| A Non-Surgical Approach To The Management Of Lumbar Spinal Stenosis. Murphy DR, Hurwitz EL, Gregory AA, Clary R. BMC Musculoskelet Disord. 2006 Feb 23;7:16. , Rhode Island Spine Center, Pawtucket, RI Non-surgical treatment for spinal stenosis is often recommended but clinical outcome efficacy data has been little-studied. 57 patients with leg pain and lumbar spinal stenosis (LSS) documented by MRI or CT were treated at the Rhode Island Spine Center with distraction manipulation and neural mobilization. NM is nerve root mobilization technique applied by having the practitioner perform a series of maneuvers moving the foot alternatively into extension and flexion while flexing the hip and extending the knee. The distraction manipulation was theorized to break up periradicular adhesion, thereby releasing nerve root entrapment and restoring vascular function. The patients were also given cat and camel exercises to complement the manual techniques. In general, patients were treated 2-3 times per week for 3 weeks then re-evaluated for outcome measurements and continued on a reduction of frequency basis for a mean number of 13 treatments. Improvement in disability and patient-rated changes were both significant and clinically meaningful. Remarkably, long term follow-up at 16.5 months found patient-rated improvement to be 76% while disability measured by Roland Morris Disability Questionnaire was 73%. They concluded this treatment approach is a viable alternative to surgery and most patients should be treated non-surgically before considering an operation. Chiropractic Manipulation In The Treatment Of Acute Back Pain And Sciatica With Disc Protrusion Santilli V, Beghi E, Finucci S. Spine J. 2006 Mar-Apr;6(2):131-7 This Italian medical study included 102 acute with back and/or leg pain patients of moderate to severe intensity and MRI evidence of disc protrusion. The patients received a maximum of 30 manipulations or simulated manipulations over a 30 day period. 28% of the manipulation group became pain-free locally vs. only 6% in the sham group, while 55% of the manipulation group experienced absence of radicular symptoms compared to 20% of the no manipulation group. The manipulation group also had a significant decrease in use and prescriptions of NSAIDs. Chronic Mechanical Neck Pain In Adults Treated By Manual Therapy Vernon H, Humphreys K, Hagino C. J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):215-27. Neck pain is common with approximately 10-15% of the population suffering from it at any given time. The researchers combed through 1980 citations and found 13 high quality trials utilizing manipulation or manual therapy to analyze. Their review found that the benefit from manipulation was larger, i.e., effect size from .56 to 3.2, and maintained for up to 12 weeks post-treatment. The long-term data regarding spinal manipulation for chronic neck pain was not as conclusive. However, it still showed great benefit with treatment up to 104 weeks. The spinal mobilization trials also showed very good benefit at a 6 to 7 week outcome point, with 70% of patients having full recovery or important improvement at that point. One study pointed to full recovery in 70% of patients at 13 and 52 weeks. The authors pondered the question whether the benefit could be just the natural history and placebo affect and compared these trials with a separate group of controlled no-treatment patients and concluded the changes obtained in this review exceeded the placebo effect and natural history of the no treatment group. A Non-Surgical Approach To The Management Of Patients With Cervical Radiculopathy Murphy DR, Hurwitz EL, Gregory A, Clary R. J Manipulative Physiol Ther. 2006 May;29(4):279-87 This study is the first of its kind where spinal manipulation played a central role in treatment of cervical radiculopathy. All 35 patients were diagnosed with cervical radiculitis caused by either lateral stenosis or cervical disk herniation. The patients were treated with spinal manipulative therapy and followed for an average of 8 months. Improvement in disability was prospectively measured with a Disability Questionnaire and Pain Rating Scale. The patient's cervical joints were palpated and SMT was applied to the level of dysfunction using both high-velocity and lower-velocity techniques. In some cases, anti-inflammatory modalities such as ice and anti-inflammatory drugs were used, although most of the patients were already taking these medications before the study began. Patients were typically treated 2 to 3 times per week with reduction of frequency thereafter. Almost 90% of the patients described their improvement as excellent or good. The patients had marked improvement in both pain intensity (62%) and disability (75%) at the end of the treatment. This improvement continued and increased at long-term follow-up. There were no major complications reported. In fact, there were no reports of even short-term increases in pain. A shortcoming of the study was lack of controls; however the researchers concluded this non-surgical approach to be safe and effective for the 35 patients in the study. Efficacy Of Treating Low Back Pain And Dysfunction Secondary To Osteoarthritis: Chiropractic Care Compared With Moist Heat Alone Kathleen L. Beyerman, RN, EdD,Mark B. Palmerino J Manipulative Physiol Ther 2006;29:107Q114) 250 subjects with low back pain thought to be secondary to Osteoarthritis were randomized to receive 20 treatments of either Chiropractic care (flexion/distraction with spinal manipulation) with hot moist packs or hot moist packs alone. Chiropractic care with heat was found to be far superior to heat alone utilizing various outcome measures including pain intensity, ROM and activities of daily living. The Chiropractic group had rapid improvement in personal care, walking, sitting and social life, while the moist heat alone group had no improvement of these factors. This was a small study conducted in a community hospital that is very significant because this is the first study to evaluate Chiropractic effectiveness in the treatment of OA. A Perspective For Considering The Risks And Benefits Of Spinal Manipulation In Patients With LBP Childs JD, Flynn TW, Fritz JM. Man Ther. 2006 Nov;11(4):316-20. Three physical therapists divided 131 low back pain patients into groups receiving either manipulation and exercise or exercise alone. They wanted to answer the question, what is the magnitude of risk of a public policy that does not routinely offer manipulation for patients with LBP? There are enormous direct and indirect costs associated with prolonged LBP disability and this study was to evaluate the risks associated with not treating LBP patients with manipulation. They asked, what is the Number Needed to Treat (NNT) to prevent one patient from worsening in disability? They analyzed their treatment data and concluded that deciding not to treat a LBP patient with manipulation is not either innocuous or conservative. Patients treated with exercise only were 8 times more likely to experience worsening in disability at 1 week. Acute patients with symptoms not distal to the knee and less than 16 days experienced a 66% probability that they would have a 50% reduction in disability over a 1-week period. The NNT with manipulation and exercise vs. exercise only to prevent worsening disability at one week was 9.9. Factors Associated With Patient Satisfaction With Chiropractic Care: Review Of The Literature. Gaumer G, PhD J Manipulative Physiol Ther. 2006 Jul-Aug;29(6):455. Chiropractic patient satisfaction has been reported to be very high in the scientific literature. A review of the literature found 8 studies where Chiropractic was compared to care from MDs. 6 showed higher satisfaction with DC care while 1 found higher satisfaction with MD care and 1 was equivocal. The data for this study was collected by a national phone survey contacting 400 adults who had used Chiropractic services and 400 who never used Chiropractic care. The 22 minutes phone survey revealed interesting demographics of Chiropractic use. The 22-minute phone interview found that 50% of all former Chiropractic users had seen a Chiropractor in the past year. Family or friends had referred 66% of Chiropractic patients while 12% were referred by their MD. Further analysis concluded that 12% of the adult US population had visited a Chiropractor in the past 12 months. 83% of the Chiropractic patients reported they were satisfied or very satisfied while only 9% were dissatisfied. The researchers concluded that the Chiropractor's communication quality appeared to be a significant predictor of patient satisfaction. Patients responded that the Chiropractors explained health problems and choices and seemed to be concerned about them as persons in addition to their overall health. The author of this study is a PhD at the School of Health Studies, Simmons College, Boston, MA A Pilot Study Comparing Two Manual Therapy Interventions For Carpal Tunnel Syndrome. Burke J, Buchberger DJ, Carey-Loghmani MT, et al J Manipulative Physiol Ther. 2007 Jan;30(1):50-61. A small group of 22 carpal tunnel syndrome patients were given a 10 session intervention of either Grastin Instrument assisted soft tissue mobilization (GISTM) or soft tissue mobilization by hand. Both groups had substantial decrease from baseline pain at 3 months-post treatment and noticed immediate improvements in ability to perform tasks that were affected by CTS. Both wrist ROM and grip strength returned to normal. The clinicians concluded this study supported the theory that manual therapy increases myofascial mobility which affects blood flow and thereby decreases nerve pressure. Nerve conduction latencies were not significantly improved. Clinical signs and symptoms such as Phalen's tests, Tinel's sign and 2-pt discrimination did not show adequate sensitivity or specificity to be useful as diagnostic criteria or outcome measures. The Effect Of Combining Manual Therapy With Exercise On The Respiratory Function Of Normal Individuals Engel RM, Vemulpad S. J Manipulative Physiol Ther. 2007 Sep;30(7):509-13. Non-communicable respiratory disease plays a significant role in worldwide mortality. Respiratory function measured with Spirometry can estimate prevalence of chronic obstructive pulmonary disease. 50 asymptomatic individuals were randomized to receive exercise, manual therapy or both; then pre and post spirometry measurements compared the treatment effects with a control group. The manual therapy group were the only group to show a significant increase in respiratory function. Does The Evidence For Spinal Manipulation Translate Into Better Outcomes In Routine Clinical Care For Patients With Occupational Low Back Pain? Fritz JM, Brennan GP, Leaman H. Spine J. 2006 May-Jun;6(3):289-95. Two physical therapists and a MD examined the effect of thrust manipulation on patient diagnoses with occupational low back pain receiving workers compensation. They stated the thrust manipulation is evidence-based, but is underutilized by physical therapists in the occupational setting. 578 patients were treated with either thrust manipulation, no-thrust manipulation or no manipulation. The thrust patients had a 66% reduction in Oswestry scores over a period of four sessions in 2.5 weeks. The thrust patients had more improvement in both pain and disability compared to the no manipulation patients and the duration of care was shorter. Also, the cost of physical therapy was found to be greater in the non-thrust techniques group. One-Year Follow-Up Of A Randomized Clinical Trial Comparing Flexion Distraction With An Exercise Program For Chronic Low-Back Pain. Cambron JA, Gudavalli MR, Hedeker D, et al J Altern Complement Med. 2006 Sep;12(7):659-68. 235 patients with chronic low back pain were randomized to receive either Chiropractic care (flexion distraction) or physical therapy (flexion distraction). The patients were treated 2-4 times per week for a period of four weeks. The purpose of this study was to assess outcomes at 13-, 25- and 53-week follow ups. Both groups of patients appeared to benefit from their treatment; however the Chiropractic group had lower pain scores at each testing interval. The researchers concluded that a four week treatment including flexion distraction is effective at reducing for up to one year. Symptomatic Outcomes And Perceived Satisfaction Levels Of Chiropractic Patients With A Primary Diagnosis Involving Acute Neck Pain. Haneline MT. J Manipulative Physiol Ther. 2006 May;29(4):288-96 94 Chiropractic patients with acute neck pain were contacted retrospectively. 50% of them described acute neck pain after an automobile crash, while 40% reported no prior traumatic event. Approximately 84% of the patients indicated limited activity prior to Chiropractic care and 57% of them described their restriction as severe. The mean number of DC visits was 24 and included adjunctive treatment modalities in 94% of the cases. Pain levels improved dramatically from a mean of 7.5 to 1.9 (on a scale of 10) after treatment. These effects appeared to be long lasting. Overall, 94% of the patients were satisfied or very satisfied. 84% of the patients had restricted activities before treatment, while only 25% of the treated patients noted restrictions at the time of the interview. Trauma patients received over 3 times as many visits as non-trauma patients. The researchers concluded the patients with acute neck pain had significant reduction in pain and activity restriction with Chiropractic care. Chiropractic Care For Non-Musculoskeletal Conditions: A Systematic Review With Implications For Whole Systems Research. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW J Altern Complement Med. 2007 Jun;13(5):491-512. The objective of this systematic review of prior studies was to evaluate the evidence of Chiropractic care on patients with non-musculoskeletal conditions. 179 papers addressing 50 different non-musculoskeletal conditions were reviewed. Unfortunately, the quality of many of the studies was not high. The researchers found research support for a total package of chiropractic care possibly benefiting patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for children with otitis media and elderly patients with pneumonia. Chiropractic Services In The Canadian Armed Forces: A Pilot Project. Boudreau LA, Busse JW, McBride G. Mil Med. 2006 Jun;171(6):572-6. Musculoskeletal complaints are a substantial source of morbidity among military personnel at this Nova Scotia military hospital. This article reviews results of surveys of 102 military personnel referred for chiropractic services in a Canadian Armed Forces Pilot Project. Traditionally, Canadian Forces have had to self-pay for Chiropractic services outside of the military system. The military personnel were all referred by the medical staff for chiropractor services. 52% of the patients complained of low back pain and surprisingly their average initial onset was over 6 years. 94% of the patients responded they were satisfied with the Chiropractic care while 80% of the referring physicians expressed satisfaction. A Population-Based Survey Of Back Pain Beliefs In Canada. Gross DP, Ferrari R, Russell AS, Battie MC, Schopflocher D, et al Spine. 2006 Aug 15;31(18):2142-5. A telephone survey of 2400 Canadian adults found a lifetime prevalence of LBP of 84% and a 1 week prevalence of 34%. 50% of those surveyed agreed with statements such as Back trouble makes everything worse, Back trouble will eventually stop you from working, and Later in life, back trouble gets progressively worse. Subjects who had taken time off from work for their last pain episode were more likely to agree with the statement, If you have back pain you should rest until it is better and they were more likely to use resting or avoiding activity and staying in bed more than usual. This study is interesting in that the authors feel that those surveyed responded contrary to recent evidence-based clinical practice guidelines that state back pain is benign and self-limiting. The sum of the experience of those surveyed was determined to lagging current evidence and re-education strategies were suggested. I find this conclusion preposterous considering the current chronicity evidence and the extreme high costs that back pain imposes upon our society. Instead of considering re-educating the public to conform to the current EBM model of back pain, I suggest the researchers take to heart the seriousness of the problem, as suggested by their own survey results and the background studies found above. |
| 2007-2006 Chiropractic Spinal Manipulation and Manual Therapy Research Synopses |