Chiropractic, Spinal Stenosis, Back Pain

Lumbar spinal stenosis (LSS) is a serious health problem, especially among the elderly. “Spinal stenosis has been defined as any narrowing of the spinal canal or the various tunnels through which nerves and other structures communicate with that canal.” 1 The most common symptoms of LSS are:

  • Pain and numbness in the low back.
  • Pain and numbness in the legs and buttocks.
  • Symptoms are usually worse after walking or extension of the lumbar spine.
  • Symptoms improve with flexion of the lower back.

The authors of a new study2 discuss the problem of LSS:

“LSS is one of the most common reasons for spine surgery in older people, although little is known about the efficacy of surgical management of patients with LSS, particularly compared to non-surgical management. It is generally felt that most patients with LSS should be managed non-surgically before considering surgical intervention, but little is also known about what non-surgical approaches are most efficacious.”

The researchers set out to determine if chiropractic is beneficial for these patients. They studied 55 patients with LSS diagnosed by MRI or CT scans. Each patient was given questionnaires to determine disability and pain intensity before treatment and at a 16-month follow-up. In addition, the subjects were questioned regarding improvement every 3 to 4 weeks during treatment.

The patients were treated with the following techniques:

  • Distraction Manipulation (DM) – a technique where the patient lies prone on a table that “allows for distraction of the spine through inferiorforward and flexion movement of the lower body.”
  • Neural Mobilization (NM) – “a manual and exercise oriented method that is theorized to mobilize nerve roots that are suspected to be the source of nerve root pain.”

Patients were given individual treatment plans, but generally were seen 2-3 times per week for three weeks, then one or two times a week after that. The average number of treatments was 13.3.

The authors reported the following findings at the completion of treatment:

  • The average patient-rated improvement was 65.1% from baseline to the end of treatment.
  • The average patient improvement in disability was 5.1 points on the Roland Morris Back Pain and Disability (RM) questionnaire.
  • There were also significant improvements in “worst pain.”

At the 16 month follow-up:

  • The average patient-rated improvement was 75.6%.
  • The average improvement in disability was 5.2 points on the RM.
  • “Clinically meaningful improvement in disability was seen in 73.2% of patients.”
  • The average improvement in “on average pain” was 3.0 points on the RM.
  • The average improvement in “at worst pain” was 4.2 points on the RM.
  • Only two patients needed surgery by the 16 month follow-up.

Other studies have looked at the natural course of LSS with conservative treatment, and it appears from this study that chiropractic may be more effective than other treatments. A 1996 study3 found that “non-surgical” treatment resulted in improvement of only 1.6 points on the RM after one year.

The authors conclude:

“The combination of DM and NM may be a safe and effective approach for patients with LSS. Because the sample size is relatively small and there is no control group, firm conclusions regarding this cannot be drawn. The outcome of this approach compares favorably with other non-surgical treatments, and treatment with DM and NM may be a viable non-surgical option before considering surgery for LSS.”

    1. Nowakowski P, Delitto A, Erhard RE. Lumbar spinal stenosis. Physical Therapy 1996;76:187-190.
    2. Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study. BMC Musculoskeletal Disorders 2006;7:16.
    3. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study. Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine 1996;21:1787-1795.

Chiropractic, Back Pain, Disc Herniation

Chiropractic and disc herniationOver the last few years, it has been recognized in the medical literature that conservative treatment works best for many cases of lumbar disc herniation. For patients with far-lateral, or extreme lateral herniation, however, the effectiveness of conservative care is less certain. This recent case study looked at the outcomes of nonsurgical management of a client with far-lateral disc herniation.

The 60-year-old male client was physically active, and had been seen at a Spine Specialty Center previously for treatment for lower back pain, which resolved. 15 months later, he presented at the Center again with severe back pain (present for 3 weeks), with pain radiating to his right buttock and calf.

Presenting Symptoms:

  • Score of 73 (out of 100) on the Oswestry Low Back Questionnaire, and Numerical Pain Ratings of 6 (best) to 10 (worst) on a 1-10 scale.
  • Difficulty transitioning from sitting to standing
  • Altered gait
  • Inability to assume erect position
  • Lateral list to left
  • Asymmetric static pelvic landmarks (right iliac crest 4 degrees high posteriorly, 2 degrees high anteriorly with standing).
  • Pain on right side with lateral and backward bends

Initial treatment included manipulation, traction, and passive movements. This was followed up by instruction in self-correction exercises to be followed at home.

Follow-up consisted of:

2 days later: More traction/passive movement and gradual increase in weight bearing, and the patient was fitted with a back brace.

6 days later: manipulation was performed and the patient returned to work part-time. A MRI and surgical consult were also requested during this fourth visit.

The lumbar MRI showed a lateral L5, S1 disc rupture with L5 nerve impingement; due to patient improvement, surgery was deferred. The patient was at work full-time, with his primary complaint sitting intolerance. With consultation, 1 week later a CT-guided transforaminal lumbar epidural and nerve root steroid injection were performed. Three days later, leg pain was reduced and the patient was sleeping better, was working full-time, and was driving.

The patient was then referred to physical therapy for further rehabilitation.

By the end of 4 weeks of physical therapy—8 weeks after being seen initially for the herniation—the patient had achieved scores of 0 on the Numeric Pain Scale, and of 2 (out of 100) on the Oswestry Low Back Pain Questionnaire.

During 2 follow-up visits at 14 weeks and 20 weeks after the initial complaint, all scores were 0. The patient was exercising by running or alternatively using a stair climbing machine with no pain, and continuing his stabilization exercises. He was asymptomatic 1 year later at follow-up.

The study authors also note that this patient responded well to nonsurgical intervention, but was very fit, motivated, and compliant with treatment. The case study did demonstrate the fact that a multi-disciplinary approach to treatment seems most effective: from manipulation and passive motion/traction, to epidural steroid injection once the effectiveness of these first interventions had plateaued, followed up by physical therapy and ongoing exercises.

Erhard RE, Welch WC, Liu B, Vignovi M. Far-lateral disk herniation: case report, review of the literature, and a description of nonsurgical management. Journal of Manipulative and Physiological Therapeutics 2004;27:e3.

Chiropractic, Neck Pain, Disc Herniation

This study examined 27 patients in a private chiropractic practice who presented with neck or back pain and who had MRI-documented cervical or lumbar disc herniations that corresponded with clinical findings.

“Patients were treated with a course of chiropractic care consisting of traction for the cervical spine or flexion distraction in the lumbar spine in the acute phase of care, in addition to interferential/ultrasound combination and cryotherapy. In the subacute phase, rotational manipulation was judiciously added, as were isometric and flexibility exercises. In the chronic stage of care, distraction manipulation and rehabilitative exercises were continually employed. Rehabilitative exercise included extension exercises in addition to pelvic tilts, lifts and knee flexion stretching.”

“Treatment frequency was typically four to five times/wk for weeks 1 and 2, then three times/wk with decreasing frequency as the patient progressed. Duration of active care varied from 6 wk to 6 months.”

“When patients reached the point at which their VAS [visual analog scale] score was ?2, their exam findings reversed and their extremity pain resolved, a repeat MRI was obtained. This scenario occurred as early as 6 wk after initiation of care.”

If the patients did not reach these milestones, follow-up MRI was performed 1 year after the initiation of care.

The study found that 22 of 27 (80%) had good clinical outcomes; 17 of the 22 (77%) “had not only good clinical outcome but also evidence of reduced or resolved disc herniation upon repeat MRI scanning.”

Five patients (18.5%) had a marginal or poor outcome, but none had worse clinical signs or pain ratings at the end of the study.
At the beginning of the study, all 27 patients had left work because of the severity of the pain; at follow-up, 21 (78%) were back to work in their former occupations.

VAS scores decreased from an average of 6.9 before treatment to 1.9 following treatment.

One important issue that the author addresses is the controversy of whether manipulation is contraindicated for disc herniation. After reviewing the literature, and from his clinical findings, he concludes that manipulation is indeed safe for disc herniation: “…in the cervical and lumbar spine, rotational manipulation most likely cannot be implicated in disc failure or exacerbation of a disc herniation, and for rotational forces from a manipulation to be involved in disc failure, facet fracture must occur first.” No complications occurred in this study.

BenEliyahu DJ. Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. Journal of Manipulative and Physiological Therapeutics 1996;19(9):597-606.

MRI Unreliable For Diagnosing Sciatica

Sciatica is a relatively common medical condition, affecting an estimated 13-40% of people during their lifetime. The most common cause is a herniated disc. Magnetic resonance imaging (MRI) is frequently used to examine patients with sciatica symptoms and lumbar-disc herniation.

However, the link between MRI findings and clinical outcome is controversial. Several studies have shown a high rate of disc herniation in people who have no symptoms. This has led some researchers to question the value of MRIs for sciatica patients, given the high rate of MRI abnormalities found in patients with no pain. Abnormal MRI findings often result in invasive procedures such as surgical treatment or epidural injections, despite the debate over the value of MRI findings.

A recent study sought to add to the understanding of MRI imaging for sciatica patients. The study involved 283 patients, all of whom underwent MRI at the start of the study and after one year. The researchers assessed the MRI for visible disc herniation.

After one year, 84% of patients reported a favorable outcome. Disc herniation was visible in the MRI images of 35% of patients who reported a favorable outcome, and 33% with an unfavorable outcome.

Therefore, MRI assessment of disc herniation after one year did not appear to be effective at distinguishing patients with a favorable outcome and those with an unfavorable outcome. Further research is needed in order to fully assess the value of MRI in making clinical decisions for patients with persistent sciatica.

Reference

el Barzouhi A, et al. Magnetic resonance imaging in follow-up assessment of sciatica. New England Journal of Medicine 2013; 368(11):999-1007. doi: 10.1056/NEJMoa1209250.

Chiropractic Safe and Effective for Back Pain During Pregnancy

Low back pain can be a serious problem during pregnancy: studies show that over half of women report back pain at some point during pregnancy. Furthermore, as a new study1 explains, many women experience their first episode of back pain during pregnancy:

“The incidence of low back pain with an onset during pregnancy has been reported to be 61%. It has been shown that among women with low back pain of pregnancy, 75% reported no low back pain before pregnancy. In a study of women with chronic low back pain, up to 28% stated that their first episode of back pain occurred during a pregnancy.”

In this report, the authors studied 17 women with low back pain lasting an average of 21.7 days. The intensity of the back pain was 5.9 on a 1-10 scale, and the onset of pain occurred at 20.6 weeks into the pregnancy.

Each study participant was treated according to the particular symptoms that the patient was experiencing. The authors reported the following:

  • About half of the women were self-referred, and the other half were referred by their obstetrician.
  • The average time to reach clinically significant pain relief was 4.5 days, while the range was from 0 to 13 days after the initial treatment.
  • The average number of treatments necessary to reach clinically relevant pain relief was 1.8.
  • The pain levels decreased from the 5.9 at the beginning of the study to 1.5 at the end.
  • The patients received between 3 to 15 treatments, with the average being 5.6.
  • One patient did not experience clinically significant pain reduction.
  • There were no adverse reactions reported by any of the patients.

Low back pain during pregnancy may not seem like a serious problem, but it can have adverse affects on the woman’s health, as the authors explain:

“In most instances, the average pain level is moderate, but severe pain has been reported in 15% of cases. Pain intensity often increases with duration and can result in significant disability. Sleep disturbances have been reported by 49% to 58% of women and impaired daily living by 57% in women with low back pain of pregnancy.

“Despite the apparent impact it has on women, many cases of low back pain of pregnancy go unreported to prenatal providers and/or untreated. Wang et al. found that just 32% of women reported their low back pain of pregnancy to their prenatal providers, and just 25% of these providers recommended a treatment. Skaggs et al. found that among women with low back pain of pregnancy, 80% thought that their providers had not offered treatment for their back pain.”

This study shows that chiropractic effectively reduced pain from low back pain during pregnancy, without any adverse effects.

Lisi AJ. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. Journal of Midwifery & Women’s Health 2006;51:e7-e10.

Chiropractic, Low Back Pain, Neck Pain

Over the last few years, there have been increasing pressures to reduce the costs associated with treating low back pain, while, at the same time, increasing the effectiveness of that treatment. A recent study1 sums up the problem:

“A growing body of clinical evidence and expert opinion indicates that a more conservative approach to the treatment of low back pain and cervical spine pain is appropriate. The evidence indicates that procedures and practices such as inpatient care, advanced imaging, surgery, and even plain-film radiographs are only infrequently necessary for the successful treatment of most cases of low back pain and neck pain.

“In spite of the evidence, these procedures and practices continue to be used at rates in excess of that which the published literature defines as clinically indicated.”

Previous studies have found that chiropractic adjustments can be an effective treatment modality for certain types of low back and neck pain. In this current study, the authors set out to examine the “effects of managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures” for the treatment of these patients.

The authors analyzed the claims data from a managed-care health plan over a period of four years. The study looked at four different medical procedures and tests and compared employer groups that provided a chiropractic benefit with those that did not.

The authors found reductions in nearly every area per episode of back pain or neck pain in the groups that had a chiropractic benefit:

Procedure or Practice

Percentage Reduction

Back Pain

 

Surgery

-32.1%

Plain film radiography

-23.1%

CT/MRI

-37.2%

Inpatient care

-40.1%

 

Neck Pain

Surgery

-49.4%

Plain film radiography

-36.0%

CT/MRI

-45.6%

Inpatient care

-49.5%

This is not the first study to find that chiropractic care reduced overall costs when included in managed care programs. A 2004 study2 also found that these patients had a lower utilization of plain film radiographs, MRI, hospitalizations, and surgery.

The 2004 study put forth four possible explanations for these findings:

  1. Positive risk selection.
  2. Substitution of chiropractic for traditional medical care.
  3. More conservative, less invasive treatment protocols.
  4. Lower health service costs associated with managed chiropractic care.

These two studies show that not only can chiropractic care be an effective treatment for certain patients with low back or neck pain, it can also reduce the use of unnecessary and expensive interventions:

“Among employer groups with chiropractic coverage compared with those without such coverage, there is a significant reduction in the use of high-cost and invasive procedures for the treatment of low back pain and neck pain…The resultant chiropractic care is far less likely to lead to the use of these invasive procedures.”

  1. Nelson CF, Metz RD, LaBrot T. Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain. Journal of Manipulative and Physiological Therapeutics 2005;28:564-569.
  2. Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, Dinubile NA. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Archives of Internal Medicine 2004;164(18):1985-1992.

Chiropractic and Back Pain

Numerous studies have shown that chiropractic can be an effective treatment for patients with low back pain. Now a new report1 has looked further into the effectiveness of chiropractic by comparing it to physical therapy treatment, and, more significantly, studying the long-term benefits of chiropractic as measured by the annual number of office visits.

Most studies that look at long-term effects of treatment simply look at self-reported outcomes: level of pain and disability. This study took a different approach. By examining how much care patients sought after the initial study period, they could determine the effect each treatment method had on future health care consumption:

“Care seeking behavior by patients with low back pain is most commonly associated with increased pain and disability, meaning more care is sought when worse symptoms are experienced. The amount of health care utilized may therefore be used as a measure of patient health status, and thus may be compared between groups of patients to determine effectiveness of certain therapies.”

“Proctor et al.2 determined that about 25% of patients with chronic, disabling, work-related musculoskeletal disorders pursue new health care services after completing a course of treatment, and among those who sought additional health care from a new provider, a subgroup of <15% accounted for a disproportionate share of lost worker productivity, more surgical procedures, and ongoing financial disputes. They further stated that in patients with chronic, disabling, work-related musculoskeletal disorders, post-treatment utilization of health care from a new provider is an important dimension of outcome…”

The authors started with 191 patients with low back pain. 107 patients received chiropractic care (flexion/distraction treatment, or FD) and 84 patients received active exercise therapy (EP) from physical therapists. All patients received treatment 2 to 4 times per week for four weeks. The study subjects were then followed for one year to assess outcomes. The authors found:

  • 38% of the FD patients and 54% of the EP patients sought care for their back pain during the one-year follow-up.
  • FD patients had an average of 2.2 visits to a health care provider after the treatment period, while EP patients had an average of 6 visits.

“We hypothesized that there would be no group difference in the average number of visits to any health care provider. The results demonstrated that actually there were significant group differences during the year after trial participation, with a higher number of visits to any health care provider and to a general practitioner in the EP group.”

The authors conclude:

“Based on one-year follow-up data imputed for complete analysis, participants who received physical therapy (exercise program) during a clinical trial attended a higher number of visits to any health care provider and to general practitioners during the year after care when compared to participants who received chiropractic care (flexion distraction) within the trial.”

  1. Cambron JA, Gudavalli MR, McGregor M, et al. Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain. Chiropractic and Osteopathy 2006:14:19.
  2. Proctor TJ, Mayer TG, Gatchel RJ, McGreary DD: Unremitting health care utilization outcomes of tertiary rehabilitation of patients with chronic musculoskeletal disorders. Journal of Bone and Joint Surgery 2004, 86A:62-69.

Chiropractic, Sciatica, Back Pain

Work-related sciatica is clinically challenging and an expensive problem for our health care systems. One recent study found that workers with sciatica are significantly more likely to be prescribed opioids for their condition.1 Another study found that workers with low back pain and sciatica showed the highest level of disability of all back pain patients.2

With these issues in mind, the orthopedic medicine department of a hospital in Norway has examined the effectiveness of chiropractic treatment with patients with severe sciatic pain. This new study3 looked at 44 workers who presented at the hospital with severe sciatic pain that required hospitalization. “The patients underwent clinical, neurologic, and radiological examinations as well as laboratory screening, including urine specimens, parameters of infection, and system diseases.”

The hospital chiropractor then performed a chiropractic examination on each patient that included an analysis of posture and gait, passive and active range of motion, and palpation of the lumbar spine. “The main treatment consisted of joint adjustment techniques of the lumbopelvic fixations, usually performed in a side posture position…Joint adjustments in other parts of the spine and limbs were usually necessary as a result of the compensatory dysfunction.” Ice treatment was applied after the adjustment, since there was soft-tissue soreness experienced by the patients.

“Patients were treated daily while they were in the hospital; they were treated for 3 days a week for the first 2 weeks while they were in the clinic. Depending on need, some patients received follow-up treatment once or twice a week for some time. Following Norwegianpublic health regulations, cost refunding is limited to 14 treatments; therefore, the total number of treatments rarely exceeded this number.”

The authors found the following:

  • All of the patients had experienced three or more weeks of pain before hospitalization.
  • 35 patients underwent MRI and 7 had CT scans; there were no structural changes on any of the imaging tests.
  • After the treatment, 40 patients (91%) returned to work full-time within an average of 21.1 days.
  • Two patients returned at reduced work levels: one at 80% and another at 50%.

“The positive effects of cooperation between orthopedic surgeons and chiropractors may be measured in the reduced duration of sick leaves.” The study refers to Norwegian public health records that show that the average patient with sciatica is disabled for 72 days; in this study, the time to return-to-work was just 21 days—a 70% reduction.

The authors point to how chiropractic can improve functioning in the spine:

Stimulation of “muscle spindles caused by sprain strain has been shown to be capable of starting a long-lasting train of action potentials in the motor neuron (i.e., long-lasting muscle contraction in the motor unit in question). Similarly, a brief inhibitory impulse, such as that from antagonistic muscles, may stop the signal train in the motor neuron. Chiropractic joint adjustment probably provides a similar inhibitory impulse. The chiropractic joint adjustments must cross the barrier of passive joint motion range to stimulate muscle spindle receptors.”

  1. Stover BD, Turner JA, Franklin G, et al. Factors associated with early opioid prescription among workers with low back injuries. Journal of Pain 2006;7(10):718-25. 
  2. Arana E, Marti-Bonmati L, Vega M, et al. Relationship between low back pain, disability, MR imaging findings and health care provider. Skeletal Radiology 2006;35(9):641-7.
  3. Orlin JR, Didriksen A. Results of chiropractic treatment of lumbopelvic fixation in 44 patients admitted to an orthopedic department. Journal of Manipulative and Physiological Therapeutics 2007;30:135-139.

Chiropractic Increases Spinal Flexibility for Low Back Pain

For many people who suffer from low back pain, chiropractic treatments ease their symptoms and increase flexibility. But why does it work? And which patients are most likely to benefit? Recently, a team of researchers based in the United States and Australia set out to investigate the effect of one chiropractic technique on spinal stiffness in patients with low back pain. They found that chiropractic manipulation can have an immediate effect on spinal stiffness and muscle growth in certain patients.

Repeated studies have confirmed the effectiveness of high impact, low velocity spinal manipulation (SMT) for reducing low back pain. Yet although it is known that SMT has a direct effect on spinal muscles, and that it stimulates a patient’s nervous system, many questions remain about exactly how SMT works. For this study, the researchers recruited 48 subjects with low back pain from physical therapy clinics and through community advertisements. The subjects were evaluated for several factors that might decrease the likelihood that their treatment would succeed – factors such as longer length of injury and fear avoidance (avoiding activity because of the fear that it may cause pain).

Each participant underwent three SMT sessions, held over a one-week period. Before and after each session, the participants rated their pain levels on a scale of 0-10 and were measured for spinal stiffness. The researchers also took ultrasounds to assess the thickness of the patient’s back muscles.

Their results showed that after patients received SMT, there was an immediate and measurable improvement in stiffness. The patients also reported experiencing less disability from their low back pain after SMT. In their measurements of muscle growth, researchers found that muscle thickness increased more quickly in patients who had been categorized as likely to have a positive outcome. This muscle increase lasted through the one-week follow-up period, which indicates that the benefits of SMT could be prolonged, especially when combined with exercise treatments designed to build muscle in the lower back.

Although the researchers acknowledge that their sample size was small, and their results preliminary, these findings help confirm that chiropractic can have immediate beneficial effects for patients suffering from low back pain. They also show that the human body has a complicated reaction to SMT, with both stiffness and muscle thickness playing a roll in the outcome of treatment.

Fritz JM, Koppenhaver SL, Kawchuk GN, Teyhen DS, Hebert JJ, Childs JD. Preliminary investigation of the mechanisms underlying the effects of manipulation: exploration of a multi-variate model including spinal stiffness, multifidus recruitment, and clinical findings. Spine. 2011 March 15.