Chiropractic management of postoperative spine pain: a report of 3 cases

Clinician approaches to spinal manipulation for persistent spinal pain after lumbar surgery: systematic review and meta-analysis of individual patient data

BACKGROUND

This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners.

METHODS

Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval.

RESULTS

71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results.

CONCLUSIONS

Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039).

Physical Therapy Considerations and Recommendations for Patients Following Spinal Cord Stimulator Implant Surgery

OBJECTIVES

Spinal cord stimulation (SCS) is an established therapy option in interventional pain medicine. Recent advances in technology have allowed for greater compliance with treatment and improved efficacy in pain control. This article was proposed to fill the gap in the literature addressing this specific patient population and to facilitate further research. Even though there is a lack of consensus among societies and experts on exact parameters of physical therapy (PT) considerations and postoperative limitations in patients with SCS, we propose rehabilitative care for this population should be standardized. As the number of patients with SCS implants grow, it is vital to understand how to appropriately approach patients with implantable devices when additional treatments such as PT are prescribed.

MATERIALS AND METHODS

A literature search was performed on the use of PT following SCS implantation. Presently, there is no literature to date which addresses the use of PT in this patient population. The lack of data is the largest hurdle in the creation of formal SCS therapy guidelines. The authors therefore proposed recommendations for rehabilitation based upon a detailed understanding of SCS hardware alongside well-studied physiotherapy concepts.

RESULTS

Considerations when initiating PT in the SCS patient population should include: 1) biomechanics and quality of SCS output; 2) therapeutic exercise and spinal manipulation in association with risk for lead migration and fracture; 3) the application of therapeutic modalities and risk for injury to the patient and/or damage to the SCS componentry; and 4) integration of a biopsychosocial, person-centered approach.

CONCLUSIONS

PT treatment protocol in patients with a recently implanted SCS device should be person-centered addressing individual needs, values, and goals. Further research is needed to fully appreciate the impact of an interprofessional approach to management of SCS patients, particularly following stimulator implantation.

Clinical decision-making for spinal manipulation for persistent spinal pain following lumbar surgery: a protocol for a systematic review and meta-analysis of individual participant data

INTRODUCTION

There are limited available research and guidance regarding the use of spinal manipulative therapy (SMT) in patients with low back-related symptoms following lumbar spine surgery, a condition called persistent spinal pain syndrome type 2 (PSPS-2). This publication outlines a review protocol to identify and synthesise individual participant data (IPD) to examine associations between patient, clinical and surgical variables and SMT application in adults with PSPS-2.

METHODS AND ANALYSIS

PubMed, OVID, Web of Science, Scopus, PEDro, Index to Chiropractic Literature and KoreaMed will be searched from inception to 1 January 2022 without language restrictions. Case reports, series, observational studies and cases from grey literature of adults receiving SMT for PSPS-2 will be included. Two investigators will independently screen citations, abstracts and full-text articles. A risk-of-bias assessment will be performed in duplicate to rate cases according to exposure and outcome ascertainment and data completeness. Data extraction will be performed in duplicate and missing IPD will be requested from corresponding authors. Multiple binary logistic regression will be used to identify independent predictors of the use of lumbar-SMT, lumbar-manual-thrust SMT and SMT within 1-year postsurgery. Patient, clinical and surgical variables will be summarised using descriptive statistics, while SMT-related outcomes (lumbar-SMT, lumbar-manual-thrust SMT and 1-year surgery-to-SMT interval) will be described using adjusted ORs with 95% CIs.

ETHICS AND DISSEMINATION

This study was deemed not human subjects research by the University Hospitals' institutional review board. The results of this review will be disseminated at conferences and/or published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021250039.

The Impact of Physical Therapy Following Cervical Spine Surgery for Degenerative Spine Disorders: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To characterize the effects of postoperative physical therapy (PT) after surgery for cervical spondylosis on patient-reported outcomes and impairments. Secondarily, to identify associated complications, adverse effects, and health care costs with postoperative PT, and to describe the content, timing, and duration of the PT.

SUMMARY OF BACKGROUND DATA

Cervical spine surgery is common; however, it is unclear if the addition of postoperative PT leads to improved patient outcomes and decreased health care costs.

MATERIALS AND METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Web of Science were searched until July 2019. All peer-reviewed articles involving cervical spine surgery with postoperative PT for cervical spondylosis were considered for inclusion. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. Findings were described narratively, and GRADE approach was used to define the quality of evidence.

RESULTS

A total of 10,743 studies were screened. Six studies met inclusion criteria; 2 randomized controlled trials and 4 subsequent follow-up studies containing study arms that included postoperative PT after cervical spine surgery. Meta-analysis was not performed due to study heterogeneity and no study compared PT+surgery to surgery alone. PT treatment included exercise therapy, cognitive behavioral therapy, and optional vestibular rehabilitation. Included studies indicated PT appeared to have positive effects on patient outcomes, however, there were no treatment control groups and the quality of evidence was very low to low. Timing, duration, and content of PT programs varied. No studies reported complications, adverse effects, or cost-effectiveness relating to PT after surgery.

CONCLUSIONS

Current literature prevents a definitive conclusion regarding the impact of postoperative PT, given the lack of treatment control groups. PT treatment was limited to exercise therapy, cognitive behavioral therapy, and optional vestibular rehabilitation in the included studies. PT treatment varied, limiting consistent recommendations for content, timing, and treatment duration. Controlled trials are needed to determine the effectiveness of the addition of postoperative PT following cervical spine surgery for cervical spondylosis.

LEVEL OF EVIDENCE

Level II.

Chiropractic Nimmo Receptor-Tonus Technique and McKenzie Self-Therapy Program in the Management of Adjacent Segment Disease: A Case Report

Objective

The objective of the present study objective was to describe adjacent segment disease (ASD) from a chiropractic management prospective and subsequently to stimulate further research into the chiropractic therapeutic effects on such cases and to contribute to chiropractic literature.

Clinical Features

A 44-year-old woman had a history of lumbar stabilization revision operation by pedicle screw fixation for spondylolisthesis. Her intractable back pain episodes, which were diagnosed as ASD, began shortly after this surgery. At presentation, she was taking pregabalin 75 mg 2 times a day for postoperative neuropathic pain without any pain relief. Clinical testing revealed myofascial tender points reproducing the pain.

Intervention and Outcome

After taking the case history and performing a physical examination, the patient was managed with chiropractic Nimmo receptor-tonus technique in combination with McKenzie exercises. Nimmo was applied by manually pressing on clinically relevant points for 5 to 15 seconds in 11 visits over 3 weeks. The patient by herself did McKenzie exercises 5 to 10 times a day for 10 to 12 repetitions over 2 months. After 3 weeks of therapy, visual analog scale and Oswestry Disability Index scores were improved. Furthermore, because of the amelioration of the patient's symptoms, her neurosurgeon successfully discontinued pregabalin 75 mg 2 times a day without negative consequences to care.

Conclusion

As far as the authors are aware, there is currently no published case of ASD care in chiropractic literature. Our rehabilitative management received a favorable response. It can be hypothesized that it offers a perspective that informs improved patient care.

Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review

BACKGROUND AND PURPOSE

Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events.

METHODS

Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events.

RESULTS

Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria.

CONCLUSION

There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.

How manual therapy provided a gateway to a biopsychosocial management approach in an adult with chronic post-surgical low back pain: a case report

BACKGROUND

The management of patients with chronic post-surgical low back pain can be very challenging to surgeons, physiotherapists, and patients alike. Subsequent surgery is often associated with post-operative complications and even lower levels of success than the initial spinal surgery. Physiotherapy is often recommended as the first-line management, however, debate exists amongst physiotherapists regarding the optimal treatment strategy. A key focus of this debate has been the use of manual therapy in chronic pain populations, leading clinicians to reevaluate its use.

CASE DESCRIPTION

A 44-year-old female presented to physiotherapy with a 13-year history of persistent pain, having had a spinal fusion 12 years prior, following a skiing accident. Her primary complaints were pain and decreased self-efficacy. The patient was treated with a 12-week multimodal approach consisting of manual therapy, exercise rehabilitation, and pain neuroscience education.

OUTCOMES

The patient had a significant reduction in the Numerical Pain Rating Scale (NPRS), the Oswestry Disability Index (ODI) and the Fear Avoidance Belief Questionnaire Physical Activity Subscale (FABQ-PA) scores following the intervention. She returned to running and cycling, reporting that pain was something she would 'work with instead of against'.

DISCUSSION

This case study suggests that manual therapy can enhance an individualized biopsychosocial approach in the physiotherapy management of a patient with chronic post-surgical low back pain. Further research is needed to evaluate optimal intervention dosages and effective strategies in the management of patients with chronic low back pain following spinal surgery.

The Variation of Cross-Sectional Area of the Sciatic Nerve in Flexion-Distraction Technique: A Cross-Sectional Study

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.

Neural Mobilization in a 54-Year-Old Woman With Postoperative Spinal Adhesive Arachnoiditis

OBJECTIVE

This case report describes the clinical features, complications, imaging characteristics, and management of postoperative spinal adhesive arachnoiditis.

CLINICAL FEATURES

A 54-year-old woman presented with right posterior thigh and leg pain after a lumbar spine fusion surgery to correct a degenerative spondylolisthesis of L3/4. Her pain was sharp and shooting and worsened with knee extension. A lumbar computed tomography myelogram demonstrated clumping and adhesion of the nerve rootlets in the cauda equina at the surgical fusion levels. Findings were consistent with spinal arachnoiditis.

INTERVENTION AND OUTCOME

The patient was treated with 2 sets of neural mobilization of the sciatic nerve with 15 repetitions each. Treatment was provided 2× per week for 3 weeks. The patient used the neural mobilization exercises at home and performed to tolerance. The patient's Oswestry Questionnaire was reduced significantly by 19% with decreased pain intensity of 2 points on the verbal analogue scale.

CONCLUSION

Neural mobilization was used successfully in the management of a patient with postoperative spinal arachnoiditis.

Chiropractic management of post spinal cord stimulator spine pain: a case report

Background

A brief overview of failed back surgery syndrome, with emphasis on low back pain status post spinal cord stimulation, and post-surgical spinal manipulation is presented.

Case Presentation

Four cases of patients within the VA Connecticut Health Care System presenting between July 2014 and July 2015 reporting low back pain after surgical insertion of spinal cord stimulators are discussed. This study describes the outcomes experienced by four patients with low back pain status post implanted spinal cord stimulators receiving manual therapy in the form of lumbar spine manipulation or mobilization.

Conclusion

All four patients denied adverse effects to spinal manipulation/mobilization and onset of new symptoms after treatment; two patients reported durable reduction in low back pain with increased tolerance to walking, standing, or lying down, one reported temporary relief of low back pain, and one reported no change in symptoms. Further investigation is needed to determine the benefit of spinal manipulation in patients with implanted spinal cord stimulators, but this study has shown the absence of adverse effects from manipulation or mobilization treatment, in regards to SCS.

Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series

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.

Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. A systematic search of Medline, CINAHL, and Index to Chiropractic Literature was performed from inception through April 2015. Thirty articles met inclusion criteria. Studies reporting utilization and policy show that chiropractic services are successfully implemented in various military and veteran health care settings and that integration varies by facility. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.