Posts Tagged ‘Spinal manipulative therapy’

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Sciatica – what is it and can Chiropractic help?

Wednesday, January 5th, 2011

Leni, one of our chiros, writes:

Is there evidence for chiropractic treatment for sciatica?

Well, we’ve blogged about sciatica before. Sciatica is a loose, nearly slang term for leg pain originating in the back or buttock.

sciatica Sciatica what is it and can Chiropractic help?

In the past we have talked about the symptoms, causes, and treatment of this problem; but does chiropractic treatment work? In practice many chiropractors report success treating this symptom, but there is little research that has been done. This makes it hard to know an actual predicted success rate, or compare the success of this to other treatment such as surgery.

Recently there has been more research done into this area, for example in October there was a study published which compared the clinical effect of chiropractic spinal manipulation against microdiskectomy (a type of surgery to remove a disk bulge). This was done in patients with sciatica secondary to lumbar disk herniation – which is when the intervertebral disk herniates, like this:

lumbar herniated disk Sciatica what is it and can Chiropractic help?

This causes entrapment and irritation of a nerve leaving the back, which causes leg pain.

They looked at patients who had failed to respond to at least 3 months of other nonoperative management (including treatment with painkillers, massage, and physiotherapy) and found that there was a significant improvement in both those treated with chiropractic and surgery. Sixty percent of the patients with sciatica benefited from spinal manipulation to the same degree as if they underwent surgical intervention (I had to do that in red as it’s a vital piece of information). This is very interesting as most people would like to avoid surgery when possible.

They also found that at 1 year follow up there was no difference in outcome based on the patients original treatment group (chiropractic or surgery), but they allowed patients to swap treatments after 3 months if they wanted to. Of the 40% left unsatisfied after their chiropractic treatment, subsequent surgical intervention had an excellent outcome (it worked as well for them as those who went for surgery straight away).

This study only compared treatment for one cause of sciatica, but this is an important cause, and the findings suggest that patients with this kind of sciatica (due to lumbar disk herniation) should definitely consider spinal manipulation. This may be followed by surgery if there is still no response.

Hopefully there will be more research into this and other causes of sciatica, as these findings are promising, and it is nice for patients to have another option than surgery.

Reference:
McMorland, Suter, Casha et al. (2010). Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study. Journal of Manipulative and Physiological Theraputics, Volume 33, Issue 8, Pages 576-584.

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Paracetamol for low-back pain – well, yes but….

Friday, September 24th, 2010

Look at this drug-centric view of back pain. It’s crazy stuff from Pharmacy News but it is a great example of how we now think.

“Paracetamol leads way in back pain relief: study

Pharmacists are ideally placed to provide advice to people with lower back pain, researchers at The George Institute of Global Health in Sydney believe.

Acetaminophen Paracetamol for low back pain well, yes but....

Following a study showing less than half of people suffering with the condition were taking paracetamol, as recommended in evidence-based guidelines, researchers have commenced recruiting patients through pharmacy for a three month study.”

Now, if you have an inflammatory issue going on in your low-back then paracetamol will help to reduce that and the pain but you’d struggle to argue that it is doing anything to address the cause. You are in effect removing the warning bulb form the dash board.

They go on to say:

“If you look at the current evidence that’s available, the first option of care for non-specific lower back pain [which encompasses 95 per cent of back pain] is to advise the patient to remain active, reassure them that they’ve got a favourable outcome, advise them against bed-rest and advise them about simple pain relief medication.”

Which is reasonable but missing one key recommendation, the spinal manipulation bit.

“The first line of care should be paracetamol, so pharmacists, we think, are ideally placed to do that,” oh, come on what tosh, a pharmacist would never suggest you go and see your osteopath or suggest you consider Pilates.

The Paracetamol for Lower Back Pain (PACE) study (sounds biased to me but…) has already started recruiting subjects. The research outline has said the study will be a double blind placebo controlled trial with patients split into three groups to compare regular paracetamol use to paracetamol as required, and a placebo.

The bottom line is that you do not have back pain because you have a lack of paracetamol in your blood stream – it’ll be for another reason and that’s what you should be looking to treat.

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Can Chiropractic help with your headache? This study suggests so.

Friday, August 27th, 2010

Rupert Clements, one of the chiros at C1, writes:

A recent study snappily called:

Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial

By Haas and co-workers was published in the uber serious Spine (The Spine Journal 2010; 10:117-128) which said that chiropractic was good at sorting out headaches.

As we all know, headaches are very common (with up to 16% of the population having one at any one time) and can very disabling (leading to work-days-lost, absenteeism costs and increased medical benefits spend).

Headaches are broken down into primary and secondary. The primary group is made up of:
• migraine,
• tension-type
and
• cervicogenic headache (CGH).

This last lot, CGH, account for a significant proportion of the 16% point estimate of those suffering primary headaches (but Nilson and Sjaastad have estimated the point to range from 0.4%-4.6%). Whatever. They are linked to neck pain and mechanical dysfunction and so, it is theorized, treating neck pain and mechanical dysfunction through manual therapies will help reduce headache symptoms.

headache woman 310x250 Can Chiropractic help with your headache? This study suggests so.

Systematic reviews have been conducted on the usefulness of spinal manipulative therapy (SMT) in the treatment of CGH, however the treatment plans offer great variability: from once per week for three weeks to twice per week for 8 weeks. This, clearly, demonstrates a lack of clinical understanding and consensus in the research. This prevents us from being able to confidently set out the prognosis and expectations with respect to SMT.

The purpose of the study was to determine the efficacy of spinal manipulation in CGH and compare a high-dose and low-dose SMT application to a light massage.

One group received low-dose SMT (8 treatments), high-dose SMT (16 treatments), low-dose light massage (8 treatments) and high-dose light massage (16 treatments). The study showed some interesting things:

• While treatment dose had no effect on the use of medication, those receiving SMT used 1/3 less medication at 24 weeks.

• With respect to the number of cervicogenic headaches experienced, those receiving SMT experienced 2.6 fewer headaches per week compared to those receiving light massage.

• At the end of 24 weeks, those receiving SMT experienced 2.1 fewer ‘other’ headaches per week compared to those receiving light massage.

• While dose effects were small, those who received high-dose SMT experienced a greater improvement in neck pain (-5.9 at 12 wks; -10.6 at 24 wks)

• CGH pain, the number of headaches experienced per week and the amount of medication intake all reduced, with sustained reductions, favouring the SMT group.

• Lastly, by eight weeks, the number of weekly headaches was reduced 50% in those patients receiving SMT and on secondary analysis, a 50% reduction in symptoms (obtained via the outcome measures) was achieved in 80% of those receiving SMT.

The authors point out several key limitations to this study:
• The study design was highly complex and multifactorial.
• There was a small number of patients within each subgroup.
• Multiple headache classifications were present within many patients.

Interestingly, for us as chiros, there was no difference between the two dosages of SMT (though SMT proved to be more effective than light massage, irrespective of dosage.). And, as we’d expect, the differences between the SMT and the light massage group were not only statistically significant, but clinically significant as well.

This study is highly relevant and helpful to clinical practice as it strengthens the use of cervical spine manipulation in the treatment of CGH. It is also helpful as it demonstrates that patients do not tend to be cured by this intervention alone, indicating that CGH may require a combined intervention approach which includes exercise, soft-tissue therapy, spinal manipulation and education.

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Can chiropractic help with back pain

Thursday, April 22nd, 2010

C1 Chiropractic Health Centre is offering free on-line consultations for Bristol back pain sufferers. Free advice and tips are available on your back pain or backache if you email the clinic or visit the website:
www.c1healthcentre.co.uk

The clinic is staffed by experienced Chiropractors, acupuncture practitioners and sports injury therapists who have a wealth of experience in treating back pain. Chiropractors can offer alternative treatments to Osteopaths and Osteopathy for your back pain and are trained to provide precise spinal manipulations should it be required. Chiropractic is acknowledged as an effective treatment for back pain and particularly low-back pain.

Associated causes of back pain such as slipped discs, bulging discs, herniated discs and trapped nerves as well as the symptoms such as sciatica and muscle spasm can all be treated by a chiropractor.
Back pain symptoms may be eased by using ice over the painful area. Using an icepack or bag of frozen peas wrapped in a damp thin towel will have 2 major beneficial effects. Firstly ice in an analgesic (pain killer) and secondly ice will cool the area and reduce inflammation if present. As a pain killer ice is natural and if used correctly can block pain signals to the brain. Temperature sensors in the body transfer information to the brain quicker than that of pain information so if you place ice or heat over an area of pain you will feel better for a while. Cold also causes vasoconstriction, which is a narrowing of capillaries and blood vessels, and you reduce the flow of inflammatory substances to the injury site.
Heat creates vasodilation which allows more blood to travel to the area. If your body is suffering the effects of an inflammatory response, then this will travel via the blood stream in increased amounts. Cold on the other hand will have the reverse effect.

Both hot and cold will generally help to ease pain but once the temperature is removed the effects of the temperature will begin to show. Heat may increase symptoms of inflammation (you wouldn’t run a burnt finger under hot water would you?) and cold will reduce heat and inflammation.
If in doubt use cold!

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Gouveia rubbishes chiropractic

Wednesday, September 2nd, 2009

Look at this appalling article for an example of rubbish dressed up as science:

Safety of Chiropractic Interventions: A Systematic Review
Gouveia L, et al.
Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal
Spine 2009; 34(11): E405-13.

Now, I’d have been really ashamed to publish such a thing and to attach my name to it. It is also a real shame that it got into ‘Spine’, which is usually a great journal, without some questions being asked about the quality of the science behind the article, though it will be interesting to see what the editors say when the letters start to pour in.

The utterly rubbish authors indicated that recent reviews on the effectiveness of chiropractic said that the efficacy of spinal manipulation was not demonstrated for the treatment of “any condition”, citing a chiropractic clinical practice guideline that was published in the Journal of the Canadian Chiropractic Association (the JCCA). However, there was no such statement in the JCCA article. What the guidelines actually said is:
“Treatment recommendation 2: Based on all the evidence…we also recommend manipulation…for patients with acute or chronic pain…”
Which I’d have suggested is about as far from “any condition” as you can get.

In the article they provided background information on chiropractic, citing negative reviews by a known chiropractic detractor (namely Professor Edzard Ernst) which is fair and should happen but only if positive reviews are not ignored, which, you’ve guessed it, they were. This prejudicial handling of the evidence set the tone for the entire review.

There were a series of shockers in the article:

1. A literature search identified 151 potentially relevant articles, so a good number that should reveal something. However, a staggering 110 of these had to be discarded because the patients had an underlying disease that predisposed them to adverse reactions and other reasons. So, far form a glorious start.

2. Only one RCT was included and the shockingly bad authors referred to it as “…the only randomized controlled trial published.” This gives the impression to the reader that only one RCT has ever been done in chiropractic. This is bonkers. There are loads of chiro RCTs and most of them have commented on the number of adverse events that occurred and therefore, you’d have thought would have been included in this shoddy review.

3. In the study six other studies were included. The manipulations were by physiotherapists, osteopaths and manipulative therapists in two of them, so 33% of the study. It has just got to be inappropriate to include adverse events attributed to other types of practitioners in a study reporting on chiropractic safety, surely.

4. And they ‘missed’:
Rubinstein SM, et al. The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. J Manipulative Physiol Ther. 2007 Jul-Aug; 30(6):408-18.

Which says:

“Adverse events may be common, but are rarely severe in intensity. Most of the patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic care for neck pain seem to outweigh the potential risks.”

5. However, the most unpleaseant error is an intentional, or not, misquote of an article by Michael Haynes who actually reported that “…there were perhaps fewer than five cases of manipulation-related stroke per 100,000 patients who had received cervical manipulation from a chiropractor.”
Gouveia and cronies turned this to read:
“5 strokes/100,000 manipulations”
Which in anyone’s book is a huge difference from what Haynes reported. To add insult to injury, this inaccuracy was repeated 4 times including the abstract. It has been reported that the typical chiropractic patient in North America is seen 12.8 times on average (7) and other studies have reported even more. Using the 12.8 figure, the statistic becomes fewer than 5 strokes per 1,280,000 manipulations.

A review of this article said:
“Being so riddled with flaws, one cannot apply any of the findings of this article to clinical practice.”

Which I have got to say I agree with.

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