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Rogers CJ, Elchert CR, Hackney ME. Chiropractic Management of a 67-Year-Old Veteran With Chronic Low Back Pain Utilizing Low-Velocity Flexion-Distraction: A Case Report. J Chiropr Med 2023; 22:157-163. [PMID: 37346235 PMCID: PMC10280086 DOI: 10.1016/j.jcm.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 06/23/2023] Open
Abstract
Objective The purpose of this case report was to describe the treatment of an older veteran with chronic low back pain, utilizing flexion-distraction as a primary intervention for management. Clinical Features A 67-year-old man with chronic low back pain for several decades presented to the chiropractic clinic for evaluation. He reported low back pain that extended into the right lower extremity intermittently. The patient's imaging demonstrated significant degenerative changes in the lumber spinal anatomy. He had never experienced chiropractic interventions or management for his condition. Intervention and Outcome A trial of conservative care with flexion-distraction was applied as a primary intervention for the management of chronic low back pain. Instrument-assisted soft-tissue mobilization and moist heat were also applied for interventions. Despite having no changes in outcome assessments, the patient reported an improvement in his condition, reduced use of pain medication, and increased mobility after 4 sessions over a 4-week period. Conclusion Flexion-distraction was a beneficial chiropractic approach to the management of an older veteran with chronic low back pain and intermittent lower extremity pain for several decades.
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Affiliation(s)
- Casey J. Rogers
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Health Care System, Birmingham, Alabama
- Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Madeleine E. Hackney
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Health Care System, Decatur, Georgia
- Department of Medicine, Division of Geriatrics & Gerontology, Emory University School of Medicine, Atlanta, Georgia
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Over Half of Clinical Trials of Mobilization and Manipulation for Patients With Low Back Pain May Have Limited Real-World Applicability: A Systematic Review of 132 Clinical Trials. J Orthop Sports Phys Ther 2022; 52:532-545. [PMID: 35722756 DOI: 10.2519/jospt.2022.10962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacyeffectiveness continuum. DESIGN Methodology systematic review. LITERATURE SEARCH PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and PEDro (Physiotherapy Evidence Database) were searched for trials published between January 1, 2000, and April 30, 2021. STUDY SELECTION CRITERIA We included randomized clinical trials investigating joint mobilization and manipulation for adults with nonspecific LBP that were available in English. DATA SYNTHESIS We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: participant characteristics, trial setting, flexibility of intervention(s), and clinical relevance of experimental and comparison intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain. RESULTS Of the 132 included trials, a greater proportion emphasized efficacy than effectiveness for domains participant characteristics (50% vs 38%), trial setting (71% vs 20%), and flexibility of intervention(s) (61% vs 25%). The domain clinical relevance of experimental and comparison intervention(s) had lower emphasis on efficacy (41% vs 50%). CONCLUSION Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (ie, they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered. J Orthop Sports Phys Ther 2022;52(8):532-545. Epub: 19 June 2022. doi:10.2519/jospt.2022.10962.
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Jenks A, de Zoete A, van Tulder M, Rubinstein SM. Spinal manipulative therapy in older adults with chronic low back pain: an individual participant data meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1821-1845. [PMID: 35633383 DOI: 10.1007/s00586-022-07210-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Many systematic reviews have reported on the effectiveness of spinal manipulative therapy (SMT) for low back pain (LBP) in adults. Much less is known about the older population regarding the effects of SMT. OBJECTIVE To assess the effects of SMT on pain and function in older adults with chronic LBP in an individual participant data (IPD) meta-analysis. SETTING Electronic databases from 2000 until June 2020, and reference lists of eligible trials and related reviews. DESIGN AND SUBJECTS Randomized controlled trials (RCTs) which examined the effects of SMT in adults with chronic LBP compared to interventions recommended in international LBP guidelines. METHODS Authors of trials eligible for our IPD meta-analysis were contacted to share data. Two review authors conducted a risk of bias assessment. Primary results were examined in a one-stage mixed model, and a two-stage analysis was conducted in order to confirm findings. MAIN OUTCOMES AND MEASURES Pain and functional status examined at 4, 13, 26, and 52 weeks. RESULTS 10 studies were retrieved, including 786 individuals, of which 261 were between 65 and 91 years of age. There is moderate-quality evidence that SMT results in similar outcomes at 4 weeks (pain: mean difference [MD] - 2.56, 95% confidence interval [CI] - 5.78 to 0.66; functional status: standardized mean difference [SMD] - 0.18, 95% CI - 0.41 to 0.05). Second-stage and sensitivity analysis confirmed these findings. CONCLUSION SMT provides similar outcomes to recommended interventions for pain and functional status in the older adult with chronic LBP. SMT should be considered a treatment for this patient population.
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Affiliation(s)
- Alan Jenks
- Faculty of Science, Department of Health Sciences, Vrije Universiteit, Gebouw MF, Flexruimte, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Annemarie de Zoete
- Faculty of Science, Department of Health Sciences, Vrije Universiteit, Gebouw MF, Flexruimte, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Maurits van Tulder
- Faculty of Movement and Behavioral Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Sidney M Rubinstein
- Faculty of Science, Department of Health Sciences, Vrije Universiteit, Gebouw MF, Flexruimte, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
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Abstract
BACKGROUND Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs. OBJECTIVES The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments. SEARCH METHODS We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update. SELECTION CRITERIA We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration. DATA COLLECTION AND ANALYSIS Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo. MAIN RESULTS We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias. Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups. AUTHORS' CONCLUSIONS We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.
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Affiliation(s)
- Jill A Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Canada
| | - Jenna Ellis
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Canada
| | - Rachel Ogilvie
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Canada
| | - Antti Malmivaara
- Centre for Health and Social Economics (CHESS), National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands
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D'Angiolillo JC, Patel NV, Hernandez RN, Hanft S. Bilateral Lumbar Radiculopathy Secondary to Myxopapillary Ependymoma: A Case Report. J Chiropr Med 2021; 20:170-175. [DOI: 10.1016/j.jcm.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 10/18/2022] Open
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Kuligowski T, Skrzek A, Cieślik B. Manual Therapy in Cervical and Lumbar Radiculopathy: A Systematic Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18116176. [PMID: 34200510 PMCID: PMC8201115 DOI: 10.3390/ijerph18116176] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/07/2021] [Accepted: 06/07/2021] [Indexed: 01/22/2023]
Abstract
The aim of this study was to describe and update current knowledge of manual therapy accuracy in treating cervical and lumbar radiculopathy, to identify the limitations in current studies, and to suggest areas for future research. The study was conducted according to PRISMA guidelines for systematic reviews. A comprehensive literature review was conducted using PubMed and Web of Science databases up to April 2020. The following inclusion criteria were used: (1) presence of radiculopathy; (2) treatment defined as manual therapy (i.e., traction, manipulation, mobilization); and (3) publication defined as a Randomized Controlled Trial. The electronic literature search resulted in 473 potentially relevant articles. Finally, 27 articles were accepted: 21 on cervical (CR) and 6 in lumbar radiculopathy (LR). The mean PEDro score for CR was 6.6 (SD 1.3), and for LR 6.7 (SD 1.6). Traction-oriented techniques are the most frequently chosen treatment form for CR and are efficient in reducing pain and improving functional outcomes. In LR, each of the included publications used a different form of manual therapy, which makes it challenging to summarize knowledge in this group. Of included publications, 93% were either of moderate or low quality, which indicates that quality improvement is necessary for this type of research.
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Affiliation(s)
- Tomasz Kuligowski
- Faculty of Physiotherapy, University School of Physical Education in Wroclaw, 51-612 Wroclaw, Poland; (T.K.); (A.S.)
| | - Anna Skrzek
- Faculty of Physiotherapy, University School of Physical Education in Wroclaw, 51-612 Wroclaw, Poland; (T.K.); (A.S.)
| | - Błażej Cieślik
- Faculty of Health Sciences, Jan Dlugosz University in Czestochowa, 42-200 Czestochowa, Poland
- Correspondence:
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de Zoete A, de Boer MR, Rubinstein SM, van Tulder MW, Underwood M, Hayden JA, Buffart LM, Ostelo R. Moderators of the Effect of Spinal Manipulative Therapy on Pain Relief and Function in Patients with Chronic Low Back Pain: An Individual Participant Data Meta-analysis. Spine (Phila Pa 1976) 2021; 46:E505-E517. [PMID: 33186277 PMCID: PMC7993913 DOI: 10.1097/brs.0000000000003814] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/28/2020] [Accepted: 09/17/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Individual participant data (IPD) meta-analysis. OBJECTIVE The aim of this study was to identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP. SUMMARY OF BACKGROUND The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies. METHODS IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a priori based on their clinical relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6, and 12 months). RESULTS We received IPD from 21 of 46 RCTs (n = 4223). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking, and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with <1 year of LBP demonstrated more positive point estimates for SMT versus recommended therapy for the outcome pain (mean differences ranged from 4.97 (95% confidence interval, CI: -3.20 to 13.13) at 3 months, 10.76 (95% CI: 1.06 to 20.47) at 6 months to 5.26 (95% CI: -2.92 to 13.44) at 12 months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data. CONCLUSION We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.Level of Evidence: 2.
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Affiliation(s)
- Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Michiel R. de Boer
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sidney M. Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maurits W. van Tulder
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
- Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Jill A. Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laurien M. Buffart
- Radboud UMC, Nijmegen, the Netherlands
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Amsterdam, The Netherlands
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de Zoete A, Rubinstein SM, de Boer MR, Ostelo R, Underwood M, Hayden JA, Buffart LM, van Tulder MW. The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis. Physiotherapy 2021; 112:121-134. [PMID: 34049207 DOI: 10.1016/j.physio.2021.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND A 2019 review concluded that spinal manipulative therapy (SMT) results in similar benefit compared to other interventions for chronic low back pain (LBP). Compared to traditional aggregate analyses individual participant data (IPD) meta-analyses allows for a more precise estimate of the treatment effect. PURPOSE To assess the effect of SMT on pain and function for chronic LBP in a IPD meta-analysis. DATA SOURCES Electronic databases from 2000 until April 2016, and reference lists of eligible trials and related reviews. STUDY SELECTION Randomized controlled trials (RCT) examining the effect of SMT in adults with chronic LBP compared to any comparator. DATA EXTRACTION AND DATA SYNTHESIS We contacted authors from eligible trials. Two review authors independently conducted the study selection and risk of bias. We used GRADE to assess the quality of the evidence. A one-stage mixed model analysis was conducted. Negative point estimates of the mean difference (MD) or standardized mean difference (SMD) favors SMT. RESULTS Of the 42 RCTs fulfilling the inclusion criteria, we obtained IPD from 21 (n=4223). Most trials (s=12, n=2249) compared SMT to recommended interventions. There is moderate quality evidence that SMT vs recommended interventions resulted in similar outcomes on pain (MD -3.0, 95%CI: -6.9 to 0.9, 10 trials, 1922 participants) and functional status at one month (SMD: -0.2, 95% CI -0.4 to 0.0, 10 trials, 1939 participants). Effects at other follow-up measurements were similar. Results for other comparisons (SMT vs non-recommended interventions; SMT as adjuvant therapy; mobilization vs manipulation) showed similar findings. SMT vs sham SMT analysis was not performed, because we only had data from one study. Sensitivity analyses confirmed these findings. LIMITATIONS Only 50% of the eligible trials were included. CONCLUSIONS Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP. Systematic Review Registration Number PROSPERO CRD42015025714.
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Affiliation(s)
- Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Michiel R de Boer
- Department of General Practice and Elderly Care Medicine, UMCG, the Netherlands.
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK; University Hospitals of Coventry and Warwickshire, Coventry CV2 2DX, UK.
| | - Jill A Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia B3H 1V7, Canada.
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark.
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Evaluation of the effect of chiropractic manipulative treatment on oxidative stress in sacroiliac joint dysfunction. Turk J Phys Med Rehabil 2020; 66:176-183. [PMID: 32760895 DOI: 10.5606/tftrd.2020.3301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/13/2018] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aims to investigate the effect of chiropractic manipulative treatment on sacroiliac joint dysfunction (SIJD) and its relationship to oxidative stress (OXS) parameters. Patients and methods Thirty-three patients diagnosed with SIJD (20 males, 13 females; mean age 36.3±9.7 years; range, 18 to 60 years) and 30 healthy volunteers (20 males, 10 females; mean age 36.4±12.2 years; range, 20 to 57 years) were included in this cross-sectional, case-control study conducted between February 2017 and September 2017. Manipulation was applied to the patients once a week for a duration of four weeks. The patients were evaluated at pre-treatment and one month after treatment with visual analog scale, SIJD test, and total thiol, native thiol, disulphide, and ischemia-modified albumin (IMA) as OXS indicators. Results Prior to treatment, we demonstrated that serum native thiol (μmol/L) and total thiol (μmol/L) levels in the patient group were lower compared to control subjects (p=0.03 and p=0.02, respectively). Serum IMA levels were higher in the patient group (p=0.01). There was no change in OXS parameters after manipulative treatment in the patient group. Conclusion Manipulation is useful in SIJD. Thiol/disulphide homeostasis and serum IMA levels may be used to measure the OXS in patients with SIJD.
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Kruse RA, White BA, Gudavalli S. Management of Lumbar Radiculopathy Associated With an Extruded L4-L5 Spondylolytic Spondylolisthesis Using Flexion-Distraction Manipulation: A Case Study. J Chiropr Med 2019; 18:311-316. [DOI: 10.1016/j.jcm.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/22/2019] [Accepted: 02/05/2019] [Indexed: 10/23/2022] Open
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Hayden JA, Wilson MN, Stewart S, Cartwright JL, Smith AO, Riley RD, van Tulder M, Bendix T, Cecchi F, Costa LOP, Dufour N, Ferreira ML, Foster NE, Gudavalli MR, Hartvigsen J, Helmhout P, Kool J, Koumantakis GA, Kovacs FM, Kuukkanen T, Long A, Macedo LG, Machado LAC, Maher CG, Mehling W, Morone G, Peterson T, Rasmussen-Barr E, Ryan CG, Sjögren T, Smeets R, Staal JB, Unsgaard-Tøndel M, Wajswelner H, Yeung EW. Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials. Br J Sports Med 2019; 54:1277-1278. [DOI: 10.1136/bjsports-2019-101205] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2019] [Indexed: 01/26/2023]
Abstract
BackgroundLow back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise.MethodsIn parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers.ResultsWe received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) −10.7 (−14.1 to –7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) −10.2 (−13.2 to –7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers—these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics.ConclusionsThis study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups.Protocol publicationhttps://doi.org/10.1186/2046-4053-1-64
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Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med 2019; 54:1279-1287. [PMID: 31666220 PMCID: PMC7588406 DOI: 10.1136/bjsports-2019-100886] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/29/2022]
Abstract
Objective Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP). Design Network meta-analysis (NMA). Data sources MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL. Eligibility criteria Exercise training randomised controlled/clinical trials in adults with NSCLBP. Results Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): −1.86 (–2.54 to –1.19)), resistance (SUCRA=80%; −1.14 (–1.71 to –0.56)) and stabilisation/motor control (SUCRA=80%; −1.13 (–1.53 to –0.74)) for physical function and resistance (SUCRA=80%; −1.26 (–2.10 to –0.41)) and aerobic (SUCRA=80%; −1.18 (–2.20 to –0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (–0.71 to 0.89)) and physical function (SUCRA=20%; −0.31 (–0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; −0.31 (–1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria. Summary/conclusion There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.
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Affiliation(s)
- Patrick J Owen
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Clint T Miller
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Niamh L Mundell
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Simone J J M Verswijveren
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Scott D Tagliaferri
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Helena Brisby
- Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Steven J Bowe
- Faculty of Health, Biostatistics Unit, Deakin University, Geelong, Victoria, Australia
| | - Daniel L Belavy
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
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Oh H, Choi S, Lee S, Choi J, Lee K. Effects of the flexion-distraction technique and drop technique on straight leg raising angle and intervertebral disc height of patients with an intervertebral disc herniation. J Phys Ther Sci 2019; 31:666-669. [PMID: 31528006 PMCID: PMC6698474 DOI: 10.1589/jpts.31.666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/27/2019] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The purpose of this study was to determine the effects of the
flexion-distraction technique and drop technique on the straight leg raising angle and
intervertebral disc height of patients with an intervertebral disc herniation.
[Participants and Methods] Thirty patients with herniated intervertebral discs were
divided into either an experimental group (n=15), who underwent flexion-distraction and
drop techniques, or a control group (n=15), who obtained spinal decompression therapy.
Both groups were treated three times per week for eight weeks. [Results] An intragroup
comparison showed that the straight leg raising angle and the intervertebral disc height
significantly increased in both groups. But it was not significantly difference in the
intergroup comparison. [Conclusion] The flexion-distraction technique and the drop
technique may serve as effective interventions for the straight leg raising angle and
intervertebral disc height in patients with intervertebral disc herniations.
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Affiliation(s)
- Hyunju Oh
- Department of Physical Therapy, Taegu Science University, Republic of Korea
| | - SeokJoo Choi
- Department of Physical Therapy, Taegu Science University, Republic of Korea
| | - Sangyong Lee
- Department of Physical Therapy, U1 University, Republic of Korea
| | - Jioun Choi
- Department of Physical Therapy, Shin Orthopedic Hospital, Republic of Korea
| | - Kwansub Lee
- Department of Physical Therapy, Daegu Health College: 15 Taejeondong, Yeongsongro, Buk-gu, Daegu 41453, Republic of Korea
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Carrasco-Martínez F, Ibáñez-Vera AJ, Martínez-Amat A, Hita-Contreras F, Lomas-Vega R. Short-term effectiveness of the flexion-distraction technique in comparison with high-velocity vertebral manipulation in patients suffering from low-back pain. Complement Ther Med 2019; 44:61-67. [DOI: 10.1016/j.ctim.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 01/12/2023] Open
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Pagnez MAM, Corrêa LA, Almeida RS, Meziat-Filho NA, Mathieson S, Ricard F, Nogueira LAC. The Variation of Cross-Sectional Area of the Sciatic Nerve in Flexion-Distraction Technique: A Cross-Sectional Study. J Manipulative Physiol Ther 2019; 42:108-116. [PMID: 31029470 DOI: 10.1016/j.jmpt.2019.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 05/23/2018] [Accepted: 03/05/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the cross-sectional area of the sciatic nerve in different positions of spinal manipulation using flexion-distraction technique. METHODS Thirty healthy participants were assessed in 6 different flexion-distraction technique positions of varying lumbar, knee, and ankle positions. Participants stood in the following 3 positions with the lumbar in the neutral position: (A) with knee extended, (B) with knee flexed, and (C) with the knee extended and ankle dorsiflexion. Participants then stood in the following 3 positions with the lumbar flexed: (D) with the knee extended, (E) with the knee flexed, and (F) with knee extended and ankle dorsiflexion. The cross-sectional area (CSA) of the sciatic nerve was measured with ultrasound imaging in transverse sections in the posterior medial region of the left thigh. The CSA values measured at each position were compared. RESULTS We analyzed 180 ultrasound images. The cross-sectional area of the sciatic nerve (in mm2) in position B (mean; standard deviation) (59.71-17.41) presented a higher mean cross-sectional area value compared with position D (51.18-13.81; P =.005), position F (48.71-15.16; P = .004), and position C (48.37-16.35; P = .009). CONCLUSION The combination of knee extension and ankle dorsiflexion reduced the CSA of the sciatic nerve, and flexing the knee and keeping the ankle in the neutral position increased it.
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Affiliation(s)
- Maria Alice Mainenti Pagnez
- Physiotherapy Department, Rehabilitation Science Postgraduate Program, Augusto Motta University Centre, Rio de Janeiro, Brazil; Academic Department, Madrid School of Osteopathy, Rio de Janeiro, Brazil.
| | - Leticia Amaral Corrêa
- Physiotherapy Department, Rehabilitation Science Postgraduate Program, Augusto Motta University Centre, Rio de Janeiro, Brazil
| | - Renato Santos Almeida
- Physiotherapy Department, Rehabilitation Science Postgraduate Program, Augusto Motta University Centre, Rio de Janeiro, Brazil; Physiotherapy Department, Serra dos Órgãos University Centre, Teresópolis, Brazil
| | - Ney Armando Meziat-Filho
- Physiotherapy Department, Rehabilitation Science Postgraduate Program, Augusto Motta University Centre, Rio de Janeiro, Brazil
| | - Stephanie Mathieson
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney New South Wales, Australia
| | - François Ricard
- Academic Department, Madrid School of Osteopathy, Rio de Janeiro, Brazil
| | - Leandro Alberto Calazans Nogueira
- Physiotherapy Department, Rehabilitation Science Postgraduate Program, Augusto Motta University Centre, Rio de Janeiro, Brazil; Physiotherapy Department, Federal Institute of Rio de Janeiro, Rio de Janeiro, Brazil
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Abstract
Spinal manipulative therapy, including low-velocity variable-amplitude spinal manipulation (LVVA-SM), relieves chronic low back pain, especially in patients with neuropathic radiating leg pain following peripheral nervous system insult. Understanding the underlying analgesic mechanisms requires animal models. The aim of the current study was to develop an animal model for the analgesic actions of LVVA-SM in the setting of peripheral neuropathic pain. Adult male Sprague-Dawley rat sciatic nerve tibial and common peroneal branches were transected, sparing the sural branch (spared nerve injury, SNI). After 15-18 days, rats were assigned randomly to one of three groups (n=9 each group): LVVA-SM at 0.15-or 0.16-Hz or Control. LVVA-SM (20° flexion at the L5 vertebra with an innovative motorized treatment table) was administered in anesthetized rats for 10 min. Control rats were administered anesthesia and positioned on the treatment table. After 10, 25, and 40 min, the plantar skin of the hindpaw ipsilateral to SNI was tested for mechanical sensitivity (paw withdrawal threshold to a logarithmic series of Semmes-Weinstein monofilaments) and cold sensitivity (duration of paw lifting, shaking, and/or licking to topical acetone application). SNI produced behavioral signs of mechanical and cold allodynia. LVVA-SM reduced mechanical, but not cold, hypersensitivity compared with Control (0.15-Hz: P=0.04 at 10 min; 0.16-Hz: P<0.001 at 10 min, P=0.04 at 25 min). The analgesic effect of LVVA-SM in chronic low back pain patients with neuropathic leg pain can be reverse-translated to a rat model Video abstract: http://links.lww.com/WNR/A453.
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Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 2019; 364:l689. [PMID: 30867144 PMCID: PMC6396088 DOI: 10.1136/bmj.l689] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting. REVIEW METHODS Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored. RESULTS 47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference -3.17, 95% confidence interval -7.85 to 1.51) and a small, clinically better improvement in function (SMD -0.25, 95% confidence interval -0.41 to -0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference -7.48, -11.50 to -3.47) and small to moderate clinically better improvement in function (SMD -0.41, -0.67 to -0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT. CONCLUSION SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.
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Affiliation(s)
- Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | - Annemarie de Zoete
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | | | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Michiel R de Boer
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
- Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
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Oh H, Choi S, Lee S, Choi J, Lee K. The impact of manual spinal traction therapy on the pain and Oswestry disability index of patients with chronic back pain. J Phys Ther Sci 2018; 30:1455-1457. [PMID: 30568333 PMCID: PMC6279706 DOI: 10.1589/jpts.30.1455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/12/2018] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The purpose of this study was to examine the effect of manual spinal traction
therapy on the pain and Oswestry disability index of patients with chronic back pain.
[Participants and Methods] In this study, 30 patients with chronic back pain were evenly
divided into an experimental group 1, who received manual traction therapy, and an
experimental group 2, who received intermittent traction therapy. Both groups received
therapy three times a week for eight weeks. A visual analogue scale was used to measure
participants’ back pain, and the Oswestry disability index was used to check the
functional impediment they experienced as a result. [Results] In a within-group
comparison, visual analogue scale and Oswestry disability index significantly decreased in
both the experimental 1 and experimental 2. In a between-group comparison after treatment,
there was a significantly greater decrease in visual analogue scale and Oswestry
disability index in the experimental group 1 compared to the experimental 2. [Conclusion]
The manual spinal traction therapy was an effective intervention scheme for the treatment
of pain and disorder in patients with chronic back pain.
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Affiliation(s)
- Hyunju Oh
- Department of Physical Therapy, Taegu Science University, Republic of Korea
| | - SeokJoo Choi
- Department of Physical Therapy, Taegu Science University, Republic of Korea
| | - Sangyong Lee
- Department of Physical Therapy, U1 University, Republic of Korea
| | - Jioun Choi
- Department of Physical Therapy, Shin Orthopedic Hospital, Republic of Korea
| | - Kwansub Lee
- Department of Physical Therapy, Daegu Health College: 15 Taejeondong, Yeongsongro, Buk-gu, Daegu 41453, Republic of Korea
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Vining R, Minkalis A, Long CR, Corber L, Franklin C, Gudavalli MR, Xia T, Goertz CM. Assessment of chiropractic care on strength, balance, and endurance in active-duty U.S. military personnel with low back pain: a protocol for a randomized controlled trial. Trials 2018; 19:671. [PMID: 30518400 PMCID: PMC6280458 DOI: 10.1186/s13063-018-3041-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/09/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Low back pain (LBP) is a common cause of disability among U.S. military personnel. Approximately 20% of all diagnoses resulting in disability discharges are linked to back-related conditions. Because LBP can negatively influence trunk muscle strength, balance, and endurance, the military readiness of active-duty military personnel with LBP is potentially compromised. Chiropractic care may facilitate the strengthening of trunk muscles, the alteration of sensory and motor signaling, and a reduction in pain sensitivity, which may contribute to improving strength, balance, and endurance for individuals with LBP. This trial will assess the effects of chiropractic care on strength, balance, and endurance for active-duty military personnel with LBP. METHODS/DESIGN This randomized controlled trial will allocate 110 active-duty military service members aged 18-40 with non-surgical acute, subacute, or chronic LBP with pain severity of ≥2/10 within the past 24 h. All study procedures are conducted at a single military treatment facility within the continental United States. Participants are recruited through recruitment materials approved by the institutional review board, such as posters and flyers, as well as through provider referrals. Group assignment occurs through computer-generated random allocation to either the study intervention (chiropractic care) or the control group (waiting list) for a 4-week period. Chiropractic care consists primarily of spinal manipulation at a frequency and duration determined by a chiropractic practitioner. Strength, balance, and endurance outcomes are obtained at baseline and after 4 weeks. The primary outcome is a change between baseline and 4 weeks of peak isometric strength, which is measured by pulling on a bimanual handle in a semi-squat position. Secondary outcomes include balance time during a single-leg standing test and trunk muscle endurance with the Biering-Sorensen test. Patient-reported outcomes include pain severity, disability measured with the Roland Morris Disability Questionnaire, symptom bothersomeness, PROMIS-29, Fear Avoidance Beliefs Questionnaire, expectations of care, physical activity, and global improvement. DISCUSSION This trial may help inform further research on biological mechanisms related to manual therapies employed by chiropractic practitioners. TRIAL REGISTRATION ClinicalTrials.gov, NCT02670148 Registered on 1 February 2016.
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Affiliation(s)
- Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady St, Davenport, IA 52803 USA
| | - Amy Minkalis
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady St, Davenport, IA 52803 USA
| | - Cynthia R. Long
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady St, Davenport, IA 52803 USA
| | - Lance Corber
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady St, Davenport, IA 52803 USA
| | - Crystal Franklin
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady St, Davenport, IA 52803 USA
| | - M. Ram Gudavalli
- College of Chiropractic Medicine, Keiser University, 2081 Vista Parkway, West Palm Beach, FL 33411 USA
| | - Ting Xia
- Mechanical Engineering, Northern Illinois University, 590 Garden Rd, DeKalb, IL 60115 USA
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Alrwaily M, Almutiri M, Schneider M. Assessment of variability in traction interventions for patients with low back pain: a systematic review. Chiropr Man Therap 2018; 26:35. [PMID: 30237870 PMCID: PMC6139896 DOI: 10.1186/s12998-018-0205-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 07/05/2018] [Indexed: 12/03/2022] Open
Abstract
Background Previous systematic reviews have concluded that lumbar traction is not effective for patients with low back pain (LBP), yet many clinicians continue to assert its clinical effectiveness. Objective To systematically identify randomized controlled trials (RCTs) of traction and explore the variability of traction interventions used in each RCT. Method A literature search started in September 2016 to retrieve systematic reviews and individual RCTs of lumbar traction. The term “lumbar traction” and other key words were used in the following databases: Cochrane Registry, MEDLINE, EMBASE, and CINAHL. The retrieved systematic reviews were used to extract individual RCTs. The most current systematic review included RCTs from inception until August 2012. We performed an additional literature search to update this systematic review with newer RCTs published between September 2012 and December 2016. All of the identified RCTs were combined and summarized into a single evidence table. Results We identified a total of 37 traction RCTs that varied greatly in their method of traction intervention. The RCTs included several types of traction: mechanical (57%), auto-traction (16%), manual (10.8%), gravitational (8.1%) and aquatic (5.4%). There was also great variability in the types of traction force, rhythm, session duration and treatment frequency used in the RCTs. Patient characteristics were a mixture of acute, subacute and chronic LBP; with or without sciatica. Conclusion There is wide variability in the type of traction, traction parameters and patient characteristics found among the RCTs of lumbar traction. The variability may call into question the conclusion that lumbar traction has little no or value on clinical outcomes. Also, this variability emphasizes the need for targeted delivery methods of traction that match appropriate dosages with specific subgroups of patients with LBP.
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Affiliation(s)
- Muhammad Alrwaily
- 1Division of Physical Therapy, School of Medicine, West Virginia University, 1 Medical Center Drive, P.O. Box 9226 - Room 8304, Morgantown, WV 26506 USA.,King Fahad Specialist Hosptial, Dammam, Saudi Arabia
| | - Mohammed Almutiri
- 3Department of Physical Therapy, School of Applied Medical Sciences, Najran University, King Abdulaziz Rd, PO Box 1988, Najran, 61441 Saudi Arabia
| | - Michael Schneider
- 4Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219 USA
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Clohesy NC, Schneiders AG, Eaton S. Utilization of Low Back Pain Patient Reported Outcome Measures Within Chiropractic Literature: A Descriptive Review. J Manipulative Physiol Ther 2018; 41:628-639. [DOI: 10.1016/j.jmpt.2017.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 10/23/2017] [Accepted: 11/14/2017] [Indexed: 01/19/2023]
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Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Suttorp Booth M, Herman PM. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J 2018; 18:866-879. [PMID: 29371112 PMCID: PMC6020029 DOI: 10.1016/j.spinee.2018.01.013] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/07/2017] [Accepted: 01/11/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies. PURPOSE The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain. STUDY DESIGN/SETTING This is a systematic literature review and meta-analysis. OUTCOME MEASURES The present study measures self-reported pain, function, health-related quality of life, and adverse events. METHODS We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912. RESULTS Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=-0.28, 95% confidence interval (CI) -0.47 to -0.09, p=.004; I2=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=-0.33, 95% CI -0.63 to -0.03, p=.03; I2=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=-0.43, 95% CI -0.86 to 0.00; p=.05, I2=79%; SMD=-0.86, 95% CI -1.27 to -0.45; p<.0001, I2=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=-0.20, 95% CI -0.35 to -0.04; p=.01; I2=0%) but not disability (SMD=-0.10, 95% CI -0.28 to 0.07; p=.25; I2=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described. CONCLUSION There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.
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Affiliation(s)
- Ian D Coulter
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407-2138, USA; UCLA School of Dentistry, Box 951668, Los Angeles, CA 90095-1668, USA; Southern California University of Health Sciences, 16200 Amber Valley Dr, Whittier, CA 90604, USA.
| | - Cindy Crawford
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407-2138, USA
| | - Eric L Hurwitz
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407-2138, USA; Office of Public Health Studies, University of Hawai'i, Mānoa, 1960 East-West Rd, Biomed D104AA, Honolulu, HI 96822, USA
| | - Howard Vernon
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407-2138, USA; Division of Research, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, Canada M2H 3J1
| | - Raheleh Khorsan
- UCI Department of Urban Planning and Public Policy, 300 Social Ecology I, Irvine, CA 92697-7075, USA
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Oakley PA, Harrison DE. Lumbar extension traction alleviates symptoms and facilitates healing of disc herniation/sequestration in 6-weeks, following failed treatment from three previous chiropractors: a CBP ® case report with an 8 year follow-up. J Phys Ther Sci 2017; 29:2051-2057. [PMID: 29200655 PMCID: PMC5702845 DOI: 10.1589/jpts.29.2051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/23/2017] [Indexed: 12/28/2022] Open
Abstract
[Purpose] To present the outcome of a patient, having sciatica and MRI-verified disc
herniation/sequestration who underwent Chiropractic BioPhysics®
(CBP®) protocol designed to improve the lumbar lordosis. [Subject and
Methods] A 56-year-old male suffered from chronic low back pain and recent sciatica due to
lumbar disc herniation despite being under continuous care from three previous
chiropractors. Radiographic analysis revealed a lumbar hypolordosis and MRI confirmed disc
herniation and sequestration at L4–L5. Generalized decreased lumbar range of motion and
multiple positive orthopedic and neurologic tests were present. [Results] After 26
treatments of CBP lumbar extension traction over 9-weeks a total reduction of the disc
herniation and sequestration occurred with concomitant improvement in neurologic symptoms.
Continuing maintenance treatments, an 8 year follow-up shows no relapse of condition and
patient remained in good health. [Conclusion] A patient with lumbar disc
herniation/sequestration was successfully treated with CBP technique procedures including
lumbar extension traction that achieved a significant healing of herniation and
significant reduction in symptoms not obtained following traditional chiropractic
procedures alone. The quick reduction in lumbar disc herniation would appear to be related
to a segmental disc unloading force produced during extension traction procedures for
increasing the lumbar curvature.
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Cox JM. Response to "Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update". J Manipulative Physiol Ther 2017; 40:544-545. [PMID: 28739016 DOI: 10.1016/j.jmpt.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 06/15/2017] [Indexed: 11/28/2022]
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Cambron JA, Dexheimer JM, Duarte M, Freels S. Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil 2017; 98:1752-1762. [PMID: 28465224 DOI: 10.1016/j.apmr.2017.03.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 02/15/2017] [Accepted: 03/30/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain compared with no treatment. DESIGN Randomized controlled trial. SETTING Integrative medicine teaching clinic at a university. PARTICIPANTS Adult subjects (N=225) with symptomatic low back pain of ≥3 months were recruited from a volunteer sample. INTERVENTIONS Subjects were randomized into 1 of 3 treatment groups (shoe orthotic, plus, and waitlist groups). The shoe orthotic group received custom-made shoe orthotics. The plus group received custom-made orthotics plus chiropractic manipulation, hot or cold packs, and manual soft tissue massage. The waitlist group received no care. MAIN OUTCOME MEASURES The primary outcome measures were change in perceived back pain (numerical pain rating scale) and functional health status (Oswestry Disability Index) after 6 weeks of study participation. Outcomes were also assessed after 12 weeks and then after an additional 3, 6, and 12 months. RESULTS After 6 weeks, all 3 groups demonstrated significant within-group improvement in average back pain, but only the shoe orthotic and plus groups had significant within-group improvement in function. When compared with the waitlist group, the shoe orthotic group demonstrated significantly greater improvements in pain (P<.0001) and function (P=.0068). The addition of chiropractic to orthotics treatment demonstrated significantly greater improvements in function (P=.0278) when compared with orthotics alone, but no significant difference in pain (P=.3431). Group differences at 12 weeks and later were not significant. CONCLUSIONS Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared with no treatment. The addition of chiropractic care led to higher improvements in function.
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Affiliation(s)
- Jerrilyn A Cambron
- Department of Research, National University of Health Sciences, Lombard, IL.
| | | | - Manuel Duarte
- Department of Clinical Practice, National University of Health Sciences, Lombard, IL
| | - Sally Freels
- School of Public Health, Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL
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Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clin Proc 2016; 91:1292-306. [PMID: 27594189 PMCID: PMC5032142 DOI: 10.1016/j.mayocp.2016.06.007] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/15/2016] [Accepted: 06/21/2016] [Indexed: 12/25/2022]
Abstract
Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches-acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga-as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.
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Affiliation(s)
- Richard L Nahin
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD.
| | - Robin Boineau
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD
| | - Partap S Khalsa
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD
| | - Barbara J Stussman
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD
| | - Wendy J Weber
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD
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Ammendolia C, Côté P, Rampersaud YR, Southerst D, Budgell B, Bombardier C, Hawker G. The boot camp program for lumbar spinal stenosis: a protocol for a randomized controlled trial. Chiropr Man Therap 2016; 24:25. [PMID: 27433335 PMCID: PMC4948101 DOI: 10.1186/s12998-016-0106-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/08/2016] [Indexed: 01/22/2023] Open
Abstract
Background Lumbar spinal stenosis (LSS) causing neurogenic claudication is a leading cause of pain, disability and loss of independence in older adults. The prevalence of lumbar spinal stenosis is growing rapidly due to an aging population. The dominant limitation in LSS is walking ability. Postural, physical and psychosocial factors can impact symptoms and functional ability. LSS is the most common reason for spine surgery in older adults yet the vast majority of people with LSS receive non-surgical treatment. What constitutes effective non-surgical treatment is unknown. The purpose of this study is to evaluate the effectiveness of a multi-modal and self-management training program, known as the Boot Camp Program for LSS aimed at improving walking ability and other relevant patient-centred outcomes. Methods We will use a pragmatic two-arm randomized controlled single blinded (assessor) study design. Eligible and consenting participants will be randomized to receive from licensed chiropractors either a 6-week (twice weekly) self-management training program (manual therapy, education, home exercises) with an instructional workbook and video and a pedometer or a single instructional session with an instructional workbook and video and pedometer. The main outcome measure will be the self-paced walking test measured at 6 months. We will also assess outcomes at 8 weeks and 3 and 12 months. Discussion Symptoms and functional limitations in LSS are variable and influenced by changes in spinal alignment. Physical and psychological factors result in chronic disability for patients with LSS. The Boot Camp Program is a 6-week self-management training program aimed at the multi-faceted aspects of LSS and trains individuals to use self-management strategies. The goal is to provide life-long self-management strategies that maximize walking and overall functional abilities and quality of life. Trial registration ClinicalTrials.gov ID: NCT02592642.
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Affiliation(s)
- Carlo Ammendolia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada ; Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, Toronto, Canada
| | - Pierre Côté
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada ; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada ; University of Ontario Institute of Technology, Ontario, Canada
| | - Y Raja Rampersaud
- Department of Orthopedics, Toronto Western Hospital, University Health Network, Toronto, Canada
| | | | - Brian Budgell
- Canadian Memorial Chiropractic College, Toronto, Ontario Canada
| | - Claire Bombardier
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada ; Department of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Gillian Hawker
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada ; Department of Medicine, University of Toronto, Toronto, Ontario Canada
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Patel S, Hee SW, Mistry D, Jordan J, Brown S, Dritsaki M, Ellard DR, Friede T, Lamb SE, Lord J, Madan J, Morris T, Stallard N, Tysall C, Willis A, Underwood M. Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundThere is good evidence that therapist-delivered interventions have modest beneficial effects for people with low back pain (LBP). Identification of subgroups of people with LBP who may benefit from these different treatment approaches is an important research priority.Aim and objectivesTo improve the clinical effectiveness and cost-effectiveness of LBP treatment by providing patients, their clinical advisors and health-service purchasers with better information about which participants are most likely to benefit from which treatment choices. Our objectives were to synthesise what is already known about the validity, reliability and predictive value of possible treatment moderators (patient factors that predict response to treatment) for therapist-delivered interventions; develop a repository of individual participant data from randomised controlled trials (RCTs) testing therapist-delivered interventions for LBP; determine which participant characteristics, if any, predict clinical response to different treatments for LBP; and determine which participant characteristics, if any, predict the most cost-effective treatments for LBP. Achieving these objectives required substantial methodological work, including the development and evaluation of some novel statistical approaches. This programme of work was not designed to analyse the main effect of interventions and no such interpretations should be made.MethodsFirst, we reviewed the literature on treatment moderators and subgroups. We initially invited investigators of trials of therapist-delivered interventions for LBP with > 179 participants to share their data with us; some further smaller trials that were offered to us were also included. Using these trials we developed a repository of individual participant data of therapist-delivered interventions for LBP. Using this data set we sought to identify which participant characteristics, if any, predict response to different treatments (moderators) for clinical effectiveness and cost-effectiveness outcomes. We undertook an analysis of covariance to identify potential moderators to apply in our main analyses. Subsequently, we developed and applied three methods of subgroup identification: recursive partitioning (interaction trees and subgroup identification based on a differential effect search); adaptive risk group refinement; and an individual participant data indirect network meta-analysis (NWMA) to identify subgroups defined by multiple parameters.ResultsWe included data from 19 RCTs with 9328 participants (mean age 49 years, 57% females). Our prespecified analyses using recursive partitioning and adaptive risk group refinement performed well and allowed us to identify some subgroups. The differences in the effect size in the different subgroups were typically small and unlikely to be clinically meaningful. Increasing baseline severity on the outcome of interest was the strongest driver of subgroup identification that we identified. Additionally, we explored the application of Bayesian indirect NWMA. This method produced varying probabilities that a particular treatment choice would be most likely to be effective for a specific patient profile.ConclusionsThese data lack clinical effectiveness or cost-effectiveness justification for the use of baseline characteristics in the development of subgroups for back pain. The methodological developments from this work have the potential to be applied in other clinical areas. The pooled repository database will serve as a valuable resource to the LBP research community.FundingThe National Institute for Health Research Programme Grants for Applied Research programme. This project benefited from facilities funded through Birmingham Science City Translational Medicine Clinical Research and Infrastructure Trials Platform, with support from Advantage West Midlands (AWM) and the Wolfson Foundation.
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Affiliation(s)
- Shilpa Patel
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Siew Wan Hee
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dipesh Mistry
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Jordan
- Brunel University, Health Economics Research Group, Uxbridge, UK
- Surrey Health Economic Centre, School of Economics, University of Surrey, Guildford, UK
| | - Sally Brown
- Universities/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - Melina Dritsaki
- Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David R Ellard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Centre Göttingen, Göttingen, Germany
| | - Sarah E Lamb
- Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanne Lord
- Brunel University, Health Economics Research Group, Uxbridge, UK
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Colin Tysall
- Universities/User Teaching and Research Action Partnership (UNTRAP), University of Warwick, Coventry, UK
| | - Adrian Willis
- Warwick Medical School, University of Warwick, Coventry, UK
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Similar Effects of Thrust and Nonthrust Spinal Manipulation Found in Adults With Subacute and Chronic Low Back Pain: A Controlled Trial With Adaptive Allocation. Spine (Phila Pa 1976) 2016; 41:E702-E709. [PMID: 26656041 PMCID: PMC4902754 DOI: 10.1097/brs.0000000000001373] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A three-arm controlled trial with adaptive allocation. OBJECTIVES The aim of this study was to compare short-term effects of a side-lying, thrust spinal manipulation (SM) procedure and a nonthrust, flexion-distraction SM procedure in adults with subacute or chronic low back pain (LBP) over 2 weeks. SUMMARY OF BACKGROUND DATA SM has been recommended in recently published clinical guidelines for LBP management. Previous studies suggest that thrust and nonthrust SM procedures, though distinctly different in joint loading characteristics, have similar effects on patients with LBP. METHODS Participants were eligible if they were 21 to 54 years old, had LBP for at least 4 weeks, scored 6 or above on the Roland-Morris disability questionnaire, and met the diagnostic classification of 1, 2, or 3 according to the Quebec Task Force Classification for Spinal Disorders. Participants were allocated in a 3:3:2 ratio to four sessions of thrust or nonthrust SM procedures directed at the lower lumbar and pelvic regions, or to a 2-week wait list control. The primary outcome was LBP-related disability using Roland-Morris Disability Questionnaire and the secondary outcomes were LBP intensity using visual analog scale, Fear-Avoidance Beliefs Questionnaire, and the 36-Item Short Form Health Survey. The study was conducted at the Palmer Center for Chiropractic Research with care provided by experienced doctors of chiropractic. Clinicians and patients were not blinded to treatment group. RESULTS Of 192 participants enrolled, the mean age was 40 years and 54% were male. Improvement in disability, LBP intensity, Fear-Avoidance Beliefs Questionnaire-work subscale, and 36-Item Short Form Health Survey-physical health summary measure for the two SM groups were significantly greater than the control group. No difference in any outcomes was observed between the two SM groups. CONCLUSION Thrust and nonthrust SM procedures with distinctly different joint loading characteristics demonstrated similar effects in short-term LBP improvement and both were superior to a wait list control. LEVEL OF EVIDENCE 2.
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Gudavalli MR, Olding K, Joachim G, Cox JM. Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series. J Chiropr Med 2016; 15:121-8. [PMID: 27330514 DOI: 10.1016/j.jcm.2016.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The purpose of this case series is to report on changes in pain levels experienced by 69 postsurgical continued pain patients who received Cox Technic Flexion Distraction (CTFD). METHODS Fifteen doctors of chiropractic collected retrospective data from the records of the postsurgical continued pain patients seen in their clinic from February to July 2012 who were treated with CTFD, which is a type of chiropractic distraction spinal manipulation. Informed consent was obtained from all patients who met the inclusion criteria for this study. Data recorded included subjective patient pain levels at the end of the treatments provided and at 24 months following the last treatment. RESULTS Fifty-four (81%) of the patients showed greater than 50% reduction in pain levels at the end of the last treatment, and 13 (19%) showed less than 50% improvement of pain levels at the end of active care (mean, 49 days and 11 treatments). At 24-month follow-up, of 56 patients available, 44 (78.6%) had continued pain relief of greater than 50% and 10 (18%) reported 50% or less relief. The mean percentage of relief at the end of active care was 71.6 (SD, 23.2) and at 24 months was 70 (SD, 25). At 24 months after active care, 24 patients (43%) had not sought further care, and 32 required further treatment consisting of chiropractic manipulation for 17 (53%), physical therapy, exercise, injections, and medication for 9 (28%), and further surgery for 5 (16%). CONCLUSION Greater than 50% pain relief following CTFD 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.
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Affiliation(s)
- Maruti R Gudavalli
- Professor, Research Department, Palmer College of Chiropractic, Davenport, IA
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Antinociceptive Effects of Spinal Manipulative Therapy on Nociceptive Behavior of Adult Rats during the Formalin Test. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:520454. [PMID: 26693243 PMCID: PMC4674607 DOI: 10.1155/2015/520454] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/26/2015] [Accepted: 11/09/2015] [Indexed: 01/08/2023]
Abstract
Optimizing pain relief resulting from spinal manipulative therapies, including low velocity variable amplitude spinal manipulation (LVVA-SM), requires determining their mechanisms. Pain models that incorporate simulated spinal manipulative therapy treatments are needed for these studies. The antinociceptive effects of a single LVVA-SM treatment on rat nociceptive behavior during the commonly used formalin test were investigated. Dilute formalin was injected subcutaneously into a plantar hindpaw. Licking behavior was video-recorded for 5 minutes. Ten minutes of LVVA-SM at 20° flexion was administered with a custom-made device at the lumbar (L5) vertebra of isoflurane-anesthetized experimental rats (n = 12) beginning 10 minutes after formalin injection. Hindpaw licking was video-recorded for 60 minutes beginning 5 minutes after LVVA-SM. Control rats (n = 12) underwent the same methods except for LVVA-SM. The mean times spent licking the formalin-injected hindpaw of both groups 1–5 minutes after injection were not different. The mean licking time during the first 20 minutes post-LVVA-SM of experimental rats was significantly less than that of control rats (P < 0.001). The mean licking times of both groups during the second and third 20 minutes post-LVVA-SM were not different. Administration of LVVA-SM had a short-term, remote antinociceptive effect similar to clinical findings. Therefore, mechanistic investigations using this experimental approach are warranted.
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Choi J, Lee S, Jeon C. Effects of flexion-distraction manipulation therapy on pain and disability in patients with lumbar spinal stenosis. J Phys Ther Sci 2015; 27:1937-9. [PMID: 26180352 PMCID: PMC4500015 DOI: 10.1589/jpts.27.1937] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/07/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] 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. According to the Oswestry Disability Index, the level of disability was significantly decreased in both groups, but the decrease was more significant in the flexion-distraction group. [Conclusion] Flexion-distraction manipulation appears to be an effective intervention for pain and disability among patients with lumbar spinal stenosis.
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Affiliation(s)
- Jioun Choi
- Department of Physical Therapy, Graduate School of Physical Therapy, Daegu University, Republic of Korea
| | - Sangyong Lee
- Department of Physical Therapy, Youngdong University, Republic of Korea
| | - Chunbae Jeon
- Department of Physical Therapy, The Most Holy Trinity Hospital, Republic of Korea
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Clinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: a retrospective study. J Manipulative Physiol Ther 2015; 38:188-94. [PMID: 25620608 DOI: 10.1016/j.jmpt.2014.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The purpose of this preliminary study was to assess the effectiveness of a 6-week, nonsurgical, multimodal program that addresses the multifaceted aspects of neurogenic claudication. METHODS In this retrospective study, 2 researchers independently extracted data from the medical records from January 2010 to April 2013 of consecutive eligible patients who had completed the 6-week Boot Camp Program. The program consisted of manual therapy twice per week (eg, soft tissue and neural mobilization, chiropractic spinal manipulation, lumbar flexion-distraction, and muscle stretching), structured home-based exercises, and instruction of self-management strategies. A paired t test was used to compare differences in outcomes from baseline to 6-week follow-up. Outcomes included self-reported pain, disability, walking ability, and treatment satisfaction. RESULTS A total of 49 patients were enrolled, with a mean age of 70 years. The mean difference in the Oswestry Disability Index was 15.2 (95% confidence interval [CI], 11.39-18.92), and that for the functional and symptoms scales of the Swiss Spinal Stenosis Questionnaire was 0.41 (95% CI, 0.26-0.56) and 0.74 (95% CI, 0.55-0.93), respectively. Numeric pain scores for both leg and back showed statistically significant improvements. Improvements in all outcomes were clinically important. CONCLUSIONS This study showed preliminary evidence for improved outcomes in patients with neurogenic claudication participating in a 6-week nonsurgical multimodal Boot Camp Program.
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The Risk of Bias and Sample Size of Trials of Spinal Manipulative Therapy for Low Back and Neck Pain: Analysis and Recommendations. J Manipulative Physiol Ther 2014; 37:523-41. [DOI: 10.1016/j.jmpt.2014.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/23/2014] [Accepted: 07/23/2014] [Indexed: 12/18/2022]
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Choi J, Hwangbo G, Park J, Lee S. The Effects of Manual Therapy Using Joint Mobilization and Flexion-distraction Techniques on Chronic Low Back Pain and Disc Heights. J Phys Ther Sci 2014; 26:1259-62. [PMID: 25202191 PMCID: PMC4155230 DOI: 10.1589/jpts.26.1259] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/18/2014] [Indexed: 01/22/2023] Open
Abstract
[Purpose] The purpose of this study was to examine the effects of manual therapy using joint mobilization and flexion-distraction techniques on chronic low back pain and disc heights. [Subjects] This study was conducted with 31 chronic low back pain patients who were divided into a manual therapy group (MTG; n=16) and a spinal decompression therapy group (SDTG; n=15). [Methods] The MTG was treated using joint mobilization techniques and flexion-distraction techniques, and the SDTG was treated using spinal decompression therapeutic apparatuses. Conservative physical therapy was used in both groups, and the therapy was implemented three times per week for 6 weeks. The visual analog scale (VAS) was used to measure patient's low back pain scores, and a picture archiving and communication system was used to measure disc height by comparing and analyzing the images. [Results] In comparisons of the VAS within each of the two groups, both the MTG and the SDTG showed significant decreases. In comparisons of disc height within each of the two groups, the MTG showed statistically significant increases. [Conclusion] Manual therapy using joint mobilization techniques and flexion-distraction techniques is considered an effective intervention for addressing low back pain and disc heights in patients with chronic low back pain.
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Affiliation(s)
- Jioun Choi
- Department of Rehabilitation Science, Graduate School Daegu University, Republic of Korea
| | - Gak Hwangbo
- Department of Physical Therapy, College of Rehabilitation Science, Daegu University, Republic of Korea
| | - Jungseo Park
- Department of Physical Therapy, Youngdong University, Republic of Korea
| | - Sangyong Lee
- Department of Physical Therapy, Youngdong University, Republic of Korea
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Cambron JA, Schneider M, Dexheimer JM, Iannelli G, Chang M, Terhorst L, Cramer GD. A pilot randomized controlled trial of flexion-distraction dosage for chiropractic treatment of lumbar spinal stenosis. J Manipulative Physiol Ther 2014; 37:396-406. [PMID: 25108751 DOI: 10.1016/j.jmpt.2014.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/20/2014] [Accepted: 05/21/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this pilot clinical trial was to assess the feasibility of recruiting older adults with lumbar spinal stenosis (LSS) into a clinical trial that used different dosages of flexion-distraction manipulation. METHODS This randomized controlled trial used a 4-group design. Three groups consisted of chiropractic flexion-distraction manipulation applied at different dosages (8, 12, or 18 treatments). The fourth group was given 8 treatments of placebo care. Feasibility measures included recruitment goals, adherence to various treatment schedules, credibility of the placebo treatment, and rates of adverse events. The primary outcome measure was the Swiss Spinal Stenosis Questionnaire, a validated self-report of LSS symptom severity and physical function. RESULTS The recruitment and adherence goals of the study were met with a total of 60 subjects randomized (n = 15 per group) and most subjects attending at least 75% of their scheduled visits. No adverse events were reported by any of the subjects in the trial. Our placebo treatment did not appear to be credible; most subjects correctly guessed that they were receiving a placebo treatment. Between-group effect size estimates were small, indicating larger samples are needed for future studies. CONCLUSION This pilot study showed that it is feasible to recruit patients with LSS and that most subjects will adhere to a 6-week treatment schedule. The information gained from this trial will be useful to inform the design of larger trials.
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Affiliation(s)
- Jerrilyn A Cambron
- Professor, Department of Research, National University of Health Sciences, Lombard, IL.
| | - Michael Schneider
- Assistant Professor, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer M Dexheimer
- Clinical Research Coordinator, Department of Research, National University of Health Sciences, Lombard, IL
| | - Grant Iannelli
- Professor of Anatomy and Physiology, ATS Institute of Technology, Chicago, IL
| | - Mabel Chang
- Assistant Professor, Department of Clinical Sciences, National University of Health Sciences, St. Petersburg, FL
| | - Lauren Terhorst
- Assistant Professor, Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Gregory D Cramer
- Dean and Professor, Department of Research, National University of Health Sciences, Lombard, IL
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Gudavalli MR, Cox JM. Real-time force feedback during flexion-distraction procedure for low back pain: A pilot study. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2014; 58:193-200. [PMID: 24932023 PMCID: PMC4025089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A form of chiropractic procedure known as Cox flexion-distraction is used by chiropractors to treat low back pain. Patient lies face down on a specially designed table having a stationery thoracic support and a moveable caudal support for the legs. The Doctor of Chiropractic (DC) holds a manual contact applying forces over the posterior lumbar spine and press down on the moving leg support to create traction effects in the lumbar spine. This paper reports on the development of real-time feedback on the applied forces during the application of the flexion-distraction procedure. In this pilot study we measured the forces applied by experienced DCs as well as novice DCs in using this procedure. After a brief training with real-time feedback novice DCs have improved on the magnitude of the applied forces. This real-time feedback technology is promising to do systematic studies in training DCs during the application of this procedure.
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Affiliation(s)
- Maruti Ram Gudavalli
- Associate Professor, Palmer Center for Chiropractic Research, 741 Brady Street, Tel. (563) 884-5260, Fax (563) 884-5227,
| | - James M Cox
- Cox Chiropractic Medicine Inc, Fort Wayne, IN 46805
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Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: a systematic review. Spine (Phila Pa 1976) 2014; 39:618-29. [PMID: 24480951 DOI: 10.1097/brs.0000000000000231] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To evaluate the quality, conduct, and reporting of subgroup analyses performed in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain (NSLBP). SUMMARY OF BACKGROUND DATA Randomized controlled trials of therapist-delivered interventions for NSLBP to date have, at best, shown small to moderate positive effects. Identifying subgroups is an important research priority. This review evaluates the quality, conduct, and reporting of subgroup analyses performed in the NSLBP literature. METHODS Multiple electronic databases were searched for randomized controlled trials of therapist-delivered interventions for NSLBP. Of the identified articles, only articles reporting subgroup analyses (confirmatory or exploratory) were included in the final review. Methodological criteria were used to evaluate the quality of subgroup analyses. The quality of conduct and reporting was also evaluated. RESULTS Thirty-nine articles were included in the final review. Of these, only 3 (8%) tested hypotheses about moderators (confirmatory findings), 18 (46%) generated hypotheses about moderators to inform future research (exploratory findings), and 18 (46%) provided insufficient findings. The appropriate statistical test for interaction was performed in 27 of the articles, of which 10 reported results from interaction tests, 4 incorrectly reported results within individual subgroups, and the remaining articles reported either P values or nothing at all. CONCLUSION Subgroup analyses performed in NSLBP trials have been severely underpowered, are only able to provide exploratory or insufficient findings, and have rather poor quality of reporting. Using current approaches, few definitive trials of subgrouping in back pain are very likely to be performed. There is a need to develop new approaches to subgroup identification in back pain research.
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Chilibeck PD, Vatanparast H, Cornish SM, Abeysekara S, Charlesworth S. Evidence-based risk assessment and recommendations for physical activity: arthritis, osteoporosis, and low back pain. Appl Physiol Nutr Metab 2013; 36 Suppl 1:S49-79. [PMID: 21800948 DOI: 10.1139/h11-037] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We systematically reviewed the safety of physical activity (PA) for people with arthritis, osteoporosis, and low back pain. We searched PubMed, MEDLINE, Sport Discus, and the Cochrane Central Register of Controlled Trials (1966 through March 2008) for relevant articles on PA and adverse events. A total of 111 articles met our inclusion criteria. The incidence for adverse events during PA was 3.4%-11% (0.06%-2.4% serious adverse events) and included increased joint pain, fracture, and back pain for those with arthritis, osteoporosis, and low back pain, respectively. Recommendations were based on the Appraisal of Guidelines for Research and Evaluation, which applies Levels of Evidence based on type of study ranging from high-quality randomized controlled trials (Level 1) to anecdotal evidence (Level 4) and Grades from A (strong) to C (weak). Our main recommendations are that (i) arthritic patients with highly progressed forms of disease should avoid heavy load-bearing activities, but should participate in non-weight-bearing activities (Level 2, Grade A); and (ii) patients with osteoporosis should avoid trunk flexion (Level 2, Grade A) and powerful twisting of the trunk (Level 3, Grade C); (iii) patients with acute low back pain can safely do preference-based PA (i.e., PA that does not induce pain), including low back extension and flexion (Level 2, Grade B); (iv) arthritic patients with stable disease without progressive joint damage and patients with stable osteoporosis or low back pain can safely perform a variety of progressive aerobic or resistance-training PAs (Level 2, Grades A and B). Overall, the adverse event incidence from reviewed studies was low. PA can safely be done by most individuals with musculoskeletal conditions.
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Affiliation(s)
- Philip D Chilibeck
- College of Kinesiology, University of Saskatchewan, 87 Campus Drive, Saskatoon, SK, Canada.
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Intradiscal Pressure Changes during Manual Cervical Distraction: A Cadaveric Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:954134. [PMID: 24023587 PMCID: PMC3762077 DOI: 10.1155/2013/954134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 07/02/2013] [Accepted: 07/06/2013] [Indexed: 11/18/2022]
Abstract
The objective of this study was to measure intradiscal pressure (IDP) changes in the lower cervical spine during a manual cervical distraction (MCD) procedure. Incisions were made anteriorly, and pressure transducers were inserted into each nucleus at lower cervical discs. Four skilled doctors of chiropractic (DCs) performed MCD procedure on nine specimens in prone position with contacts at C5 or at C6 vertebrae with the headpiece in different positions. IDP changes, traction forces, and manually applied posterior-to-anterior forces were analyzed using descriptive statistics. IDP decreases were observed during MCD procedure at all lower cervical levels C4-C5, C5-C6, and C6-C7. The mean IDP decreases were as high as 168.7 KPa. Mean traction forces were as high as 119.2 N. Posterior-to-anterior forces applied during manual traction were as high as 82.6 N. Intraclinician reliability for IDP decrease was high for all four DCs. While two DCs had high intraclinician reliability for applied traction force, the other two DCs demonstrated only moderate reliability. IDP decreases were greatest during moving flexion and traction. They were progressevely less pronouced with neutral traction, fixed flexion and traction, and generalized traction.
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Wegner I, Widyahening IS, van Tulder MW, Blomberg SEI, de Vet HCW, Brønfort G, Bouter LM, van der Heijden GJ. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev 2013; 2013:CD003010. [PMID: 23959683 PMCID: PMC6823219 DOI: 10.1002/14651858.cd003010.pub5] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Traction has been used to treat low-back pain (LBP), often in combination with other treatments. We included both manual and machine-delivered traction in this review. This is an update of a Cochrane review first published in 1995, and previously updated in 2006. OBJECTIVES To assess the effects of traction compared to placebo, sham traction, reference treatments and no treatment in people with LBP. SEARCH METHODS We searched the Cochrane Back Review Group Specialized Register, the Cochrane Central Register of Controlled Trials (2012, Issue 8), MEDLINE (January 2006 to August 2012), EMBASE (January 2006 to August 2012), CINAHL (January 2006 to August 2012), and reference lists of articles and personal files. The review authors are not aware of any important new randomized controlled trial (RCTs) on this topic since the date of the last search. SELECTION CRITERIA RCTs involving traction to treat acute (less than four weeks' duration), subacute (four to 12 weeks' duration) or chronic (more than 12 weeks' duration) non-specific LBP with or without sciatica. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. As there were insufficient data for statistical pooling, we performed a descriptive analysis. We did not find any case series that identified adverse effects, therefore we evaluated adverse effects that were reported in the included studies. MAIN RESULTS We included 32 RCTs involving 2762 participants in this review. We considered 16 trials, representing 57% of all participants, to have a low risk of bias based on the Cochrane Back Review Group's 'Risk of bias' tool.For people with mixed symptom patterns (acute, subacute and chronic LBP with and without sciatica), there was low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status, global improvement or return to work when compared to placebo, sham traction or no treatment. Similarly, when comparing the combination of physiotherapy plus traction with physiotherapy alone or when comparing traction with other treatments, there was very-low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status or global improvement.For people with LBP with sciatica and acute, subacute or chronic pain, there was low- to moderate-quality evidence that traction probably has no impact on pain intensity, functional status or global improvement. This was true when traction was compared with controls and other treatments, as well as when the combination of traction plus physiotherapy was compared with physiotherapy alone. No studies reported the effect of traction on return to work.For chronic LBP without sciatica, there was moderate-quality evidence that traction probably makes little or no difference in pain intensity when compared with sham treatment. No studies reported on the effect of traction on functional status, global improvement or return to work.Adverse effects were reported in seven of the 32 studies. These included increased pain, aggravation of neurological signs and subsequent surgery. Four studies reported that there were no adverse effects. The remaining studies did not mention adverse effects. AUTHORS' CONCLUSIONS These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias. The effects shown by these studies are small and are not clinically relevant. Implications for practice To date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction. Implications for research Only new, large, high-quality studies may change the point estimate and its accuracy, but it should be noted that such change may not necessarily favour traction. Therefore, little priority should be given to new studies on the effect of traction treatment alone or as part of a package.
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Affiliation(s)
- Inge Wegner
- University Medical Center UtrechtDepartment of Otorhinolaryngology ‐ Head and Neck Surgery; G05.129Heidelberglaan 100UtrechtNetherlands3584 CX
| | - Indah S Widyahening
- Faculty of Medicine Universitas Indonesia ‐ Cipto Mangunkusumo HospitalCentre for Clinical Epidemiology & Evidence‐Based MedicineJakartaIndonesia
| | - Maurits W van Tulder
- VU UniversityDepartment of Health Sciences, Faculty of Earth and Life SciencesPO Box 7057Room U454AmsterdamNetherlands1007 MB
| | - Stefan EI Blomberg
- Department of Public Health and Caring SciencesFamily Medicine SectionUppsala Science ParkUppsalaSwedenSE‐751 85
| | - Henrica CW de Vet
- VU University Medical CenterDepartment of Epidemiology and Biostatistics, EMGO Institute for Health and Care ResearchPO Box 7057AmsterdamNetherlands1007 MB
| | - Gert Brønfort
- Northwestern Health Sciences UniversityWolfe‐Harris Center for Clinical Studies2501 West 84th StreetBloomingtonMNUSA55431
| | - Lex M Bouter
- VU UniversityDe Boelelaan 1105AmsterdamNetherlands1081 HV
| | - Geert J van der Heijden
- Academic Center for Dentistry Amsterdam (ACTA)Department of Social Dentistry5th Floor, Room 5N03Gustav Mahlerlaan 3004AmsterdamNetherlands1081LA
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Abstract
With the rapidly expanding number of studies reporting on treatment subgroups come new challenges in analyzing and interpreting this sometimes complex area of the literature. This article discusses 3 important issues regarding the analysis and interpretation of existing trials or systematic reviews that report on treatment effect modifiers (subgroups) for specific physical therapy interventions. The key messages are: (1) point estimates of treatment modifier effect size (interaction effect) and their confidence intervals can be calculated using group-level data when individual patient-level data are not available; (2) interaction effects do not define the total effect size of the intervention in the subgroup but rather how much more effective it is in the subgroup than in those not in the subgroup; (3) recommendations regarding the use of an intervention in a subgroup need to consider the size and direction of the main effect and the interaction effect; and (4) rather than simply judging whether a treatment modifier effect is clinically important based only on the interaction effect size, a better criterion is to determine whether the combined effect of the interaction effect and main effect makes the difference between an overall effect that is clinically important and one that is not clinically important.
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Cramer GD, Cambron J, Cantu JA, Dexheimer JM, Pocius JD, Gregerson D, Fergus M, McKinnis R, Grieve TJ. Magnetic resonance imaging zygapophyseal joint space changes (gapping) in low back pain patients following spinal manipulation and side-posture positioning: a randomized controlled mechanisms trial with blinding. J Manipulative Physiol Ther 2013; 36:203-17. [PMID: 23648055 DOI: 10.1016/j.jmpt.2013.04.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 02/22/2013] [Accepted: 03/25/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to quantify lumbar zygapophyseal (Z) joint space separation (gapping) in low back pain (LBP) subjects after spinal manipulative therapy (SMT) or side-posture positioning (SPP). METHODS This was a controlled mechanisms trial with randomization and blinding. Acute LBP subjects (N = 112; four n = 28 magnetic resonance imaging [MRI] protocol groups) had 2 MRI appointments (initial enrollment and after 2 weeks of chiropractic treatment, receiving 2 MRI scans of the L4/L5 and L5/S1 Z joints at each MRI appointment. After the first MRI scan of each appointment, subjects were randomized (initial enrollment appointment) or assigned (after 2 weeks of chiropractic treatment appointment) into SPP (nonmanipulation), SMT (manipulation), or control MRI protocol groups. After SPP or SMT, a second MRI was taken. The central anterior-posterior joint space was measured. Difference between most painful side anterior-posterior measurements taken postintervention and preintervention was the Z joint "gapping difference." Gapping differences were compared (analysis of variance) among protocol groups. Secondary measures of pain (visual analog scale, verbal numeric pain rating scale) and function (Bournemouth questionnaire) were assessed. RESULTS Gapping differences were significant at the first (adjusted, P = .009; SPP, 0.66 ± 0.48 mm; SMT, 0.23 ± 0.86; control, 0.18 ± 0.71) and second (adjusted, P = .0005; SPP, 0.65 ± 0.92 mm; SMT, 0.89 ± 0.71; control, 0.35 ± 0.32) MRI appointments. Verbal numeric pain rating scale differences were significant at first MRI appointment (P = .04) with SMT showing the greatest improvement. Visual analog scale and Bournemouth questionnaire improved after 2 weeks of care in all groups (both P < .0001). CONCLUSIONS Side-posture positioning showed greatest gapping at baseline. After 2 weeks, SMT resulted in greatest gapping. Side-posture positioning appeared to have additive therapeutic benefit to SMT.
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Affiliation(s)
- Gregory D Cramer
- Department of Research, National University of Health Sciences, Lombard, IL 60148, USA.
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Kruse RA, Cambron JA. Cox decompression chiropractic manipulation of a patient with postsurgical lumbar fusion: a case report. J Chiropr Med 2013; 10:255-60. [PMID: 22654683 DOI: 10.1016/j.jcm.2011.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 01/11/2011] [Accepted: 01/18/2011] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The purpose of this case report is to describe a patient with an L5/S1 posterior surgical fusion who presented to a chiropractic clinic with subsequent low back and leg pain and was treated with Cox decompression manipulation. CLINICAL FEATURES A 55-year-old male postal clerk presented to a private chiropractic practice with complaints of pain and spasms in his low back radiating down the right buttock and leg. His pain was a 5 of 10, and Oswestry Disability Index score was 18%. The patient reported a previous surgical fusion at L5/S1 for a grade 2 spondylolytic spondylolisthesis. Radiographs revealed surgical hardware extending through the pedicles of L5 and S1, fusing the posterior arches. INTERVENTION AND OUTCOME Treatment consisted of ultrasound, electric stimulation, and Cox decompression manipulation (flexion distraction) to the low back. After 13 treatments, the patient had a complete resolution of his symptoms with a pain score of 0 of 10 and an Oswestry score of 2%. A 2-year follow-up revealed continued resolution of the patient's symptoms. CONCLUSIONS Cox chiropractic decompression manipulation may be an option for patients with back pain subsequent to spinal fusion. More research is needed to verify these results.
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Affiliation(s)
- Ralph A Kruse
- Chiropractic Care, Ltd and Chiropractic Care Millennium Park, Chicago, IL., USA
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Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial. Trials 2013; 14:18. [PMID: 23324133 PMCID: PMC3557195 DOI: 10.1186/1745-6215-14-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 01/03/2013] [Indexed: 12/19/2022] Open
Abstract
Background Low back pain is a prevalent and debilitating condition that affects the health and quality of life of older adults. Older people often consult primary care physicians about back pain, with many also receiving concurrent care from complementary and alternative medicine providers, most commonly doctors of chiropractic. However, a collaborative model of treatment coordination between these two provider groups has yet to be tested. The primary aim of the Collaborative Care for Older Adults Clinical Trial is to develop and evaluate the clinical effectiveness and feasibility of a patient-centered, collaborative care model with family medicine physicians and doctors of chiropractic for the treatment of low back pain in older adults. Methods/design This pragmatic, pilot randomized controlled trial will enroll 120 participants, age 65 years or older with subacute or chronic low back pain lasting at least one month, from a community-based sample in the Quad-Cities, Iowa/Illinois, USA. Eligible participants are allocated in a 1:1:1 ratio to receive 12 weeks of medical care, concurrent medical and chiropractic care, or collaborative medical and chiropractic care. Primary outcomes are self-rated back pain and disability. Secondary outcomes include general and functional health status, symptom bothersomeness, expectations for treatment effectiveness and improvement, fear avoidance behaviors, depression, anxiety, satisfaction, medication use and health care utilization. Treatment safety and adverse events also are monitored. Participant-rated outcome measures are collected via self-reported questionnaires and computer-assisted telephone interviews at baseline, and at 4, 8, 12, 24, 36 and 52 weeks post-randomization. Provider-rated expectations for treatment effectiveness and participant improvement also are evaluated. Process outcomes are assessed through qualitative interviews with study participants and research clinicians, chart audits of progress notes and content analysis of clinical trial notes. Discussion This pragmatic, pilot randomized controlled trial uses a mixed method approach to evaluate the clinical effectiveness, feasibility, and participant and provider perceptions of collaborative care between medical doctors and doctors of chiropractic in the treatment of older adults with low back pain. Trial registration This trial registered in ClinicalTrials.gov on 04 March 2011 with the ID number of NCT01312233.
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Abstract
Complementary and alternative medicine, often referred to as integrated medicine, is often used for the treatment of low back pain. This article presents 6 therapies (ie, behavioral treatment, acupuncture, manipulation, prolotherapy, neuroreflexotherapy, and herbal treatments), which are discussed in terms of the specifics of the modality, as well as the empirical evidence related to their effectiveness.
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Affiliation(s)
- Dan Marlowe
- Department of Applied Psychosocial Medicine, Southern Regional Area Health Education Center, 1601 Owen Drive, Fayetteville, NC 28304, USA.
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Manison AM. Chiropractic management using Cox cervical flexion-distraction technique for a disk herniation with left foraminal narrowing in a 64-year-old man. J Chiropr Med 2012; 10:316-21. [PMID: 22654692 DOI: 10.1016/j.jcm.2011.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/24/2011] [Accepted: 04/30/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The purpose of this case report is to describe chiropractic management of a patient with a C6/C7 left posteromedial disk herniation with foraminal narrowing and concomitant neurological compromise in the form of left upper extremity radiating pain and hypoesthesia/anesthesia using Cox flexion-distraction technique. CLINICAL FEATURES A 64-year-old man presented to a chiropractic clinic with complaints of neck/left shoulder pain and hypoesthesia/anesthesia into the palmar side of his left hand. Magnetic resonance images of the cervical spine revealed a left posteromedial C6/C7 disk herniation along with foraminal narrowing. In addition, there were other levels of degeneration, most noted at the C3/C4 spinal level, which also had significant left-sided foraminal narrowing. INTERVENTION AND OUTCOME Treatment included Cox flexion-distraction protocols aimed to reduce nerve root compression along with supportive physiological therapeutic interventions to aid with pain reduction and functional improvement. The patient was treated a total of 10 times over a course of 4 weeks. The patient reported being pain-free and fully functional 8 months following the conclusion of care. CONCLUSION This case study demonstrated the use of Cox flexion-distraction for treatment of a patient with a cervical disk herniation, foraminal narrowing, and associated radiating pain and radiculopathy in the left upper extremity.
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Rubinstein SM, Terwee CB, de Boer MR, van Tulder MW. Is the methodological quality of trials on spinal manipulative therapy for low-back pain improving? INT J OSTEOPATH MED 2012. [DOI: 10.1016/j.ijosm.2012.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Rowell RM, Rylander SJ. Low-Back Pain, Leg Pain, and Chronic Idiopathic Testicular Pain Treated with Chiropractic Care. J Altern Complement Med 2012; 18:420-2. [DOI: 10.1089/acm.2010.0698] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert M. Rowell
- Diagnosis and Radiology Department, Palmer College of Chiropractic, Davenport, Davenport, IA
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