A Spinal Manipulative Therapy or Lumbar Nerve Root Injections comparative study

Herniated discs, especially those that result in pain down the leg are troubling for  athletes, weekend warriors or just the regular Joe/Jane.  I am sure there are people who avoid seeing a chiropractor because they have been told that they have a herniated disc. They have been told by others that a chiropractic adjustment would make them worse and to not go see one.

I treat people with herniated discs, sciatic, and back pain every day.  This is what I treat the most in my practice.  Spinal Manipulative Therapy, the chiropractic adjustment,  is often a part of a person’s treatment.  It does help and this paper shows that. The paper even shows that spinal manipulation has similar effects to medical procedures.

Should you be exercising when you are feeling sick?

A couple of weeks ago I started to feel ill.  I had a cough and stuffy nose. I caught a cold.  This put a damper on my training.  I took a couple days off from my workouts and on the third day I tried to exercise but with little success.  I felt short of breath. The next day a full blown fever hit me and I couldn’t train at all that day.  Not long after that I received an email from Tribesports.com to contribute to their website and they asked me to write a post on training for sport while sick.  Interesting coincidence.

So should you exercise when you are sick?

Generally speaking if your symptoms are above your neck then moderate training/activity is acceptable during the course of the cold.  

Light to moderate walking during the common cold does not negatively effect the severity or symptoms of sports performance.  Check out http://europepmc.org/abstract/MED/9140895 &
http://europepmc.org/abstract/MED/9813869.  If you have  a runny nose and sore throat without a fever or general body aches and pains then intensive exercise training may be safely resumed a few days after the resolution of symptoms.

If symptoms are below the neck  then don’t train and get to bed!

If you have a flu symptoms, fever, extreme tiredness, muscle aches, dizziness, light-headedness, diarrhea, vomiting, and/or swollen lymph glands, then don’t exercise.  Once the symptoms are gone take 2 to 4 weeks to build up to your previous intense training.

Words of Caution

If you are using a decongestant an increase in heart rate will result in addition to the increase from the workout.  This may lead to shortness of breath and difficulty breathing.  This is why I stopped working out during one of my workouts during my cold.

For those with asthma exercise with cold may worsen your asthma symptoms. Diabetics may also have problems when they are sick.  Being sick results in an increase in blood sugar at rest as well as a decrease in blood sugar during activity.  Monitoring your blood sugar more closely is recommended for diabetics who are sick.

Listen to your body before you decide to train.

Dr Notley
Winnipeg Chiropractor and Athletic Therapist

References:
http://www.acsm.org/docs/current-comments/exerciseandcommoncold.pdf
http://www.medicalnewstoday.com/articles/252516.php
http://www.webmd.com/cold-and-flu/cold-guide/exercise-when-you-have-cold

Conditions Chiropractic May Help: Lower back pain

When you see the word, Chiropractor, there are a number images that people conjure up; both positive and negative.  One of the most common images is the image of back pain.  Back pain is one of the most common ailments that people come in to see me at my chiropractic office.  Spinal manipulation is often used in my treatments, in addition to Active Release Techniques, acupuncture and corrective exercises.

This blog is a continuation of a blog post seeking out the evidence of the above image.  Though I have not found the specific statements in the research regarding the effectiveness of manipulation on lower back pain here is what the evidence says in the literature.

I would like to comment on some of the findings you will read in this post. When a conclusion is made that says that there is no evidence that the treatment is superior to other forms of treatment this doesn’t mean that it is not effective.  What it does mean is that it is equally as effective as those treatments.  That’s a good thing.  It means it is a viable option for care for back pain.

Check out some of the research.  Read the highlights, read the entire abstract or seek out the full paper.  If you have questions seek out further information or just ask and I’ll try and find that information for you.

Dr Notley
Chiropractor and Athletic Therapist in Winnipeg

Lower Back Pain

Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis.

BACKGROUND CONTEXT:
Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain.

PURPOSE:
To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB.
STUDY DESIGN:
RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time).
METHODS:
Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence.

RESULTS:
Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy.

CONCLUSIONS:
Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.

Overall, studies have shown that spinal manipulation is one of several options—including exercise, massage, and physical therapy—that can provide mild-to-moderate relief from low-back pain. Spinal manipulation also appears to work as well as conventional treatments such as applying heat, using a firm mattress, and taking pain-relieving medications.

In 2007 guidelines, the American College of Physicians and the American Pain Society included spinal manipulation as one of several treatment options for practitioners to consider when low-back pain does not improve with self-care. More recently, a 2010 Agency for Healthcare Research and Quality (AHRQ) report noted that complementary health therapies, including spinal manipulation, offer additional options to conventional treatments, which often have limited benefit in managing back and neck pain. The AHRQ analysis also found that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity. However, the researchers noted inconsistent results when they compared spinal manipulation with massage or physical therapy to reduce low-back pain intensity or disability.

Researchers continue to study spinal manipulation for low-back pain.
Researchers are investigating whether the effects of spinal manipulation depend on the length and frequency of treatment. In one study funded by NCCAM that examined long-term effects in more than 600 people with low-back pain, results suggested that chiropractic care involving spinal manipulation was at least as effective as conventional medical care for up to 18 months. However, less than 20 percent of participants in this study were pain free at 18 months, regardless of the type of treatment used.

Researchers are also exploring how spinal manipulation affects the body. In an NCCAM-funded study of a small group of people with low-back pain, spinal manipulation affected pain perception in specific ways that other therapies (stationary bicycle and low-back extension exercises) did not.

A Cochrane review of combined chiropractic interventions for low-back pain.

STUDY DESIGN:
Cochrane systematic review of randomized controlled trials.

OBJECTIVE:
To determine the effects of combined chiropractic interventions on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with low-back pain (LBP).

SUMMARY OF BACKGROUND DATA:
Chiropractors commonly use a combination of interventions to treat people with LBP, but little is known about the effects of this care.

METHODS:
We used a comprehensive search strategy. All randomized trials comparing combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies were included. At least two authors selected studies, assessed bias risk, and extracted data. Descriptive synthesis and meta-analyses were performed.

RESULTS:
We included 12 studies involving 2887 LBP participants. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of subpopulations with LBP. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (standardized mean difference [SMD] -0.25 [95% CI: -0.46 to -0.04] and MD -0.89 [95%CI: -1.60 to -0.18]) compared with other treatments, but there was no significant difference in long-term pain (MD -0.46 [95% CI -1.18 to 0.26]). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 [95% CI: -0.70 to -0.02]). However, the effect was small and studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and studies that had a mixed population of LBP.

CONCLUSION:
Combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.

BACKGROUND:
Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain.
OBJECTIVES:
To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.
SEARCH STRATEGY:
The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened.
SELECTION CRITERIA:
Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure.
DATA COLLECTION AND ANALYSIS:
Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).

MAIN RESULTS:

Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.
REVIEWER’S CONCLUSIONS:
There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Conditions Chiropractic May Help With: Carpal Tunnel and Tennis Elbow

 

Do you have tennis elbow or carpal tunnel? Have you been trying other forms of care without success?  Chiropractic manipulation is one of the tools that I use to successfully treat these ailments.
This blog is a continuation of a blog post seeking out the evidence of the above image.  Though I have not found the specific statements in the research regarding the effectiveness of manipulation on tennis elbow and carpal tunnel here is what the evidence says in the literature.
Tennis Elbow
Manipulation of the Wrist for Management of Lateral Epicondylitis: A Randomized Pilot Study

Background and Purpose. Lateral epicondylitis (“tennis elbow”) is a common entity. Several nonoperative interventions, with varying success rates, have been described. The aim of this study was to compare the effectiveness of 2 protocols for the management of lateral epicondylitis: (1) manipulation of the wrist and (2) ultrasound, friction massage, and muscle stretching and strengthening exercises.

Subjects and Methods. Thirty-one subjects with a history and examination results consistent with lateral epicondylitis participated in the study. The subjects were randomly assigned to either a group that received manipulation of the wrist (group 1) or a group that received ultrasound, friction massage, and muscle stretching and strengthening exercises (group 2). Three subjects were lost to follow-up, leaving 28 subjects for analysis. Follow-up was at 3 and 6 weeks. The primary outcome measure was a global measure of improvement, as assessed on a 6-point scale. Analysis was performed using independent t tests, Mann-Whitney U tests, and Fisher exact tests.

Results. Differences were found for 2 outcome measures: success rate at 3 weeks and decrease in pain at 6 weeks. Both findings indicated manipulation was more effective than the other protocol. After 3 weeks of intervention, the success rate in group 1 was 62%, as compared with 20% in group 2. After 6 weeks of intervention, improvement in pain as measured on an 11-point numeric scale was 5.2 (SD=2.4) in group 1, as compared with 3.2 (SD=2.1) in group 2.

Discussion and Conclusion. Manipulation of the wrist appeared to be more effective than ultrasound, friction massage, and muscle stretching and strengthening exercises for the management of lateral epicondylitis when there was a short-term follow-up. However, replication of our results is needed in a large-scale randomized clinical trial with a control group and a longer-term follow-up.

Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia 
note: I am unable to read a full copy of this paper therefore I do not know the “specific manipulative treatment”.

The treatment of lateral epicondylalgia, a widely-used model of musculoskeletal pain in the evaluation of many physical therapy treatments, remains somewhat of an enigma. The protagonists of a new treatment technique for lateral epicondylalgia report that it produces substantial and rapid pain relief, despite a lack of experimental evidence. A randomized, double blind, placebo-controlled repeated-measures study evaluated the initial effect of this new treatment in 24 patients with unilateral, chronic lateral epicondylalgia. Pain-free grip strength was assessed as an outcome measure before, during and after the application of the treatment, placebo and control conditions. Pressure-pain thresholds were also measured before and after the application of treatment, placebo and control conditions. The results demonstrated a significant and substantial increase in pain-free grip strength of 58% (of the order of 60 N) during treatment but not during placebo and control. In contrast, the 10% change in pressure-pain threshold after treatment, although significantly greater than placebo and control, was substantially smaller than the change demonstrated for pain-free grip strength. This effect was only present in the affected limb. The selective and specific effect of this treatment technique provides a valuable insight into the physical modulation of musculoskeletal pain and requires further investigation.

Carpal Tunnel Syndrome
An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome.

Carpal tunnel syndrome is the most common peripheral entrapment neuropathy. There is little literature available that addresses the management of this condition, which may partly explain why physiotherapy is often overlooked as a treatment approach in its management. This study investigated the effects of two manual therapy techniques in the treatment of patients experiencing carpal tunnel syndrome. An experimental different subject design compared three groups of subjects in three different conditions (two treatment interventions and one control group). Each group consisted of seven patients. The objectives of the study were: (1) to investigate differences between treated and untreated groups; (2) to investigate differences in the effectiveness of treatment I (median nerve mobilization) compared with treatment II (carpal bone mobilization). Measurements were taken applying several measurement tools, including active range of wrist movement (ROM flexion and extension), upper limb tension test with a median nerve bias (ULTT2a), three different scales to evaluate pain perception and function, and lastly numbers of patients continuing to surgery in each group were compared. In visual terms a clear trend was demonstrated between subjects who received treatment compared to those who were not treated, in particular the descriptive analysis of results for ULTT2a and numbers of patients continuing to surgery. When analysed statistically, less could be concluded. Only scores on a Pain Relief Scale (P<0.01) demonstrated highly significant differences between the three groups when analyzed using Kruskal-Wallis Test. In exploring the results of the two intervention groups, no statistically significant difference in effectiveness of treatment was demonstrated between carpal bone mobilization and median nerve mobilization.

Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trail.

OBJECTIVE: To compare the efficacy of conservative medical care with chiropractic care in the treatment of carpal tunnel syndrome.

DESIGN: Two-group, randomized, single-blind trial with 9 wk of treatment and a 1-month follow-up interview.

SETTING: Wolfe-Harris Center for Clinical Studies at Northwestern College of Chiropractic in Bloomington, Minnesota.

PATIENTS: Ninety-one of 96 eligible subjects who reported symptoms that were confirmed by clinical exam and nerve conduction studies.

INTERVENTIONS: Interventions included ibuprofen (800 mg 3 times a day for 1 wk, 800 mg twice a day for 1 wk and 800 mg as needed to a maximum daily dose of 2400 mg for 7 wk) and nocturnal wrist supports for medical treatment. Chiropractic treatment included manipulation of the soft tissues and bony joints of the upper extremities and spine (three treatments/week for 2 wk, two treatments/week for 3 wk and one treatment/week for 4 wk), ultrasound over the carpal tunnel and nocturnal wrist supports.

MAIN OUTCOME MEASURES: Outcome measures were pre- and postassessments of self-reported physical and mental distress, nerve conduction studies and vibrometry.

RESULTS: There was significant improvement in perceived comfort and function, nerve conduction and finger sensation overall, but no significant differences between groups in the efficacy of either treatment.

CONCLUSIONS: Carpal tunnel syndrome associated with median nerve demyelination but not axonal degeneration may be treated with commonly used components of conservative medical or chiropractic care.

OBJECTIVE: To determine if chiropractic manipulation could relieve carpal tunnel syndrome (CTS).
CLINICAL FEATURES: A 42-yr-old female suffered from pain, tingling and numbness in the right wrist. Paresthesia along the C6 dermatome, a positive Phalen’s test and Tinel’s sign was present. EMG testing confirmed the clinical diagnosis of CTS.
INTERVENTION AND OUTCOME: Chiropractic manipulations were rendered 3 times per week for 4 wk, to the subject’s cervical spine, right elbow and wrist using a low amplitude, short lever, low force, high velocity thrust. Significant increase in grip strength and normalization of motor and sensory latencies were noted. Orthopedic tests were negative. Symptoms dissipated.
CONCLUSION: In this case study, chiropractic made a demonstrable difference through objective and subjective outcomes. Further investigations using double-blind, cross-over designs with larger samples are warranted.

I hope you found this interesting.

Dr Notley
Chiropractor and Athletic Therapist of Winnipeg

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Conditions Chiropractic May Help With: Chronic Neck Pain