Manipulation and mobilization in the treatment of chronic pain

Effects of lower limb neurodynamic mobilization on intraneural fluid dispersion of the fourth lumbar nerve root: an unembalmed cadaveric investigation

OBJECTIVES

Manual and physical therapists incorporate neurodynamic mobilisation (NDM) to improve function and decrease pain. Little is known about the mechanisms by which these interventions affect neural tissue. The objective of this research was to assess the effects of repetitive straight leg raise (SLR) NDM on the fluid dynamics within the fourth lumbar nerve root in unembalmed cadavers.

METHODS

A biomimetic solution (Toluidine Blue Stock 1% and Plasma) was injected intraneurally, deep to the epineurium, into the L4 nerve roots of seven unembalmed cadavers. The initial dye spread was allowed to stabilise and measured with a digital calliper. Once the initial longitudinal dye spread stabilised, an intervention strategy (repetitive SLR) was applied incorporating NDMs (stretch/relax cycles) at a rate of 30 repetitions per minute for 5 minutes. Post-intervention calliper measurements of the longitudinal dye spread were measured.

RESULTS

The mean experimental posttest longitudinal dye spread measurement (1.1 ± 0.9 mm) was significantly greater (P = 0.02) than the initial stabilised pretest longitudinal dye spread measurement. Increases ranged from 0.0 to 2.6 mm and represented an average of 7.9% and up to an 18.1% increase in longitudinal dye spread.

DISCUSSION

Passive NDM in the form of repetitive SLR induced a significant increase in longitudinal fluid dispersion in the L4 nerve root of human cadaveric specimen. Lower limb NDM may be beneficial in promoting nerve function by limiting or altering intraneural fluid accumulation within the nerve root, thus preventing the adverse effects of intraneural oedema.

Identifying and treating the causes of neck pain

Future studies are needed to further understand the pathophysiology of mechanical neck pain. Robust scientific evidence is sparse on which noninvasive treatments are the most beneficial and how to better select patients for particular noninvasive or invasive treatments.

Acupuncture and chiropractic care for chronic pain in an integrated health plan: a mixed methods study

BACKGROUND

Substantial recent research examines the efficacy of many types of complementary and alternative (CAM) therapies. However, outcomes associated with the "real-world" use of CAM has been largely overlooked, despite calls for CAM therapies to be studied in the manner in which they are practiced. Americans seek CAM treatments far more often for chronic musculoskeletal pain (CMP) than for any other condition. Among CAM treatments for CMP, acupuncture and chiropractic (A/C) care are among those with the highest acceptance by physician groups and the best evidence to support their use. Further, recent alarming increases in delivery of opioid treatment and surgical interventions for chronic pain--despite their high costs, potential adverse effects, and modest efficacy--suggests the need to evaluate real world outcomes associated with promising non-pharmacological/non-surgical CAM treatments for CMP, which are often well accepted by patients and increasingly used in the community.

METHODS/DESIGN

This multi-phase, mixed methods study will: (1) conduct a retrospective study using information from electronic medical records (EMRs) of a large HMO to identify unique clusters of patients with CMP (e.g., those with differing demographics, histories of pain condition, use of allopathic and CAM health services, and comorbidity profiles) that may be associated with different propensities for A/C utilization and/or differential outcomes associated with such care; (2) use qualitative interviews to explore allopathic providers' recommendations for A/C and patients' decisions to pursue and retain CAM care; and (3) prospectively evaluate health services/costs and broader clinical and functional outcomes associated with the receipt of A/C relative to carefully matched comparison participants receiving traditional CMP services. Sensitivity analyses will compare methods relying solely on EMR-derived data versus analyses supplementing EMR data with conventionally collected patient and clinician data.

DISCUSSION

Successful completion of these aggregate aims will provide an evaluation of outcomes associated with the real-world use of A/C services. The trio of retrospective, qualitative, and prospective study will also provide a clearer understanding of the decision-making processes behind the use of A/C for CMP and a transportable methodology that can be applied to other health care settings, CAM treatments, and clinical populations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01345409.

Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized controlled trials of a single session

We report a systematic analysis of group change scores of subjects with chronic neck pain not due to whiplash and without headache or arm pain, in randomized clinical trials of a single session of manual therapy. A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2006 was conducted. Trials that scored above 60% on the PEDro Scale were included. Change scores were analyzed for absolute, percentage change and effect size (ES) whenever possible. Nine trials were identified: 6 for spinal manipulation, 4 for spinal mobilization or non-manipulative manual therapy (2 overlapping trials), and 1 trial using ischemic compression. No trials were identified for massage therapy or manual traction. Four manipulation trials (five groups) reported mean immediate changes in 100-mm VAS of -18.94 (9.28) mm. ES for these changes ranged from .33 to 2.3. Two mobilization trials reported immediate VAS changes of -11.5 and -4 mm (ES of .36 and .22, respectively); one trial reported no difference in immediate pain scores versus sham mobilization. The ischemic compression study showed statistically significant immediate decreases in 100-mm pain VAS (average = -14.6 mm). There is moderate-to-high quality evidence that immediate clinically important improvements are obtained from a single session of spinal manipulation. The evidence for mobilization is less substantial, with fewer studies reporting smaller immediate changes. There is insufficient evidence for ischemic compression to draw conclusions. There is no evidence for a single session of massage or manual traction for chronic neck pain.

Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials

OBJECTIVE

This study provides a systematic analysis of group change scores in randomized clinical trials of chronic neck pain not due to whiplash and not including headache or arm pain treated with manual therapy.

METHODS

A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2005. Only clinical trials scoring above 11.5 (Amsterdam-Maastricht Scale) were included in the analysis.

RESULTS

From 1980 citations, 19 publications were selected. Of the 16 trials analyzed (3 were rejected for poor quality), 9 involved spinal manipulation (12 groups), 5 trials (5 groups) were for spinal mobilization or nonmanipulative manual therapy (1 trial overlapped), and 2 trials (2 groups) involved massage therapy. No trials included trigger point therapy or manual traction of the neck. For manipulation studies, the mean effect size (ES) at 6 weeks for 7 trials (10 groups) was 1.63 (95% confidence interval [CI], 1.13-2.13); 1.56 (95% CI, 0.73-2.39) at 12 weeks for 4 trials (5 groups); 1.22 (95% CI, 0.38-2.06) from 52 to 104 weeks for 2 trials (2 groups). For mobilization studies, 1 trial reported an ES of 2.5 at 6 weeks, 2 trials reported full recovery in 63.8% to 71.7% of subjects at 7 to 52 weeks, and 1 trial reported greater than 2/10 point pain score reduction in 78.3% of subjects at 4 weeks. For massage studies, 1 reported an ES of 0.03 at 6 weeks, whereas the other reported mean change scores of 7.89/100 and 14.4/100 at 1 and 12 weeks of, respectively.

CONCLUSIONS

There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment. The current evidence does not support a similar level of benefit from massage.

A systematic review of conservative treatments for acute neck pain not due to whiplash

OBJECTIVE

To identify the evidence base of clinical trials of conservative treatments for acute neck pain not due to whiplash injury.

DESIGN AND SETTING

A comprehensive literature search was performed in MEDLINE, CINHAHL, AMED, MANTIS, Index to Chiropractic Literature, Alt HealthWatch, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Registry, and several EBSCO Information Services databases. Systematic retrieval and evaluation procedures were used.

RESULTS

The search generated 1980 citations. Four trials (5 publications) were accepted according to the inclusion/exclusion criteria. Three trials used a form of spinal manual therapy. One of these trials used only one manipulation and reported immediate effects on pain, with real manipulation producing significantly greater pain reduction than control procedure. The other 2 of these trials reported on outcomes over 1 to 3 weeks. In 1 trial, the group receiving manipulation showed significantly greater pain reduction at 1 week than did the group receiving only medication. In the other trial, the group receiving transcutaneous electrical nerve stimulation had a significantly greater level of pain reduction at 3 weeks. In the fourth trial, exercise was compared to passive physiotherapy; however, outcomes were not reported until 6 and 12 months, so the results cannot be compared to the natural history of acute neck pain not due to whiplash.

CONCLUSION

There is limited evidence of the benefit of spinal manipulation and transcutaneous electrical nerve stimulation in the treatment of acute neck pain not due to whiplash injury. There is a dearth of high-quality clinical trials of conservative treatments for this condition.

A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain

Many clinical trials on chiropractic management of low back pain have neglected to include specific forms of care. This study compared two well-defined treatment protocols. The objective was to compare the outcome of flexion-distraction (FD) procedures performed by chiropractors with an active trunk exercise protocol (ATEP) performed by physical therapists. A randomized clinical trial study design was used. Subjects, 18 years of age and older, with a primary complaint of low back pain (>3 months) were recruited. A 100 mm visual analogue scale (VAS) for perceived pain, the Roland Morris (RM) Questionnaire for low back function, and the SF-36 for overall health status served as primary outcome measures. Subjects were randomly allocated to receive either FD or ATEP. The FD intervention consisted of the application of flexion and traction applied to specific regions in the low back, with the aid of a specially designed manipulation table. The ATEP intervention included stabilizing and flexibility exercises, the use of modalities, and cardiovascular training. A total of 235 subjects met the inclusion/exclusion criteria and signed the informed consent. Of these, 123 were randomly allocated to FD and 112 to the ATEP. Study patients perceived significantly less pain and better function after intervention, regardless of which group they were allocated to (P<0.01). Subjects randomly allocated to the flexion-distraction group had significantly greater relief from pain than those allocated to the exercise program (P=0.01). Subgroup analysis indicated that subjects categorized as chronic, with moderate to severe symptoms, improved most with the flexion-distraction protocol. Subjects categorized with recurrent pain and moderate to severe symptoms improved most with the exercise program. Patients with radiculopathy did significantly better with FD. There were no significant differences between groups on the Roland Morris and SF-36 outcome measures. Overall, flexion-distraction provided more pain relief than active exercise; however, these results varied based on stratification of patients with and without radiculopathy and with and without recurrent symptoms. The subgroup analysis provides a possible explanation for contrasting results among randomized clinical trials of chronic low back pain treatments and these results also provide guidance for future work in the treatment of chronic low back pain.

Dose-response for chiropractic care of chronic low back pain

BACKGROUND CONTEXT

There have been no trials of optimal chiropractic care in terms of number of office visits for spinal manipulation and other therapeutic modalities.

PURPOSE

To conduct a pilot study to make preliminary identification of the effects of number of chiropractic treatment visits for manipulation with and without physical modalities (PM) on chronic low back pain and disability.

STUDY DESIGN/SETTING

Randomized controlled trial with a balanced 4x2 factorial design. Conducted in the faculty practice of a chiropractic college outpatient clinic.

PATIENT SAMPLE

Seventy-two patients with chronic, nonspecific low back pain of mechanical origin.

MAIN OUTCOME MEASURES

Von Korff pain and disability (100-point) scales.

METHODS

Patients were randomly allocated to visits (1, 2, 3 or 4 visits/week for 3 weeks) and to treatment regimen (spinal manipulation only or spinal manipulation with PM). All patients received high-velocity low-amplitude spinal manipulation. Half received one or two of the following PM at each visit: soft tissue therapy, hot packs, electrotherapy or ultrasound.

RESULTS

Pain intensity: At 4 weeks, there was a substantial linear effect of visits favoring a larger number of visits: 5.7 points per 3 visits (SE=2.3, p=.014). There was no effect of treatment regimen. At 12 weeks, the data suggested the potential for a similar effect of visits on patients receiving both manipulation and PM. Functional disability: At 4 weeks, a visits effect was noted (p=.018); the slope for group means was approximately 5 points per 3 visits. There were no group differences at 12 weeks.

CONCLUSIONS

There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.

A Practice-Based Study of Patients with Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-Week to 48-Month Follow-Up

OBJECTIVE

This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain (LBP) and assesses the influence of doctor type and pain duration on clinical outcomes.

DESIGN

Prospective, longitudinal, nonrandomized, practice-based, observational study.

SETTING

Fifty-one chiropractic and 14 general practice community clinics.

SUBJECTS

A total of 2870 acute and chronic ambulatory patients with LBP of mechanical origin.

METHODS

Sixty chiropractic (DC) and 111 general practice (MD) physicians participated. Primary outcomes were pain, using a 100-point visual analogue scale (VAS), and functional disability, using the Revised Oswestry Disability Questionnaire. These were measured at baseline and 8 time points. Regression analysis compared acute and chronic DC and MD patients after correcting for baseline differences in the 4 cohorts.

RESULTS

Most improvement was seen by 3 months and sustained for 1 year; exacerbation was seen thereafter. Acute patients demonstrated greater relief at all time points. A clinically important advantage for chiropractic patients was seen in chronic patients in the short-term (>10 VAS points), and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year (P<.000). The advantage for DC care was prominent for chronic patients with leg pain below the knee (P<.001). More than 50% of chronic patients had over 50 days of pain in the third year.

CONCLUSION

Study findings were consistent with systematic reviews of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP. Patient choice and interdisciplinary referral should be prime considerations by physicians, policymakers, and third-party payers in identifying health services for patients with LBP.

Alternative therapies in the management of headache and facial pain

Complementary therapies are now becoming the rule rather than the exception in the management of headache and facial pain. It is incumbent on physicians to be aware of and to have a working knowledge of these increasingly popular modalities.