INTERVERTEBRAL DISC AT ACUTE AND CHRONIC PERIODS FROM 49 PATIENTS (24 WOMEN, 25 MEN) WITH AN AVERAGE AGE OF 38.2±4.9 TREATED SURGICALLY BY MEANS OF MICRODISCECTOMY. LEVELS OF IL-1Β, IL-6, IL-10 AND TNF-Α WERE ASSESSED IN TISSUE SAMPLES PREPARED FROM NUCLEUS PULPOSUS TISSUE OBTAINED DURING MICRODISCECTOMY PROCEDURE.

 

Chen YM1, Shen RW2, Zhang B3, Zhang WN4. Regional tissue immune responses after sciatic nerve injury in rats. Int J Clin Exp Med. 2015 Aug 15;8(8):13408-12. EXPRESSION OF INTERFERON-Γ(INF-Γ), INTERLEUKIN-10 (IL-10) WAS SIGNIFICANTLY ELEVATED ONE WEEK FOLLOWING NERVE INJURY, BUT GRADUALLY DECREASED THEREAFTER. OUR FINDINGS DEMONSTRATE THAT IMMUNE RESPONSES AND INFLAMMATORY CELL ACTIVATION ARE INVOLVED DURING RECOVERY FROM SCIATIC NERVE INJURY.

 

Rydevik: Spine 9(2). Intraneural edema results in ischemia of nerve at 20-30 mm pressure which results in numbness. Axonal transport is blocked at or over 30mm of pressure. Axons regenerate 1 mm per day. Peripheral nerves require 30-50mm pressure to cause damage.

 

Takahashi K: Nerve root pressure in lumbar disc herniation. Spine 24(1). Average nerve root pressure of herniated nuclear pulposis was 53 mm Hg. 10 mm reduced circulation and impairs nutrition. 20 mm paraesthesia results in no neuro deficits. Edema of the nerve root at 50 mm for 2 minutes. Neurological deficits has 60mm pressure. Trunk list at 82.1 mm. Paralysis, foot drop, cauda equine syndrome at 104-256 mm.

 

Weinstein: Spine 11(10). Neuroactive peptide produced in brain, spinal cord and dorsal root ganglion. 80% is produced in the dorsal root ganglion. Produced in posterior longitudinal ligament, facet capsule annulus fibrosis. It stimulates nociceptors and proprioceptors. Stimulated by mechanical or chemical irritants.

 

Cavanaugh: Lumbar facet pain: biomechanics, neuroanatomy and neurophysiology. J Biomechanics 1996; 29(9). Facet joint is heavily inner acted by small nerve fibers and free and encapsulated nerve endings that produce Substance P. Under inflammation, chemical irritants are secreted by the facet capsule that result in low back pain.

 

Freemont: Backletter 12(7). Damaged discs have nociceptors grow into them.

 

Kikuchi: Spine 19(1). Facet indents the dorsal root ganglion in 71% of cases studied.

 

Curcumin derived from Tumeric

Neurology Research International. 2016;2016:9468193. doi: 10.1155/2016/9468193. Epub 2016 May 19. The Potential of Curcumin in Treatment of Spinal Cord Injury. Sanivarapu R1, Vallabhaneni V2, Verma V3. Curcumin, the active ingredient in turmeric, a spice known for its medicinal and anti-inflammatory properties, has been validated to harbor immense effects for a multitude of inflammatory-based diseases. Curcumin shows superior results over corticosteroids. Curcumin has shown improvements from current standards of care in other diseases with few true treatment options (eg. Osteoarthritis), there is immense potential for this compound in treating spinal cord injury. Awareness of the incredible potential that curcumin shows for spinal cord injury in a patient population that direly needs improvements on current therapy.

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