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PubMed2002

Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation.

STUDY DESIGN: A retrospective review of 64 medicolegal records describing cerebrovascular ischemia after cervical spine manipulation was conducted. OBJECTIVES: To describe 64 cases of cerebrovascular accidents temporally associated with cervical spine manipulation therapy in terms of patient characteristics, potential risk factors, nature of complication, and neurologic sequelae. SUMMARY OF BACKGROUND DATA: Approximately 117 cases of postmanipulation cerebrovascular ischemia have been reported in the English language literature. Proposed risk factors include age, gender, migraine headaches, hypertension, diabetes, birth control pills, cervical spondylosis, and smoking. It is often assumed that these complications may be avoided by clinically screening patients and by premanipulation positioning of the head and neck to evaluate the patency of the vertebral arteries. METHODS: Three researchers using a uniform data abstraction instrument performed an independent review of 64 previously unpublished medicolegal records describing cerebrovascular ischemia after cervical spine manipulation. These cases were referred to a single physician for review over a 16-year period from across the United States and Canada. Descriptive statistics were calculated for characteristics of the patients and the complications. Means and standard deviations were computed for continuous variables. Frequencies and proportions were calculated for categorical variables. RESULTS: This study was unable to identify factors from the clinical history and physical examination of the patient that would assist a physician attempting to isolate the patient at risk of cerebral ischemia after cervical manipulation. CONCLUSION: Cerebrovascular accidents after manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of this treatment approach.

Adult↗
PubMed2002

Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial.

STUDY DESIGN: A randomized, assessor-blinded clinical trial was conducted. OBJECTIVE: To investigate the relative effectiveness of three manual treatments and back school for patients with subacute low back pain. SUMMARY OF BACKGROUND DATA: Literature comparing the relative effectiveness of specific therapies for low back pain is limited. METHODS: Among the 5925 inquiries, 206 patients met the specific admission criteria, and 200 patients randomly received one of four treatments for 3 weeks: back school, joint manipulation, myofascial therapy, and combined joint manipulation and myofascial therapy. These patients received assessments at baseline, after 3 weeks of therapy, and 6 months after the completion of therapy. The primary outcomes were evaluated using visual analog pain scales and Roland-Morris activity scales. RESULTS: All four groups showed significant improvement in pain and activity scores after 3 weeks of care, but did not show further significant improvement at the 6-month follow-up assessment. No statistically significant between-group differences were found either at the 3-week or 6-month reassessments. CONCLUSIONS: For subacute low back pain, combined joint manipulation and myofascial therapy was as effective as joint manipulation or myofascial therapy alone. Additionally, back school was as effective as three manual treatments.

Ambulatory Care Facilities↗
PubMed2002

Treatment of chronic lower back pain with lumbar extension and whole-body vibration exercise: a randomized controlled trial.

STUDY DESIGN: A randomized controlled trial with a 6-month follow-up period was conducted. OBJECTIVE: To compare lumbar extension exercise and whole-body vibration exercise for chronic lower back pain. SUMMARY OF BACKGROUND DATA: Chronic lower back pain involves muscular as well as connective and neural systems. Different types of physiotherapy are applied for its treatment. Industrial vibration is regarded as a risk factor. Recently, vibration exercise has been developed as a new type of physiotherapy. It is thought to activate muscles via reflexes. METHODS: In this study, 60 patients with chronic lower back pain devoid of "specific" spine diseases, who had a mean age of 51.7 years and a pain history of 13.1 years, practiced either isodynamic lumbar extension or vibration exercise for 3 months. Outcome measures were lumbar extension torque, pain sensation (visual analog scale), and pain-related disability (pain disability index). RESULTS: A significant and comparable reduction in pain sensation and pain-related disability was observed in both groups. Lumbar extension torque increased significantly in the vibration exercise group (30.1 Nm/kg), but significantly more in the lumbar extension group (+59.2 Nm/kg; SEM 10.2; P < 0.05). No correlation was found between gain in lumbar torque and pain relief or pain-related disability (P > 0.2). CONCLUSIONS: The current data indicate that poor lumbar muscle force probably is not the exclusive cause of chronic lower back pain. Different types of exercise therapy tend to yield comparable results. Interestingly, well-controlled vibration may be the cure rather than the cause of lower back pain.

Chronic Disease↗
PubMed2006

Lumbar disc herniations: surgical versus nonsurgical treatment.

UNLABELLED: Lumbar disc herniation is among the most common causes of lower-back pain and sciatica. The cause(s) of lumbar disc herniation and the relation of lumbar disc herniation to back pain and sciatica have not been fully elucidated, but most likely comprise a complex combination of mechanical and biologic processes. Furthermore, the natural history of lumbar disc herniation seems generally to be favorable, leaving the optimum treatment for lumbar disc herniation a debate in the literature. Various nonoperative and operative treatment strategies have been tried with varying degrees of success. Treatment often involves patient education, physical therapy, alternative medicine options, and pharmaco-therapy. If these fail, surgical intervention is usually recommended. A literature search was conducted to evaluate the currently known effectiveness of traditional and novel non-operative and surgical techniques for the treatment lumbar disc herniation and to determine if there are substantive new advantages in these newer contemporary treatments or combinations thereof. A structured approach to treatment of a patient who may have a symptomatic lumbar disc herniation is presented, based on analysis of the current literature. No one method of nonoperative or operative treatment would seem definitively to be superior to another. Appropriate multidisciplinary treatment including behavioral analysis and support may offer the hope of improved outcomes for patients with lumbar disc herniation. LEVEL OF EVIDENCE: Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2004

A Cochrane review of manipulation and mobilization for mechanical neck disorders.

STUDY DESIGN AND OBJECTIVES: Our systematic review of randomized trials assessed whether manipulation and mobilization relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders. SUMMARY OF BACKGROUND DATA: Neck disorders are common, disabling, and costly. METHODS: Computerized bibliographic databases were searched up to March 2002. Two independent reviewers conducted study selection, data abstraction, and methodologic quality assessment. Relative risk and standardized mean differences were calculated. In the absence of heterogeneity, pooled effect measures were calculated using a random effects model. RESULTS: Of the 33 selected trials, 42% were high quality trials. Single or multiple (3-11) sessions of manipulation or mobilization showed no benefit in pain relief when assessed against placebo, control groups, or other treatments for acute/subacute/chronic mechanical neck disorders with or without headache. There was strong evidence of benefit favoring multimodal care (mobilization and/or manipulation plus exercise) over a waiting list control for pain reduction [pooled standardized mean differences -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [standardized mean differences -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic mechanical neck disorders with or without headache. CONCLUSIONS: Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. Factorial design would help determine the active agent(s) within a treatment mix.

Adult↗
PubMed2004

A randomized clinical trial of manipulative therapy and interferential therapy for acute low back pain.

STUDY DESIGN: A multicenter assessor-blinded randomized clinical trial was conducted. OBJECTIVES: To investigate the difference in effectiveness of manipulative therapy and interferential therapy for patients with acute low back pain when used as sole treatments and in combination. SUMMARY OF BACKGROUND DATA: Both manipulative therapy and interferential therapy are commonly used treatments for low back pain. Evidence for the effectiveness of manipulative therapy is available only for the short-term. There is limited evidence for interferential therapy, and no study has investigated the effectiveness of manipulative therapy combined with interferential therapy. METHODS: Consenting subjects (n = 240) recruited following referral by physicians to physiotherapy departments in the (government-funded) National Health Service in Northern Ireland were randomly assigned to receive a copy of the Back Book and either manipulative therapy (MT; n = 80), interferential therapy (IFT; n = 80), or a combination of manipulative therapy and interferential therapy (CT; n = 80). The primary outcome was a change in functional disability on the Roland Morris Disability Questionnaire. Follow-up questionnaires were posted at discharge and at 6 and 12 months. RESULTS: The groups were balanced at baseline for low back pain and demographic characteristics. At discharge all interventions significantly reduced functional disability (Roland Morris scale, MT: -4.53; 95% CI, -5.7 to -3.3 vs. IFT: -3.56; 95% CI, -4.8 to -2.4 vs. CT: -4.65; 95% CI, -5.8 to -3.5; P = 0.38) and pain (McGill questionnaire, MT: -5.12; 95% CI, -7.7 to -2.5 vs. IFT: -5.87; 95% CI, -8.5 to -3.3 vs. CT: -6.64; 95% CI, -9.2 to -4.1; P = 0.72) and increased quality of life (SF-36 Role-Physical, MT: 28.6; 95% CI, 18.3 to 38.9 vs. IFT: 31.4; 95% CI, 21.2 to 41.5 vs. CT: 30; 95% CI, 19.9 to 40; P = 0.93) to the same degree and maintained these improvements at 6 and 12 months. No significant differences were found between groups for reported LBP recurrence, work absenteeism, medication consumption, exercise participation, or healthcare use at 12 months (P > 0.05). CONCLUSIONS: For acute low back pain, there was no difference between the effects of a combined manipulative therapy and interferential therapy package and either manipulative therapy or interferential therapy alone.

Adult↗
PubMed2004

Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise.

STUDY DESIGN: A single blind randomized controlled trial comparing two models of care for patients with acute simple low back pain. OBJECTIVES: To compare two research-based models of care for acute low back pain and investigate the effect of the timing of physical intervention. SUMMARY OF BACKGROUND DATA: National guidelines offer conflicting information on the delivery of physical treatment in the management of acute low back pain. The guidelines suggest two different models of care. Direct comparisons between these models are lacking in the literature. The present study aims to compare these approaches to the management of acute low back pain. METHODS: Among 804 referred patients, 102 subjects met the specific admission criteria and were randomly assigned to an "assess/advise/treat" group or an "assess/advise/wait" group. The intervention consisted of biopsychosocial education, manual therapy, and exercise. Assessment of short-term outcome enables comparison to be made between intervention and advice to stay active. Assessment of long-term outcome enables comparison to be made between early and late intervention. Study outcomes of reported pain (Visual Analogue Scale), functional disability (the Roland and Morris Disability Questionnaire), mood (Modified Zung Self Rated Depression Score, Modified Somatic Perception Questionnaire, State-Trait Anxiety Inventory), general health (Euroqol), and quality of life (Short Form 36) were assessed at baseline, 6 weeks, 3 months, and 6 months. RESULTS: At 6 weeks, the assess/advise/treat group demonstrated greater improvements in disability, mood, general health, and quality of life than patients in the assess/advise/wait group (P < 0.05). Disability and pain were not significantly different between the groups at long-term follow up (P > 0.05). However, mood, general health, and quality of life remained significantly better in the assess/advise/treat group (P < 0.05). CONCLUSIONS: At short-term, intervention is more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life, and general health. The timing of intervention affects the development of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore, an assess/advise/treat model of care seems to offer better outcomes than an assess/advise/wait model of care.

Adult↗
PubMed2006

The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study.

STUDY DESIGN: Randomized open study. OBJECTIVE: To evaluate the efficacy of intrarectal manual treatment of chronic coccydynia; and to determine the factors predictive of a good outcome. SUMMARY OF BACKGROUND DATA: In 2 open uncontrolled studies, the success rate of intrarectal manipulation of the coccyx was around 25%. METHODS: Patients were randomized into 2 groups of 51 patients each: 1 group received three sessions of coccygeal manipulation, and the other low-power external physiotherapy. The manual treatment was guided by the findings on stress radiographs. Patients were assessed, at 1 month and 6 months, using a VAS and (modified) McGill Pain, Paris (functional coccydynia impact), and (modified) Dallas Pain questionnaires. RESULTS: At baseline, the 2 groups were similar regarding all parameters. At 1 month, all the median VAS and questionnaire values were modified by -34.7%, -36.0%, -20.0%, and -33.8%, respectively, in the manipulation group, versus -19.1%, -7.7%, 20.0%, and -15.7%, respectively, in the control (physiotherapy) group (P = 0.09 [borderline], 0.03, 0.02, and 0.02, respectively). Good results were twice as frequent in the manipulation group compared with the control group, at 1 month (36% vs. 20%, P = 0.075) and at 6 months (22% vs. 12%, P = 0.18). The main predictors of a good outcome were stable coccyx, shorter duration, traumatic etiology, and lower score in the affective parts of the McGill and Dallas questionnaires. CONCLUSIONS: We found a mild effectiveness of intrarectal manipulation in chronic coccydynia.

Adult↗
PubMed2005

Physical treatments for headache: a structured review.

BACKGROUND: Primary headache disorders, especially migraine, are commonly accompanied by neck pain or other symptoms. Because of this, physical therapy (PT) and other physical treatments are often prescribed. This review updates and synthesizes published clinical trial evidence, systematic reviews, and case series regarding the efficacy of selected physical modalities in the treatment of primary headache disorders. METHODS: The National Library of Medicine (MEDLINE), The Cochrane Library, and other sources of information were searched through June 2004 to identify clinical studies, systematic reviews, case series, or other information published in English that assessed the treatment of headache or migraine with chiropractic, osteopathic, PT, or massage interventions. RESULTS: PT is more effective than massage therapy or acupuncture for the treatment of TTH and appears to be most beneficial for patients with a high frequency of headache episodes. PT is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback, relaxation training, and exercise. Chiropractic manipulation demonstrated a trend toward benefit in the treatment of TTH, but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of tension-type headache (TTH) than it is in the treatment of migraine. Evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration, and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality. CONCLUSIONS AND RECOMMENDATIONS: Further studies of improved quality are necessary to more firmly establish the place of physical modalities in the treatment of primary headache disorders. With the exception of high velocity chiropractic manipulation of the neck, the treatments are unlikely to be physically dangerous, although the financial costs and lost treatment opportunity by prescribing potentially ineffective treatment may not be insignificant. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant better-validated forms of therapy.

Headache Disorders↗
PubMed2006

Migraine: a review and future directions for treatment.

Migraine is a chronic, neurological disorder generally manifesting itself in attacks with severe headache, nausea and an increased reactivity to sensory stimuli. A low migraine threshold is set by genetic factors, although the phenotype also modulates the manifestations. The 1-year prevalence is approximately 13% and is higher among women. Patients usually experience neuropsychological dysfunction, and sometimes also reversible focal neurological symptoms. The trajectories of the characteristic symptoms of acute migraine usually follow a similar time course, indicating a reciprocal underlying mechanism. A central nervous system hyperexcitability has been demonstrated in neurophysiological studies. The dibilitating effects of migraine are not confined to the attacks per se. Many individuals do not recover completely between the attacks and most report a negative impact on the most important life domains, and an interest in testing other treatments. Young persons have a higher frequency of attacks. Acute treatment should routinely be initiated with an analgesic plus a prokinetic anti-emetic. Triptans must not be provided early during the attack to ensure their efficacy. The natural course of attacks is commonly only temporarily altered by acute treatment. Non-pharmacological treatment and drugs may be equally viable in prophylaxis for migraine. In more complicated cases, conjoint therapy should be considered. New strategies to improve adherence with existing therapeutic regimens might yield greater benefits than will new pharmacological agents.

Adult↗
PubMed2006

A pilot study on the effects of pre-event manipulation on jump height and running velocity.

PURPOSE: To compare changes in jump height and running velocity with and without pre-event high-velocity, low-amplitude manipulation (HVLA). METHODS: A crossover study design with elite healthy athletes was used. After a 15 min warm-up, the subjects were tested for countermovement jump height (CMJ) and flying 40 m sprint time (SPRINT). A sport chiropractor then evaluated each subject. Subjects were randomised to either HVLA (applied to joints based on examination) or placebo (simulated performance-enhancement stickers). They then rested for 60 min, performed another 15 min warm-up, and were retested. The protocol was repeated 48 h later with the alternative intervention. The mean of two sprints and three jumps were analysed, as well as peak performances. The sample size was based on prior results from the effects of stretching. RESULTS: 19 subjects involved in sprint sports were enrolled; two were too sore to participate on day 2, and one could only participate in the jump (all had HVLA on day 1). Of the 17 participants analysed, seven were female, age range was 19-35, and 17 were national or world-class athletes. The ranges for baseline measures were: SPRINT 4.1-5.5 s; CMJ 47.4-92.7 cm. Overall, the greater than expected variability in this pilot study led to the study being underpowered. Subjects tended to perform better after HVLA for both CMJ and SPRINT (both mean and peak results), but none of the results were statistically significant (p = 0.30-0.61). CONCLUSION: Although the larger than expected variability in the pilot study means that the observed clinically relevant differences were not statistically significant, the direction and magnitude of the changes associated with HVLA suggest that it may be beneficial. That said, the increased soreness after HVLA suggests that it may be detrimental. HVLA warrants further study.

Adult↗