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Herniated Disc

Herniated Disc: refers to a problem with one of the rubbery cushions (discs) between the individual bones (vertebrae) that stack up to make your spine.

A spinal disc, has a soft center encased within a tougher exterior. Sometimes called a slipped disc or a ruptured disc, a herniated disc occurs when some of the soft center pushes out through a tear in the tougher exterior.

A herniated disc can irritate the surrounding nerves which can cause pain, numbness or weakness in an arm or leg. On the other hand, many people experience no symptoms from a herniated disk. Most people who have a herniated disc will not need surgery to correct the problem.

Symptoms

Most herniated disks occur in the lower back (lumbar spine), although they can also occur in the neck (cervical spine). Most common symptoms of a herniated disk:

Arm or leg pain: A herniated disk in the lower back, typically an individual will feel the most intense pain in the buttocks, thigh and calf. It may also involve part of the foot. If the herniated disc is in the neck, the pain will typically be most intense in the shoulder and arm. This pain may shoot into the arm or leg when coughing, sneezing or movin spine into certain positions.

Numbness or tingling: A herniated disk can feel like numbness or tingling in the body part served by the affected nerves.

Weakness: Muscles served by the affected nerves tend to weaken. This may cause stumbling or impair the ability to lift or hold items.

Someone can have a herniated disc without knowing. Herniated discs sometimes show up on spinal images of people who have no symptoms of a disc problem. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900


Nervous About Chiropractic Treatment for Herniated Disc El Paso, TX.

Nervous About Chiropractic Treatment for Herniated Disc El Paso, TX.

Q: My primary healthcare provider recently diagnosed me with a herniated disc in the lumbar spine. They referred me to get chiropractic treatment, but I’m nervous because it’s new to me and I’m afraid of being adjusted wrong, paralyzed, etc. Can I trust chiropractic treatment to work?

A: It’s normal to be nervous about going to a chiropractic clinic.

If you’re not sure whether chiropractic is for you, there is scientific evidence that shows how chiropractic techniques like spinal manipulation/spinal adjustment and forms of manual/mechanical therapy are safe and effective for relieving pain and other musculoskeletal pain, conditions, and symptoms.

I encourage everyone to try chiropractic treatment as a non-surgical treatment option for a herniated disc.

 

11860 Vista Del Sol, Ste. 128 Nervous About Chiropractic Treatment for Herniated Disc El Paso, TX.

 

It Is Your Decision

At the first appointment, a chiropractor will take a medical history and perform a thorough exam to determine the nature of the symptoms and their possible causes, which include a herniated disc.

Sometimes with a herniated disc, there may be no symptoms at all.

But usually a herniated disc causes:

  • Back pain
  • Referred pain or pain that is felt in other parts of the body like the legs, feet, etc.
  • An irritated spinal nerve can cause symptoms in the legs

This can lead to neurological symptoms like:

  • Tingling
  • Numbness
  • Weakness in the legs

Once the chiropractor determines your symptoms, they may use one or several techniques to relieve the back pain and other symptoms.

Techniques used by chiropractors for disc-related problems include:

  • Specific self-treatment exercises to improve motion & decrease back pain
  • McKenzie method for relieving leg symptoms
  • Cox technique like spinal traction using special tables
  • Spinal manipulation
  • Hands-on techniques that relieve pain and restore movement to the spine and body

These techniques have been proven to be very safe. There are other techniques a chiropractor can recommend for various conditions, as each has their own style and method.

A chiropractic treatment plan will also include:

  1. Education
  2. Self-management instructions

This is to teach you how to control/eliminate pain with proper posture and proper body mechanics.

Whichever treatment the chiropractor recommends, he or she will discuss it with you, including the benefits and risks.

Although the treatments listed above will most likely be a part of your treatment plan, your chiropractor will answer your questions and work with you to select a treatment that meets your specific goals and preferences.

11860 Vista Del Sol, Ste. 128 Nervous About Chiropractic Treatment for Herniated Disc El Paso, TX.

 

Don’t Be Nervous A Chiropractor Monitors Treatment Progress

If symptoms do not improve within a reasonable time frame, then a chiropractor may refer the patient to other treatments to manage disc-related pain, including:

  • Physical therapy
  • Acupuncture
  • Spinal injections
  • Surgery

Fortunately, self-management and time can be the best treatment. Allowing the body to heal itself is the way to go. But if rest is not enough then chiropractic treatment may be just what is needed to kick in the body’s self-healing function.

If you decide to give chiropractic treatment a try, don’t be nervous, as a chiropractor will monitor progress throughout the treatment.

In any case, chiropractors are qualified to discuss the benefits and risks of other treatments, depending on the condition.

Hopefully, this article has given you the basics of chiropractic medicine and how it works so you can make the best choice for your herniated disc/s.


 

Low Back Pain Management El Paso, TX Chiropractor

 

 

Denise suffered an auto accident injury which resulted in back pain. When she realized she could not sit, walk or sleep for lengthy periods of time without having painful symptoms, Denise found chiropractic care with Dr. Alex Jimenez at El Paso, TX. Once she received therapy for her automobile accident injuries, Denise experienced relief from her symptoms and she was able to execute her regular tasks once again. Thanks to the education and maintenance Dr. Alex Jimenez supplied, Denise regained her initial health and health.

Back pain is more most common, with roughly nine out of ten adults undergoing it at some time in their lifetime, and five functioning adults developing it annually. Some quote around 95 percent of Americans will experience back pain at some time in their lifetime. It is undoubtedly the typical cause of chronic pain since it’s also a substantial contributor to missed work and handicap. In the United States alone, acute cases of lower back pain are the fifth most frequent reason for doctor visits and cause 40% of missed days off work. What’s more, it is the leading cause of disability worldwide.


 

NCBI Resources

A herniated disc is a common spinal condition that typically affects the cervical spine (neck region) or the lumbar spine (lower back), although it can occur in any part of the spine. Most often, a herniated disc happens at the L4 – L5 and the L5 – S1.  This is because this portion of the spine, the lumbar region, bears the bulk of the body’s weight.

 

Herniated Discs – What We Want To Know |El Paso, Tx.

Herniated Discs – What We Want To Know |El Paso, Tx.

A herniated disc is a common spinal disc issue. The spine is a very intricate structure, and when one component fails to function correctly, it can affect the entire body, causing pain and loss of mobility.

Tiny bones, called vertebrae, are stacked on each other to form the spine. They are joined in such a way to facilitate movement, flexibility, and a wide range of motion. There are small, fluid-filled discs that rest between each vertebra, providing a cushion between the bones. When one of these discs becomes damaged, it can affect the surrounding nerves, causing pain and making movement difficult.

What is It?

A herniated disc is a common spinal condition that typically affects the cervical spine (neck region) or the lumbar spine (lower back), although it can occur in any part of the spine. Most often, a herniated disc happens at the L4 – L5 and the L5 – S1.  This is because this portion of the spine, the lumbar region, bears the bulk of the body’s weight.

It is often referred to as a ruptured disc or slipped disc and occurs when the disc moves or slips out of place. It can also be the result of a disc that has a small tear and is leaking the jelly-like substance that is inside. This can put pressure on the surrounding nerves, causing pain and discomfort.

a herniated disc chiropractic help el paso tx.

What are the Progression and Symptoms?

There are four stages of a disc herniation:

  1. Disc protrusion
  2. Prolapsed disc
  3. Disc extrusion
  4. Sequestered disc

The first two stages are called incomplete herniations while the last two stages are called complete herniations.

Symptoms of a herniated disc may increase or worsen as the condition progresses although some patients do not experience any at all Typical symptoms include:

  • Pain in the affected area
  • Tingling
  • Numbness
  • Weakness
  • Leg or arm pain
  • Loss of reflex
  • Loss of mobility
  • Loss of flexibility
  • Decreased range of motion

What Causes It?

There are several causes. The most common are aging and degeneration, overuse, and normal wear and tear on the body.

A herniated disc resulting from an injury or trauma, such as a blow to the back, is less common, but it does happen. Because the back does bear most of the body’s weight, it can put a significant amount of pressure on the spine and discs. Over time, the discs may begin to weaken and a herniation can occur.

Injury or trauma that results in a herniation may include a car accident that involves sudden jerking, or incorrectly lifting heaving objects can put excessive pressure on the spine, causing it to herniate.

How is it Diagnosed?

A physical examination is usually the first step in diagnosing a herniated disc. The physician or chiropractor will examine the spine while the patient is standing, then while they are lying down. Depending on the severity and location of the herniation, they may note a decrease in spinal curvature.

Radicular pain will also be assessed, when the spine is unmoving, while in motion, and when pressure is applied. Other tests may also be administered. X-rays may also be taken, but an MRI is usually more accurate and provides greater detail.

What are the Treatments?

Medications may be recommended or prescribed, including NSAIDs, narcotics, muscle relaxers, and anticonvulsants. Some doctors may advise cortisone injections to reduce inflammation. Physical therapy may be recommended as a stand-alone treatment or in conjunctions with other treatments. Surgery for herniated discs is rare and usually reserved as a last resort option.

Chiropractic has been very effective in helping patients manage their pain and regain their mobility so they can return to their normal life. Therefore, it should be your first option for treatment before you go down the road with drugs or surgery.

a herniated disc chiropractic help el paso tx.

El Paso Back Clinic

The Role of Emergency Radiology in Spinal Trauma

The Role of Emergency Radiology in Spinal Trauma

Spinal trauma consists of spine fractures, or spinal fractures, and spinal cord injuries. Approximately 12,000 spinal trauma cases are reported in the United States every year. While the most prevalent causes of spinal cord injuries and spine fractures are automobile accidents and falls, spinal trauma can also be attributed to assault, sports injuries, and work-related accidents. Diagnosis of spinal trauma includes imaging and assessment of nerve function, such as reflex, motor, and sensation. The following article discusses the role of emergency radiology in spinal trauma. Chiropractic care can help provide diagnostic evaluations for spinal trauma.

Abstract

Spinal trauma is very frequent injury with different severity and prognosis varying from asymptomatic condition to temporary neurological dysfunction, focal deficit or fatal event. The major causes of spinal trauma are high- and low- energy fall, traffic accident, sport and blunt impact. The radiologist has a role of great responsibility to establish the presence or absence of lesions, to define the characteristics, to assess the prognostic influence and therefore treatment. Imaging has an important role in the management of spinal trauma. The aim of this paper was to describe: incidence and type of vertebral fracture; imaging indication and guidelines for cervical trauma; imaging indication and guidelines for thoracolumbar trauma; multidetector CT indication for trauma spine; MRI indication and protocol for trauma spine.

Introduction

The trauma of the spine weighs heavily on the budget of social and economic development of our society. In the USA, 15–40 cases per million populations with 12,000 cases of paraplegia every year, 4000 deaths before admission and 1000 deaths during hospitalization are estimated. The young adult population is the most frequently involved in road accidents, followed by those at home and at work, with a prevalence of falls from high and sports injuries.1

Imaging has an important role in the management of spinal trauma. Quick and proper management of the patients with trauma, from diagnosis to therapy, can mean reduction of the neurological damage of vital importance for the future of the patient. Radiologists have a role of great responsibility to establish the presence or absence of lesions, defining the characteristics, assessing the prognostic influence and therefore treatment.

The aim of this paper was to describe:

  • incidence and type of vertebral fracture
  • imaging indication and guidelines for cervical trauma
  • imaging indication and guidelines for thoracolumbar trauma
  • multidetector CT (MDCT) pattern for trauma spine
  • MRI pattern for trauma spine.
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Spinal trauma, including spine fractures and spinal cord injuries, represent about 3 percent to 6 percent of all skeletal injuries. Diagnostic assessments are fundamental towards the complex diagnosis of spinal trauma. While plain radiography is the initial diagnostic modality used for spine fractures and/or spinal cord injuries, CT scans and MRI can also help with diagnosis. As a chiropractic care office, we can offer diagnostic assessments, such as X-rays, to help determine the best treatment.

Dr. Alex Jimenez D.C., C.C.S.T.

Vertebral Fracture Management and Imaging Indication and Evaluation

The rationale of imaging in spinal trauma is:

  • To diagnose the traumatic abnormality and characterize the type of injury.
  • To estimate the severity, potential spinal instability or damaged stability with or without neurological lesion associated, in order to avoid neurological worsening with medical legal issue.
  • To evaluate the state of the spinal cord and surrounding structures (MR is the gold standard technique).

Clinical evaluation involving different specialities—emergency medicine, trauma surgery, orthopaedics, neurosurgery and radiology or neuroradiology—and trauma information is the most important key point in order to decide when and which type of imaging technique is indicated.2

A common question in patients with spine trauma is: is there still a role for plain-film X-ray compared with CT?

In order to clarify when and what is more appropriate for spinal trauma, different guidelines were published distinguishing cervical and thoracolumbar level.

Cervical Spinal Trauma: Standard X-Ray and Multidetector CT Indication

For cervical level, controversy persists regarding the most efficient and effective method between cervical standard X-ray with three film projections (anteroposterior and lateral view plus open-mouth odontoid view) and MDCT.

X-ray is generally reserved for evaluating patients suspected of cervical spine injury and those with injuries of the thoracic and lumbar areas where suspicion of injury is low. Despite the absence of a randomized controlled trial and thanks to the high quality and performance of MDCT and its post-processing (multiplanar reconstruction and three-dimensional volume rendering), the superiority of cervical CT (CCT) compared with cervical standard X-ray for the detection of clinically significant cervical spine injury is well demonstrated.

Figure 1. (a–l). A 20-year-old male involved in a motorbike accident. The multidetector CT with multiplanar reformatted and three- dimensional volume-rendering reconstructions (a–d) showed traumatic fracture of C6 with traumatic posterior spondylolisthesis grade III with spinal cord compression. The MRI (e–h) confirmed the traumatic fracture of C6 with traumatic posterior spondylolisthesis grade III with severe spinal cord compression. The post-surgical treatment MRI control (i–l) showed the sagittal alignment of cervical level and severe hyperintensity signal alteration of the spinal cord from C3 to T1.

In order to reduce the patient radiation exposure, it is important to determine and to select patients who need imaging and those who do not, through the clinical evaluation and probability of cervical spine injury, using only MDCT for the appropriate patient as is more cost-effective screening.3

First of all, it is necessary to distinguish the type of trauma:

  • minor trauma (stable patient, mentally alert, not under the influence of alcohol or other drugs and who has no history or physical findings suggesting a neck injury)
  • major and severe trauma (multitrauma, unstable patient with a simple temporary neurological dysfunction, with focal neurological deficit or with a history or mechanism of injury sufficient to have exceeded the physiologic range of motion).

Second, it is important to establish if trauma risk factors are presents, such as:

  • violence of trauma: high-energy fall (high risk) or low-energy fall (low risk)
  • age of the patient: <5years old, >65 years old 
  • associated lesions: head, chest, abdomen (multitrauma) etc.
  • clinical signs: Glasgow Coma Scale (GCS), neurological deficit, vertebral deformation.

Combining these elements, patients can be divided into “low
risk” and “high risk” for cervical injury.

The first group consists of patients who are awake (GCS 15), alert, cooperative and non-intoxicated without any distract- ing injury.

The second group consists of unconscious, sedated, intoxicated or non-cooperative patients or those with a distracting injury or an altered mental state (GCS ,15) with a 5% chance of cervical spine injuries.3,4

CCT has a wider indication than X-ray for patients at very high risk of cervical spine injury (major trauma or multitrauma). No evidence suggests CCT instead of X-ray for a patient who is at low risk for cervical spine injury.5

Figure 2. (a–g). A 30-year-old male involved in a motorbike accident. The multidetector CT with multiplanar reformatted and three-dimensional volume-rendering reconstructions (a–d) showed traumatic burst fracture of L1 (A2-type Magerl class) with posterior bone fragment dislocation into spinal canal. The MRI (e–g) confirmed the burst fracture of L1 with moderate spinal cord compression.
Figure 3. (a–d) A 50-year-old male involved in a motorbike accident with acute spinal cord compression symptoms on anticoagulation treatment. The MRI showed an acute haemorrhagic lesion at the C2–C4 posterior epidural space, hypointense on sagittal T1 weighted (a) and hyperintense on T2 weighted (b) with spinal cord compression and dislocation on axial T2* (c) and T2 weighted (d).

In 2000, the National Emergency X-Radiography Utilization (NEXUS) study, analysing 34,069 patients, established low-risk criteria to identify patients with a low probability of cervical spine injury, who consequently needed no cervical spine imaging. To meet the NEXUS criteria, a patient must have the following conditions:

  1. no tenderness at the posterior midline of the cervical spine
  2. no focal neurologic deficit
  3. normal level of alertness
  4. no evidence of intoxication
  5. no clinically apparent painful injury that might distract the patient from the pain of a cervical spine injury.6

If all of these roles are present, the patient does not need to undergo X-ray because he has a low possibility of having a cervical spine injury with a sensitivity of 99% and a specificity of 12.9%.7

In 2001, the Canadian C-spine rule (CCSR) study developed a second decision rule using the risk factor of the trauma: three high-risk criteria (age $ 65 years, dangerous mechanism and paraesthesias in extremities), five low-risk criteria (simple rear-end motor vehicle collision, sitting position in emergency department, ambulatory at any time, delayed onset of neck pain and absence of midline cervical spine tenderness) and the ability of the patient to actively rotate his or her neck to determine the need for cervical spine radiography. In practice, if one of these risk factors is present, the patient needs to undergo imaging evaluation. On the other hand, if the risk factors are not present, the use of the NEXUS criteria plus a functional evaluation of the cervical spine is needed (left and right cervical spine rotation .45°); if this functional evaluation is possible, imaging is unnecessary. If an incomplete cervical movement is present, then the patient needs to be checked with imaging. The results showed the criteria to have a sensitivity of up to 100% and a specificity of up to 42.5%.8

Applying these criteria, before cervical spine imaging, the authors report a decrease of about 23.9% in the number of negative CCT, and applying a more liberal NEXUS criteria including the presence or absence of pain, limited range of motion or posterolateral cervical spine tenderness, they report a decrease of up to 20.2% in the number of negative studies.2

If these clinical criteria cannot be applied, CCT must be performed.

Major and severe traumas request a direct CCT screening, especially because there could be associated lesions, according to the high-risk criteria developed by Blackmore and Hanson to identify patients with trauma at high risk of c-spine injury who would benefit from CT scanning as the primary radiological investigation9 Figure 1.

Thoracolumbar Spinal Trauma: Standard X-Ray and Multidetector CT Indication

For thoracolumbar level, MDCT is a better examination for depicting spine fractures than conventional radiography. It has wider indication in the diagnosis of patients with thoracolumbar trauma for bone evaluation. It is faster than X-ray, more sensitive, thanks to multiplanar reformatted or volume-rendering reconstruction detecting small cortical fracture, and the sagittal alignment can be evaluated with a wide segment evaluation.10

It can replace conventional radiography and can be performed alone in patients who have sustained severe trauma.10

In fact, thoracolumbar spinal injuries can be detected during visceral organ-targeted CT protocol for blunt traumatic injury.

Figure 4. A 55-year-old female involved in a car accident with acute left cervical brachialgia. The sagittal T2 weighted (a) and axial T2 weighted (b) MRI showed a post-traumatic posterolateral herniated disc with spinal cord compression and soft hyper signal alteration on the C3–C4 spinal cord.

Thanks to multidetector technology, images reconstructed using a soft algorithm and wide-display field of view that covers the entire abdomen using a visceral organ-targeted protocol with 1.5-mm collimation are sufficient for the evaluation of spine fractures in patients with trauma, given that multiplanar reformatted images are provided without performing new CT study and without increasing radiation dose11 Figure 2.

With MDCT there is no information about spinal cord status or ligament lesion or acute epidural haematoma; it can only evaluate bone status. Spinal cord injury is suspected only by clinical data.

CCT is strictly recommended in patients affected by blunt cerebrovascular injuries. Both lesions can be strictly correlated and generally; contrast medium administration to exclude hemorrhagic brain lesion and cervical fracture is not needed.10

Dr Jimenez White Coat

Magnetic resonance imaging, or MRI, is a medical diagnostic assessment technique utilized in radiology to create pictures of the anatomy and the physiological processes of the human body. Alongside radiography and CT scans, MRI can be helpful in the diagnosis of spinal trauma, including spine fractures and spinal cord injuries. Magnetic resonance imaging may not be necessary for all cases of spinal trauma. However, it could provide detailed information on the other soft tissues of the spine. 

Dr. Alex Jimenez D.C., C.C.S.T.

Spinal Trauma and MRI

Even if MDCT is the first imaging modality in a patient with trauma, MRI is essential for the soft assessment of the ligament, muscle or spinal cord injury, spinal cord, disc, ligaments and neural elements, especially using T2 weighted sequences with fat suppression or T2 short tau inversion recovery (STIR) sequence.12 MRI is also used to classify burst fracture, obtaining information about the status of the posterior ligamentous complex, a critical determinant of surgical indication even if the diagnosis of ligament injuries remains complex, and its grade is also underestimated using high-field MRI.13

Figure 5. A 65-year-old female involved in domestic trauma with spinal cord symptoms. The sagittal T1 weighted (a) and T2 weighted (b) MRI showed a traumatic T12–L1 spinal cord contusion hypointense on T1 weighted and hyperintense on T2 weighted.

In the management of patients with polytrauma, MDCT total-body scan is necessary in an emergency condition, and MRI whole-spine indication is secondary to the clinical status of the patient: spinal cord compression syndrome Figure 3–5 MRI protocols recommended for patients affected by spinal injury and trauma are the following:13,14

  • Sagittal T1 weighted, T2 weighted and STIR sequence for the bone marrow and spinal cord injury or spinal cord compression evaluation owing to epidural haematoma or traumatic herniated disc
  • Sagittal gradient echo T2* sequence for haemorrhage evaluation of the spinal cord or into the epidural–subdural space
  • Sagittal diffusion-weighted imaging helpful when evaluating spinal cord injury, differentiating cytotoxic from vasogenic oedema, assisting in detecting intramedullary haemorrhage. It can help to evaluate the degree of compressed spinal cord.
  • Axial T1 weighted and T2 weighted sequence for the right localization of the injury. Recently, for patients affected by acute blunt trauma and cervical spinal cord injury, the axial T2 weighted sequence has been shown to be important for trauma-predicting outcomes. On axial T2 weighted imaging, five patterns of intramedullary spinal cord signal alteration can be distinguished at the injury’s epicentre. Ordinal values ranging from 0 to 4 can be assigned to these patterns as Brain and Spinal Injury Center scores, which encompassed the spectrum of spinal cord injury severity correlating with neurological symptoms and MRI axial T2 weighted imaging. This score improves on current MRI-based prognostic descriptions for spinal cord injury by reflecting functionally and anatomically significant patterns of intramedullary T2 signal abnormality in the axial plane.15
Figure 6. A 20-year-old female involved in domestic trauma with back pain resistance to medical therapy. The standard antero- posterior–laterolateral X-ray (a) showed no vertebral fractures. The MRI showed a bone marrow alteration at lumbar vertebral body hyperintense on T2 weighted (T2W) (a), hypointense on T1 weighted (T1W) (b) and short tau inversion recovery (STIR) (c).

MRI has also an important role in case of discordance between clinical status and CT imaging. In the absence of vertebral fracture, patients can suffer from back pain resistant to medical therapy owing to bone marrow traumatic oedema that can be detected only using STIR sequence on MRI Figure 6.

In spinal cord injury without radiologic abnormalities (SCI- WORA), MRI is the only imaging modality that can detect intramedullary or extramedullary pathologies or show the absence of neuroimaging abnormalities.16 SCIWORA refers to spinal injuries, typically located in the cervical region, in the absence of identifiable bony or ligamentous injury on complete, technically adequate, plain radiographs or CT. SCIWORA should be suspected in patients subjected to blunt trauma who report early or transient symptoms of neurologic deficit or who have existing findings upon initial assessment.17

Vertebral Fracture Type and Classification

The rationale of imaging is to distinguish the vertebral fracture type into two groups:

• vertebral compression fracture as vertebral body fracture
compressing the anterior cortex, sparing the middle posterior
columns associated or not with kyphosis
• burst fracture as comminuted fracture of the vertebral body
extending through both superior and inferior endplates with kyphosis or posterior displacement of the bone into the canal. and to distinguish which type of treatment the patient needs; by imaging, it is possible to classify fractures into stable or unstable fracture, giving indication to conservative or surgical therapy.

Figure 7. (a–f) A 77-year-old female involved in domestic trauma with back pain resistance to medical therapy. The multidetector CT (a) showed no vertebral fractures. The MRI showed a Magerl A1 fracture with bone marrow oedema at T12–L1 vertebral body hypointense on T1 weighted (b), hyperintense on T2 weighted (c) and short tau inversion recovery (d) treated by vertebroplasty (e–f).
Figure 8. (a–d) A 47-year-old male involved in a motorbike accident with back pain resistance to medical therapy. The MRI showed a Magerl A1 fracture with bone marrow oedema at T12 vertebral body hypointense on T1 weighted (a) hyperintense on T2 weighted (b) and short tau inversion recovery (c) treated by assisted-technique vertebroplasty—vertebral body stenting technique (d).

Using MDCT and MRI, thanks to morphology and injury distribution, various classification systems have been used for identifying those injuries that require surgical intervention, distinguishing among stable and unstable fractures and surgical and non-surgical fractures.1

Denis proposed the “three-column concept”, dividing the spinal segment into three parts: anterior, middle and posterior columns. The anterior column comprises the anterior longitudinal ligament and anterior half of the vertebral body; the middle column comprises the posterior half of the vertebral body and posterior longitudinal ligament; and the posterior column comprises the pedicles, facet joints and supraspinous ligaments. Each column has different contributions to stability, and their damages may affect stability differently. Generally, if two or more of these columns are damaged, the spine becomes unstable.18

Magerl divided the vertebral compression fracture (VCF) into three main categories according to trauma force: (a) compression injury, (b) distraction injury and (c) rotation injury. Type A has conservative or non-surgical mini-invasive treatment indication.19

The thoracolumbar injury classification and severity score (TLICS) system assigns numerical values to each injury based on the categories of morphology of injury, integrity of the posterior ligament and neurological involvement. Stable injury patterns (TLICS,4) may be treated non-operatively with brace immobilization. Unstable injury patterns (TLICS.4) may be treated operatively with the principles of deformity correction, neurological decompression if necessary and spinal stabilization.20

The Aebi classification is based on three major groups: A = isolated anterior column injuries by axial compression, B = disruption of the posterior ligament complex by distraction posteriorly and C = corresponding to group B but with rotation. There is an increasing severity from A to C, and within each group, the severity usually increases within the subgroups from 1 to 3. All these pathomorphologies are supported by the mechanism of injury, which is responsible for the extent of the injury. The type of injury with its groups and subgroups is able to suggest the treatment modality.21

Thoracolumbar Fracture and Mini-Invasive Vertebral Augmentation Procedure: Imaging Target

Recently, different mini-invasive procedures called assisted- technique vertebroplasty (balloon kyphoplasty KP or kyphoplasty-like techniques) have been developed in order to obtain pain relief and kyphosis correction as alternative treatment for non-surgical but symptomatic vertebral fracture.

The rationale of these techniques is to combine the analgesic and vertebral consolidation effect of vertebroplasty with the restoration of the physiological height of the collapsed vertebral body, reducing the kyphotic deformity of the vertebral body, delivering cement into the fractured vertebral body with a vertebral stabilization effect compared with conservative therapy (bed rest and medical therapy).22

From interventional point of view, imaging has an important role for treatment indication together with clinical evaluation. Both MDCT and MRI are recommended Figure 7 and 8.

In fact, MDCT has the advantage of diagnosing VCF with kyphosis deformity easily, while MRI with STIR sequence is useful to evaluate bone marrow oedema, an important sign of back pain.

Patients affected by vertebral fracture without bone marrow oedema on STIR sequence are not indicated for interventional procedure.

According to imaging, Magerl A1 classification fractures are the main indication of treatment.

However, the treatment must be performed within 2–3 weeks from trauma in order to avoid sclerotic bone response: the younger the fractures, the better the results and easier the treatment and vertebral augmentation effect. To exclude sclerotic bone reaction, CT is recommended.

Conclusion

The management of spinal trauma remains complex. MDCT has a wide indication for bone evaluation in patients affected by severe trauma or patients with high risk of spine injury. MRI has a major indication in the case of spinal cord injury and the absence of bone lesion. Diagnostic assessment of spinal trauma, including radiography, CT scans, and MRI are fundamental towards the diagnosis of spine fractures and spinal cord injury for treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

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Additional Topics: Acute Back Pain

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

 

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EXTRA IMPORTANT TOPIC: Sciatica Pain Chiropractic Therapy

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References
  1. Pneumaticos SG, Triantafyllopoulos GK, Gian- noudis PV. Advances made in the treatment of thoracolumbar fractures: current trends and future directions. Injury 2013; 44: 703–12. doi: 10.1016/j.injury.2012.12.005

  2. Griffith B, Bolton C, Goyal N, Brown ML, Jain R. Screening cervical spine CT in a level I trauma center: overutilization? AJR Am J Roentgenol 2011; 197: 463–7.doi: 10.2214/ AJR.10.5731

  3. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CTscreening. AJR Am J Roentgenol 2000; 174: 713–17.

  4. Saltzherr TP, Fung Kon Jin PH, Beenen LF, Vandertop WP, Goslings JC. Diagnostic imaging of cervical spine injuries following blunt trauma: a review of the literature and practical guideline. Injury 2009; 40: 795–800. doi: 10.1016/j.injury.2009.01.015

  5. Holmes JF, Akkinepalli R. Computed to- mography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma 2005; 58: 902–5. doi: 10.1097/01. TA.0000162138.36519.2A

  6. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998; 32: 461–9. doi: 10.1016/S0196-0644(98)70176-3

  7. Dickinson G, Stiell IG, Schull M, Brison R, Clement CM, Vandemheen KL, et al. Retro- spective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments. Ann Emerg Med 2004; 43: 507–14. doi: 10.1016/j. annemergmed.2003.10.036

  8. Stiell IG, Wells GA, Vandemheen KL, Clem- ent CM, Lesiuk H, De Maio VJ, et al. The Canadian C-spine rule for radiography in

alert and stable trauma patients. JAMA 2001;

286: 1841–8. doi: 10.1001/jama.286.15.1841 9. Berne JD, Velmahos GC, El-Tawil Q, Deme- triades D, Asensio JA, Murray JA, et al. Value

of complete cervical helical computed to- mographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. J Trauma 1999; 47: 896–902. doi: 10.1097/00005373-199911000-00014

10. Wintermark M, Mouhsine E, Theumann N, Mordasini P, van Melle G, Leyvraz PF, et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi-detector row CT. Radiology 2003; 227: 681–9. doi: 10.1148/radiol.2273020592

11. Kim S, Yoon CS, Ryu JA, Lee S, Park YS, Kim SS, et al. A comparison of the diagnostic performances of visceral organ-targeted ver- sus spine-targeted protocols for the evalua- tion of spinal fractures using sixteen-channel multidetector row computed tomography: is additional spine-targeted computed tomog- raphy necessary to evaluate thoracolumbar spinal fractures in blunt trauma victims? J Trauma 2010; 69: 437–46. doi: 10.1097/ TA.0b013e3181e491d8

12. Pizones J, Castillo E. Assessment of acute thoracolumbar fractures: challenges in mul- tidetector computed tomography and added value of emergency MRI. Semin Musculoskelet Radiol 2013; 17: 389–95. doi: 10.1055/s- 0033-1356468

13. Emery SE, Pathria MN, Wilber RG, Masaryk T, Bohlman HH. Magnetic resonance imag- ing of posttraumatic spinal ligament injury. J Spinal Disord 1989; 2: 229–33. doi: 10.1097/ 00002517-198912000-00003

14. Zhang JS, Huan Y. Multishot diffusion- weighted MR imaging features in acute trauma of spinal cord. Eur Radiol 2014; 24: 685–92. doi: 10.1007/s00330-013-3051-3

15. Talbott JF, Whetstone WD, Readdy WJ, Ferguson AR, Bresnahan JC, Saigal R, et al. The Brain and Spinal Injury Center score:
a novel, simple, and reproducible method for assessing the severity of acute cervical spinal cord injury with axial T2-weighted MRI findings. J Neurosurg Spine 2015; 23: 495–504. doi: 10.3171/2015.1.SPINE141033

16. Boese CK, Oppermann J, Siewe J, Eysel P, Scheyerer MJ, Lechler PJ. Spinal cord injury without radiologic abnormality in children: a systematic review and meta-analysis. Trauma Acute Care Surg 2015; 78: 874–82. doi: 10.1097/TA.0000000000000579

17. Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of
103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg 2001; 36: 1107–14. doi: 10.1053/jpsu.2001.25665

18. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 1983; 8: 817–31. doi: 10.1097/ 00007632-198311000-00003

19. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3: 184–201.

20. Patel AA, Dailey A, Brodke DS, Daubs M, Harrop J, Whang PG, et al; Spine Trauma Study Group. Thoracolumbar spine trauma classification: the Thoracolumbar Injury Classification and Severity Score system and case examples. J Neurosurg Spine 2009; 10: 201–6. doi: 10.3171/2008.12.SPINE08388

21. Aebi M. Classification of thoracolumbar fractures and dislocations. Eur Spine J 2010; 19(Suppl. 1): S2–7. doi: 10.1007/s00586-009-1114-6

22. Muto M, Marcia S, Guarnieri G, Pereira V. Assisted techniques for vertebral cementoplasty: why should we do it? Eur J Radiol 2015; 84: 783–8. doi: 10.1016/j.ejrad.2014.04.002

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Lumbar Disc Nomenclature: Version 2.0

Lumbar Disc Nomenclature: Version 2.0

What is a Herniated Disc?

The spine is made up of 24 bones, called vertebrae, which are stacked on top of one another. These spinal bones are ultimately connected, creating a canal to protect the spinal cord. In between each vertebra are fluid-filled intervertebral discs which act as shock absorbers for the spine. Over time, however, these flexible, jelly donut-like discs can begin to herniate, where the nucleus of the intervertebral disc pushes against its outer ring, causing low back pain. Below, we will demonstrate the various types of herniated discs and discuss their causes, symptoms and treatment options.

Abstract

Background Context

The paper ‘‘Nomenclature and classification of lumbar disc pathology, recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology,’’ was published in 2001 in Spine (© Lippincott, Williams & Wilkins). It was authored by David Fardon, MD, and Pierre Milette, MD, and formally endorsed by the American Society of Spine Radiology (ASSR), American Society of Neuroradiology (ASNR), and North American Spine Society (NASS). Its purpose was to promote greater clarity and consistency of usage of spinal terminology, and it has served this purpose well for over a decade. Since 2001, there has been sufficient evolution in our understanding of the lumbar disc to suggest the need for revision and updating of the original document. The revised document is presented here, and it represents the consensus recommendations of contemporary combined task forces of the ASSR, ASNR, and NASS. This article reflects changes consistent with current concepts in radiologic and clinical care.

Purpose

To provide a resource that promotes a clear understanding of lumbar disc terminology amongst clinicians, radiologists, and researchers. All the concerned need standard terms for the normal and pathologic conditions of lumbar discs that can be used accurately and consistently and thus best serve patients with disc disorders.

Study Design

This article comprises a review of the literature.

Methods

A PubMed search was performed for literature pertaining to the lumbar disc. The task force members individually and collectively reviewed the literature and revised the 2001 document. The revised document was then submitted for review to the governing boards of the ASSR, ASNR, and NASS. After further revision based on the feedback from the governing boards, the article was approved for publication by the governing boards of the three societies, as representative of the consensus recommendations of the societies.

Results

The article provides a discussion of the recommended diagnostic categories pertaining to the lumbar disc: normal; congenital/developmental variation; degeneration; trauma; infection/inflammation; neoplasia; and/or morphologic variant of uncertain significance. The article provides a glossary of terms pertaining to the lumbar disc, a detailed discussion of these terms, and their recommended usage. Terms are described as preferred, nonpreferred, nonstandard, and colloquial. Updated illustrations pictorially portray certain key terms. Literature references that provided the basis for the task force recommendations are included.

Conclusions

We have revised and updated a document that, since 2001, has provided a widely acceptable nomenclature that helps maintain consistency and accuracy in the description of the anatomic and physiologic properties of the normal and abnormal lumbar disc and that serves as a system for classification and reporting built upon that nomenclature.

Keywords

Annular fissure, Annular tear, Disc bulge (bulging disc), Disc degeneration, Disc extrusion, Disc herniation, Disc nomenclature, Disc protrusion, High-intensity zone, Lumbar intervertebral disc

Preface

The nomenclature and classification of lumbar disc pathology consensus, published in 2001, by the collaborative efforts of the North American Spine Society (NASS), the American Society of Spine Radiology (ASSR) and the American Society of Neuroradiology (ASNR), has guided radiologists, clinicians, and interested public for over a decade [1]. This document has passed the test of time. Responding to an initiative from the ASSR, a task force of spine physicians from the ASSR, ASNR, and NASS has reviewed and modified the document. This revised document preserves the format and most of the language of the original, with changes consistent with current concepts in radiologic and clinical care. The modifications deal primarily with the following: updating and expansion of Text, Glossary, and References to meet contemporary needs; revision of Figures to provide greater clarity; emphasis of the term ‘‘annular fissure’’ in place of ‘‘annular tear’’; refinement of the definitions of ‘‘acute’’ and ‘‘chronic’’ disc herniations; revision of the distinction between disc herniation and asymmetrically bulging disc; elimination of the Tables in favor of greater clarity from the revised Text and Figures; and deletion of the section of Reporting and Coding because of frequent changes in those practices, which are best addressed by other publications. Several other minor amendments have been made. This revision will update a workable standard nomenclature, accepted and used universally by imaging and clinical physicians.

Introduction and History

Physicians need standard terms for normal and pathologic conditions of lumbar discs [2, 3, 4, 5]. Terms that can be interpreted accurately, consistently, and with reasonable precision are particularly important for communicating impressions gained from imaging for clinical diagnostic and therapeutic decision-making. Although clear understanding of the disc terminology between radiologists and clinicians is the focus of this work, such understanding can be critical, also to patients, families, employers, insurers, jurists, social planners, and researchers.

In 1995, a multidisciplinary task force from the NASS addressed the deficiencies in commonly used terms defining the conditions of the lumbar disc. It cited several documentations of the problem [6, 7, 8, 9, 10, 11] and made detailed recommendations for standardization. Its work was published in a copublication of the NASS and the American Academy of Orthopaedic Surgeons [9]. The work had not been otherwise endorsed by major organizations and had not been recognized as authoritative by radiology organizations. Many previous [3, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19] and some subsequent [20, 21, 22, 23, 24, 25] efforts addressed the issues, but were of more limited scope and none had gained a widespread acceptance.

Although the NASS 1995 effort was the most comprehensive at the time, it remained deficient in clarifying some controversial topics, lacking in its treatment of some issues, and did not provide recommendations for standardization of classification and reporting. To address the remaining needs, and in hopes of securing endorsement sufficient to result in universal standardizations, joint task forces (Co-Chairs David Fardon, MD, and Pierre Milette, MD) were formed by the NASS, ASNR, and ASSR, resulting in the first version of the document ‘‘Nomenclature and classification of lumbar disc pathology’’ [1]. Since then, time and experience suggested the need for revisions and updating of the original document. The revised document is presented here.

The general principles that guided the original document remain unchanged in this revision. The definitions are based on the anatomy and pathology, primarily as visualized on imaging studies. Recognizing that some criteria, under some circumstances, may be unknowable to the observer, the definitions of the terms are not dependent on or imply the value of specific tests. The definitions of diagnoses are not intended to imply external etiologic events such as trauma, they do not imply relationship to symptoms, and they do not define or imply the need for specific treatment.

The task forces, both current and former, worked from a model that could be expanded from a primary purpose of providing understanding of reports of imaging studies. The result provides a simple classification of diagnostic terms, which can be expanded, without contradiction, into more precise subclassifications. When reporting pathology, degrees of uncertainty would be labeled as such rather than compromising the definitions of the terms.

All terms used in the classifications and subclassifications are defined and those definitions are adhered to throughout the model. For a practical purpose, some existing English terms are given meanings different from those found in some contemporary dictionaries. The task forces provide a list and classification of the recommended terms, but, recognizing the nature of language practices, discuss and include in the Glossary, commonly used and misused nonrecommended terms and nonstandard definitions.

Although the principles and most of the definitions of this document can be easily extrapolated to the cervical and dorsal spine, the focus is on the lumbar spine. Although clarification of terms related to posterior elements, dimensions of the spinal canal, and status of neural tissues is needed, this work is limited to the discussion of the disc. While it is not always possible to discuss fully the definition of anatomical and pathologic terms without some reference to symptoms and etiology, the definitions themselves stand the test of independence from etiology, symptoms, or treatment. Because of the focus on anatomy and pathology, this work does not define certain clinical syndromes that may be related to lumbar disc pathology [26].

Guided by those principles, we have revised and updated a document that, since 2001, has provided a widely acceptable nomenclature that is workable for all forms of observation, that addresses contour, content, integrity, organization, and spatial relationships of the lumbar disc; and that serves a system of classification and reporting built upon that nomenclature.

Diagnostic Category & Subcategory Recommendations

These recommendations present diagnostic categories and subcategories intended for classification and reporting of imaging studies. The terminology used throughout these recommended categories and subcategories remains consistent with detailed explanations given in the Discussion and with the preferred definitions presented in the Glossary.

The diagnostic categories are based on pathology. Each lumbar disc can be classified in terms of one, and occasionally more than one, of the following diagnostic categories: normal; congenital/developmental variation; degeneration; trauma; infection/inflammation; neoplasia; and/or morphologic variant of uncertain significance. Each diagnostic category can be subcategorized to various degrees of specificity according to the information available and purpose to be served. The data available for categorization may lead the reporter to characterize the interpretation as ‘‘possible,’’ ‘‘probable,’’ or ‘‘definite.’’

Note that some terms and definitions discussed below are not recommended as preferred terminology, but are included to facilitate the interpretation of vernacular and, in some cases, improper use. Terms may be defined as preferred, nonpreferred, or nonstandard. Nonstandard terms by consensus of the organizational task forces should not be used in the manner described.

Normal

Normal defines discs that are morphologically normal, without the consideration of the clinical context and not inclusive of degenerative, developmental, or adaptive changes that could, in some contexts (eg, normal aging, scoliosis, spondylolisthesis), be considered clinically normal (Fig. 1).

Figure 1: Normal lumbar disc. (Top Left) Axial, (Top Right) sagittal, and (Bottom) coronal images demonstrate that the normal disc, composed of central NP and peripheral AF, is wholly within the boundaries of the disc space, as defined, craniad and caudad by the vertebral body end plates and peripherally by the planes of the outer edges of the vertebral apophyses, exclusive of osteophytes. NP, nucleus pulposus; AF, annulus fibrosus.

Congenital/Developmental Variation

The congenital/developmental variation category includes discs that are congenitally abnormal or that have undergone changes in their morphology as an adaptation of abnormal growth of the spine, such as from scoliosis or spondylolisthesis.

Degeneration

Degenerative changes in the discs are included in a broad category that includes the subcategories annular fissure, degeneration, and herniation.

Annular fissures are separations between the annular fibers or separations of annular fibers from their attachments to the vertebral bone. Fissures are sometimes classified by their orientation. A ‘‘concentric fissure’’ is a separation or delamination of annular fibers parallel to the peripheral contour of the disc (Fig. 2). A ‘‘radial fissure’’ is a vertically, horizontally, or obliquely oriented separation of (or rent in) annular fibers that extends from the nucleus peripherally to or through the annulus. A ‘‘transverse fissure’’ is a horizontally oriented radial fissure, but the term is sometimes used in a narrower sense to refer to a horizontally oriented fissure limited to the peripheral annulus that may include separation of annular fibers from the apophyseal bone. Relatively wide annular fissures, with stretch of the residual annular margin, at times including avulsion of an annular fragment, have sometimes been called ‘‘annular gaps,’’ a term that is relatively new and not accepted as standard [27]. The term ‘‘fissures’’ describes the spectrum of these lesions and does not imply that the lesion is a consequence of injury.

Figure 2: Fissures of the annulus fibrosus. Fissures of the annulus fibrosus occur as radial (R), transverse (T), and/or concentric (C) separations of fibers of the annulus. The transverse fissure depicted is a fully developed, horizontally oriented radial fissure; the term ‘‘transverse fissure’’ is often applied to a less extensive separation limited to the peripheral annulus and its bony attachments.

Use of the term ‘‘tear’’ can be misunderstood because the analogy to other tears has a connotation of injury, which is inappropriate in this context. The term ‘‘fissure’’ is the correct term. Use of the term ‘‘tear’’ should be discouraged and, when it appears, should be recognized that it is usually meant to be synonymous with ‘‘fissure’’ and not reflective of the result of injury. The original version of this document stated preference for the term ‘‘fissure’’ but regarded the two terms as almost synonymous. However, in this revision, we regard the term ‘‘tear’’ as nonstandard usage.

Degeneration may include any or all of the following: desiccation, fibrosis, narrowing of the disc space, diffuse bulging of the annulus beyond the disc space, fissuring (ie, annular fissures), mucinous degeneration of the annulus, intradiscal gas [28], osteophytes of the vertebral apophyses, defects, inflammatory changes, and sclerosis of the end plates [15, 29, 30, 31, 32, 33, 34].

Herniation is broadly defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space. The disc material may be nucleus, cartilage, fragmented apophyseal bone, annular tissue, or any combination thereof. The disc space is defined craniad and caudad by the vertebral body end plates and, peripherally, by the outer edges of the vertebral ring apophyses, exclusive of osteophytes. The term ‘‘localized’’ or ‘‘focal’’ refers to the extension of the disc material less than 25% (90°) of the periphery of the disc as viewed in the axial plane.

The presence of disc tissue extending beyond the edges of the ring apophyses, throughout the circumference of the disc, is called ‘‘bulging’’ and is not considered a form of herniation (Fig. 3, Top Right). Asymmetric bulging of disc tissue greater than 25% of the disc circumference (Fig. 3, Bottom), often seen as an adaptation to adjacent deformity, is, also, not a form of herniation. In evaluating the shape of the disc for a herniation in an axial plane, the shape of the two adjacent vertebrae must be considered [15, 35].

Figure 3: Bulging disc. (Top Left) Normal disc (for comparison); no disc material extends beyond the periphery of the disc space, depicted here by the broken line. (Top Right) Symmetric bulging disc; annular tissue extends, usually by less than 3 mm, beyond the edges of the vertebral apophyses symmetrically throughout the circumference of the disc. (Bottom) Asymmetric bulging disc; annular tissue extends beyond the edges of the vertebral apophysis, asymmetrically greater than 25% of the circumference of the disc.

Herniated discs may be classified as protrusion or extrusion, based on the shape of the displaced material.

Protrusion is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space. The base is defined as the width of disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with the disc material within the disc space (Fig. 4). Extrusion is present when, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material beyond the disc space or when no continuity exists between the disc material beyond the disc space and that within the disc space (Fig. 5). The latter form of extrusion is best further specified or subclassified as sequestration if the displaced disc material has lost continuity completely with the parent disc (Fig. 6). The term migration may be used to signify displacement of disc material away from the site of extrusion. Herniated discs in the craniocaudad (vertical) direction through a gap in the vertebral body end plate are referred to as intravertebral herniations (Schmorl nodes) (Fig. 7).

Figure 4: Herniated disc: protrusion. (Left) Axial and (Right) sagittal images demonstrate displaced disc material extending beyond less than 25% of the disc space, with the greatest measure, in any plane, of the displaced disc material being less than the measure of the base of displaced disc material at the disc space of origin, measured in the same plane.
Figure 5: Herniated disc: extrusion. (Left) Axial and (Right) sagittal images demonstrate that the greatest measure of the displaced disc material is greater than the base of the displaced disc material at the disc space of origin, when measured in the same plane.
Figure 6: Herniated disc: sequestration. (Left) Axial and (Right) sagittal images show that a sequestrated disc is an extruded disc in which the displaced disc material has lost all connection with the disc of origin.
Figure 7: Intravertebral herniation (Schmorl node). Disc material is displaced beyond the disc space through the vertebral end plate into the vertebral body, as shown here in sagittal projection

Disc herniations may be further specifically categorized as contained, if the displaced portion is covered by outer annulus fibers and/or the posterior longitudinal ligament, or uncontained when absent of any such covering. If the margins of the disc protrusion are smooth on axial computed tomography (CT) or magnetic resonance imaging (MRI), then the displaced disc material is likely contained by the posterior longitudinal ligament and perhaps a few superficial posterior annular fibers [21, 35, 36, 37]. If the posterior margin of the disc protrusion is irregular, the herniation is likely uncontained. Displaced disc tissue is typically described by location, volume, and content, as discussed later in this document.

An alternative scheme of distinguishing protrusion from extrusion is discussed in the Discussion section.

Trauma

The category of trauma includes disruption of the disc associated with physical and/or imaging evidence of violent fracture and/or dislocation and does not include repetitive injury, contribution of less than violent trauma to the degenerative process, fragmentation of the ring apophysis in conjunction with disc herniation, or disc abnormalities in association with degenerative subluxations. Whether or not a ‘‘less than violent’’ injury has contributed to or been superimposed on a degenerative change is a clinical judgment that cannot be made based on images alone; therefore, from the standpoint of description of images, such discs, in the absence of significant imaging evidence of associated violent injury, should be classified as degeneration rather than trauma.

Inflammation/Infection

The category of inflammation/infection includes infection, infection-like inflammatory discitis, and inflammatory response to spondyloarthropathy. It also includes inflammatory spondylitis of the subchondral end plate and bone marrow manifested by Modic Type I MRI changes [29, 30, 38] and usually associated with degenerative pathologic changes in the disc. To simplify the classification scheme, the category is inclusive of disparate conditions; therefore, when data permit, the diagnosis should be subcategorized for appropriate specificity.

Neoplasia

Primary or metastatic morphologic changes of disc tissues caused by malignancy are categorized as neoplasia, with subcategorization for appropriate specificity.

Miscellaneous Paradiscal Masses of Uncertain Origin

Although most intraspinal cysts are of meningeal or synovial origin, a minority arise from the disc and create a paradiscal mass that does not contain nuclear material. Epidural bleeding and/or edema, unrelated to trauma or other known origin may create a paradiscal mass or may increase the size of herniated disc material. Such cysts and hematomas may be seen acutely and unaccompanied by other pathology or may be a component of chronic disc pathology.

Morphologic Variant of Unknown Significance

Instances in which data suggest abnormal morphology of the disc, but in which data are not complete enough to support a diagnostic categorization can be categorized as a morphologic variant of unknown significance.

Discussion of Nomenclature in Detail

This document provides a nomenclature that facilitates the description of surgical, endoscopic, or cadaveric findings as well as imaging findings; and also, with the caveat that it addresses only the morphology of the disc, it facilitates communication for patients, families, employers, insurers, and legal and social authorities and permits accumulation of more reliable data for research.

Normal Disc

Categorization of a disc as ‘‘normal’’ means the disc is fully and normally developed and free of any changes of disease, trauma, or aging. Only the morphology, and not the clinical context, is considered. Clinically ‘‘normal’’ (asymptomatic) people may have a variety of harmless imaging findings, including congenital or developmental variations of discs, minor bulging of the annuli, age-related desiccation, anterior and lateral marginal vertebral body osteophytes, prominence of disc material beyond one end plate as a result of luxation of one vertebral body relative to the adjacent vertebral body (especially common at L5–S1), and so on [39]. By this article’s morphology-based nomenclature and classification, however, such individual discs are not considered ‘‘normal,’’ but rather are described by their morphologic characteristics, independent of their clinical import unless otherwise specified.

Disc with Fissures of the Annulus

There is a general agreement about the various forms of loss of integrity of the annulus, such as radial, transverse, and concentric fissures. Yu et al. [40] have shown that annular fissures, including radial, concentric, and transverse types, are present in nearly all degenerated discs [41]. If the disc is dehydrated on an MRI scan, it is likely that there is at least one or more small fissures in the annulus. Relatively wide, radially directed annular fissures, with stretch of the residual annular margin, at times involving avulsion of an annular fragment, have sometimes been called ‘‘annular gaps,’’ although the term is relatively new and not accepted as a standard [27].

The terms ‘‘annular fissure’’ and ‘‘annular tear’’ have been applied to the findings on T2-weighted MRI scans of localized high intensity zones (HIZ) within the annulus [30, 42, 43, 44]. High intensity zones represent fluid and/or granulation tissue and may enhance with gadolinium. Fissures occur in all degenerative discs but are not all visualized as HIZs. Discography reveals some fissures not seen by the MRI, but not all fissures are visualized by discography. Description of the imaging findings is most accurate when limited to the observation of an HIZ or discographically demonstrated fissure, with the understood caveat that there is an incomplete concordance with the HIZs, discogram images, and anatomically observed fissures.

As far back as the 1995 NASS document, authors have recommended that such lesions be termed ‘‘fissures’’ rather than ‘‘tears,’’ primarily out of concern that the word ‘‘tear’’ could be misconstrued as implying a traumatic etiology [9, 30, 45, 46]. Because of potential misunderstanding of the term ‘‘annular tear,’’ and consequent presumption that the finding of an annular fissure indicates that there has been an injury, the term ‘‘annular tear’’ should be considered nonstandard and ‘‘annular fissure’’ be the preferred term. Imaging observation of an annular fissure does not imply an injury or related symptoms, but simply defines the morphologic change in the annulus.

Degenerated Disc

Because there is a confusion in the differentiation of changes of pathologic degenerative processes in the disc from those of normal aging [17, 31, 47, 48, 49], the classification ‘‘degenerated disc’’ includes all such changes, thus does not compel the observer to differentiate the pathologic from the normal consequence of aging.

Perceptions of what constitutes the normal aging process of the spine have been greatly influenced by postmortem anatomic studies involving a limited number of specimens, harvested from cadavers from different age groups, with unknown past medical histories and the presumption of absence of lumbar symptoms [23, 50, 51, 52, 53, 54, 55, 56, 57]. With such methods, pathologic change is easily confused with consequences of normal aging. Resnick and Niwayama [31] emphasized the differentiating features of two degenerative processes involving the intervertebral disc that had been previously described by Schmorl and Junghanns [58]; ‘‘spondylosis deformans,’’ which affects essentially the annulus fibrosus and adjacent apophyses (Fig. 8, Left) and ‘‘intervertebral osteochondrosis,’’ which affects mainly the nucleus pulposus and the vertebral body end plates and may include extensive fissuring of the annulus fibrosus that may be followed by atrophy (Fig. 8, Right). Although Resnick and Niwayama stated that the cause of the two entities was unknown, other studies suggest that spondylosis deformans is the consequence of normal aging, whereas intervertebral osteochondrosis, sometimes also called ‘‘deteriorated disc,’’ results from a clearly pathologic, although not necessarily symptomatic, process [29, 31, 42, 59, 60].

Figure 8: Types of disc degeneration by radiographic criteria. (Left) Spondylosis deformans is manifested by apophyseal osteophytes, with relative preservation of the disc space. (Right) Intervertebral osteochondrosis is typified by disc space narrowing, severe fissuring, and end plate cartilage erosion.

Degrees of disc degeneration have been graded based on gross morphology of midsagittal sections of the lumbar spine (Thompson scheme) [19]; postdiscography CT observations of integrity of the interior of the disc (Dallas classification) (Fig. 9) [42]; MRI observations of vertebral body marrow changes adjacent to the disc (Modic classification) [30], (Fig. 10); and MRI-revealed changes in the nucleus (Pfirrmann classification) [61]. Various modifications of these schemes have been proposed to suit specific clinical and research needs [17, 35, 62, 63].

Figure 9: Internal disc integrity. The extent of radial fissuring, as visualized on postdiscography CT, graded 0 to 5 by the Modified Dallas Discogram classification, as depicted.
Figure 10: Reactive vertebral body marrow changes. These bone marrow signal changes adjacent to a degenerated disc on magnetic resonance imaging. T1- and T2-weighted sequences are frequently classified as (Top Left) Modic I, (Top Right) Modic II, or (Bottom) Modic III.

Herniated Disc

The needs of common practices make necessary a diagnostic term that describes disc material beyond the intervertebral disc space. Herniated disc, herniated nucleus pulposus (HNP), ruptured disc, prolapsed disc (used nonspecifically), protruded disc (used nonspecifically), and bulging disc (used nonspecifically) have all been used in the literature in various ways to denote imprecisely defined displacement of disc material beyond the interspace. The absence of clear understanding of the meaning of these terms and the lack of definition of limits that should be placed on an ideal general term have created a great deal of confusion in clinical practice and in attempts to make meaningful comparisons of research studies.

For the general diagnosis of displacement of disc material, the single term that is most commonly used and creates least confusion is ‘‘herniated disc.’’ ‘‘Herniated nucleus pulposus’’ is inaccurate because materials other than nucleus (cartilage, fragmented apophyseal bone, and fragmented annulus) are common components of displaced disc material [64]. ‘‘Rupture’’ casts an image of tearing apart and therefore carries more implication of traumatic etiology than ‘‘herniation,’’ which conveys an image of displacement rather than disruption.

Though ‘‘protrusion’’ has been used by some authors in a nonspecific general sense to signify any displacement, the term has a more commonly used specific meaning for which it is best reserved. ‘‘Prolapse,’’ which has been used as a general term, as synonymous with the specific meaning of protrusion, or to denote inferior migration of extruded disc material, is not frequently used in a way to provide specific meaning and is best regarded as nonstandard, in deference to the more specific terms ‘‘protrusion’’ and ‘‘extrusion.’’

By exclusion of other terms, and by reasons of simplicity and common usage, ‘‘herniated disc’’ is the best general term to denote displacement of disc material. The term is appropriate to denote the general diagnostic category when referring to a specific disc and to be inclusive of various types of displacements when speaking of groups of discs. The term includes discs that may properly be characterized by more specific terms, such as ‘‘protruded disc’’ or ‘‘extruded disc.’’ The term ‘‘herniated disc,’’ as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space. ‘‘Localized’’ is defined as less than 25% of the disc circumference. The disc space is defined, craniad and caudad, by the vertebral body end plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of the osteophyte formation. This definition was deemed more practical, especially for the interpretation of imaging studies, than a pathologic definition requiring identification of disc material forced out of normal position through an annular defect. Displacement of disc material, either through a fracture or defect in the bony end plate or in conjunction with displaced fragments of fractured walls of the vertebral body, may be described as ‘‘herniated’’ disc, although such description should accompany description of the fracture so as to avoid confusion with primary herniation of disc material. Displacement of disc materials from one location to another within the interspace, as with intraannular migration of nucleus without displacement beyond the interspace, is not considered herniation.

To be considered ‘‘herniated,’’ disc material must be displaced from its normal location and not simply represent an acquired growth beyond the edges of the apophyses, as is the case when connective tissues develop in gaps between osteophytes or when annular tissue is displaced behind one vertebra as an adaptation to subluxation. Herniation, therefore, can only occur in association with disruption of the normal annulus or, as in the case of intravertebral herniation (Schmorl node), a defect in the vertebral body end plate.

Details of the internal architecture of the annulus are most often not visualized by even the best quality MRIs [21]. The distinction of herniation is made by the observation of displacement of disc material beyond the edges of the ring apophysis that is ‘‘focal’’ or ‘‘localized,’’ meaning less than 25% of the circumference of the disc. The 25% cutoff line is established by way of convention to lend precision to terminology and does not designate etiology, relation to symptoms, or treatment indications.

The terms ‘‘bulge’’ or ‘‘bulging’’ refer to a generalized extension of disc tissue beyond the edges of the apophyses [65]. Such bulging involves greater than 25% of the circumference of the disc and typically extends a relatively short distance, usually less than 3 mm, beyond the edges of the apophyses (Fig. 3). ‘‘Bulge’’ or ‘‘bulging’’ describes a morphologic characteristic of various possible causes. Bulging is sometimes a normal variant (usually at L5–S1), can result from an advanced disc degeneration or from a vertebral body remodeling (as consequent to osteoporosis, trauma, or adjacent structure deformity), can occur with ligamentous laxity in response to loading or angular motion, can be an illusion caused by posterior central subligamentous disc protrusion, or can be an illusion from volume averaging (particularly with CT axial images).

Bulging, by definition, is not a herniation. Application of the term ‘‘bulging’’ to a disc does not imply any knowledge of etiology, prognosis, or need for treatment or imply the presence of symptoms.

A disc may have, simultaneously, more than one herniation. A disc herniation may be present along with other degenerative changes, fractures, or abnormalities of the disc. The term ‘‘herniated disc’’ does not imply any knowledge of etiology, relation to symptoms, prognosis, or need for treatment.

When data are sufficient to make the distinction, a herniated disc may be more specifically characterized as ‘‘protruded’’ or ‘‘extruded.’’ These distinctions are based on the shape of the displaced material. They do not imply knowledge of the mechanism by which the changes occurred.

Protruded Discs

Disc protrusions are focal or localized abnormalities of the disc margin that involve less than 25% of the disc circumference. A disc is ‘‘protruded’’ if the greatest dimension between the edges of the disc material presenting beyond the disc space is less than the distance between the edges of the base of that disc material that extends outside the disc space. The base is defined as the width of the disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with the disc material within the disc space (Fig. 4). The term ‘‘protrusion’’ is only appropriate in describing herniated disc material, as discussed previously.

Extruded Discs

The term ‘‘extruded’’ is consistent with the lay language meaning of material forced from one domain to another through an aperture [37, 64]. With reference to a disc, the test of extrusion is the judgment that, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base measured in the same plane or when no continuity exists between the disc material beyond the disc space and that within the disc space (Fig. 5). Extruded disc material that has no continuity with the disc of origin may be characterized as ‘‘sequestrated’’ [53, 66] (Fig. 6). A sequestrated disc is a subtype of ‘‘extruded disc’’ but, by definition, can never be a ‘‘protruded disc.’’ Extruded disc material that is displaced away from the site of extrusion, regardless of continuity with the disc, may be called ‘‘migrated,’’ a term that is useful for the interpretation of imaging studies because it is often impossible from images to know if continuity exists.

The aforementioned distinctions between protrusion and extrusion and between contained and uncontained are based on common practice and wide acceptance of the definitions in the original version of this document. Another set of criteria, espoused by some respected practitioners, defines extrusion as uncontained and protrusion as a persistence of containment, regardless of the relative dimensions of the base to displaced portion of disc material. Per these criteria, a disc extrusion can be identified by the presence of a continuous line of low signal intensity surrounding the disc herniation. They state that current advanced imaging permits this basis of distinction and that the presence or absence of containment has more clinical relevance than the morphology of the displaced material [35].

Whether their method will prove superior to the currently recommended method will be determined by future study. The use of the distinction between ‘‘protrusion’’ and ‘‘extrusion’’ is optional and some observers may prefer to use, in all cases, the more general term ‘‘herniation.’’ Further distinctions can often be made regarding containment, continuity, volume, composition, and location of the displaced disc material.

Containment, Continuity, and Migration

Herniated disc material can be ‘‘contained’’ or ‘‘uncontained.’’ The test of containment is whether the displaced disc tissues are wholly held within intact outer annulus and/or posterior longitudinal ligament fibers. Fluid or any contrast that has been injected into a disc with a ‘‘contained’’ herniation would not be expected to leak into the vertebral canal. Although the posterior longitudinal ligament and/or peridural membrane may partially cover the extruded disc tissues, such discs are not considered ‘‘contained’’ unless the posterior longitudinal ligament is intact. The technical limitations of currently available noninvasive imaging modalities (CT and MRI) often preclude the distinction of a contained from an uncontained disc herniation. CT-discography does not always allow one to distinguish whether the herniated components of a disc are contained, but only whether there is a communication between the disc space and the vertebral canal.

Displaced disc fragments are sometimes characterized as ‘‘free.’’ A ‘‘free fragment’’ is synonymous with a ‘‘sequestrated fragment,’’ but not synonymous with ‘‘uncontained.’’ A disc fragment should be considered ‘‘free’’ or ‘‘sequestrated’’ only if there is no remaining continuity of the disc material between it and the disc of origin. A disc can be ‘‘uncontained,’’ with the loss of integrity of the posterior longitudinal ligament and the outer annulus, but still have continuity between the herniated/displaced disc material and the disc of origin.

The term ‘‘migrated’’ disc or fragment refers to the displacement of most of the displaced disc material away from the opening in the annulus through which the material has extruded. Some migrated fragments will be sequestrated, but the term ‘‘migrated’’ refers only to position and not to continuity.

The terms ‘‘capsule’’ and ‘‘subcapsular’’ have been used to refer to containment by an unspecified combination of annulus and ligament. These terms are nonpreferred.

Referring specifically to the posterior longitudinal ligament, some authors have distinguished displaced disc material as ‘‘subligamentous,’’ ‘‘extraligamentous,’’ ‘‘transligamentous,’’ or ‘‘perforated.’’ The term ‘‘subligamentous’’ is favored as an equivalent to ‘‘contained.’’

Volume and Composition of Displaced Material

A scheme to define the degree of canal compromise produced by disc displacement should be practical, objective, reasonably precise, and clinically relevant. A simple scheme that fulfills the criteria uses two-dimensional measurements taken from an axial section at the site of the most severe compromise. Canal compromise of less than one third of the canal at that section is ‘‘mild,’’ between one and two-thirds is ‘‘moderate,’’ and greater than two-thirds is ‘‘severe.’’ The same grading can be applied for foraminal involvement.

Such characterizations of volume describe only the cross-sectional area at one section and do not account for the total volume of displaced material; proximity to, compression, and distortion of neural structures; or other potentially significant features, which the observer may further detail by narrative description.

Composition of the displaced material may be characterized by terms such as nuclear, cartilaginous, bony, calcified, ossified, collagenous, scarred, desiccated, gaseous, or liquefied.

Clinical significance related to the observation of volume and composition depends on the correlation with clinical data and cannot be inferred from morphologic data alone.

Location

Bonneville proposed a useful and simple alphanumeric system to classify, according to location, the position of disc fragments that have migrated in the horizontal or sagittal plane [6, 13]. Using anatomic boundaries familiar to surgeons, Wiltse proposed another system [14, 67]. Anatomic ‘‘zones’’ and ‘‘levels’’ are defined using the following landmarks: medial edge of the articular facets; medial, lateral, upper, and lower borders of the pedicles; and coronal and sagittal planes at the center of the disc. On the horizontal (axial) plane, these landmarks determine the boundaries of the central zone, the subarticular zone (lateral recess), the foraminal zone, the extraforaminal zone, and the anterior zone, respectively (Fig. 11). On the sagittal (craniocaudal) plane, they determine the boundaries of the disc level, the infrapedicular level, the pedicular level, and the suprapedicular level, respectively (Fig. 12). The method is not as precise as the drawings depict because borderlines such as the medial edges of facets and the walls of the pedicles are curved, but the method is simple, practical, and in common usage.

Figure 11: Anatomic zones depicted in axial and coronal projections.
Figure 12: Anatomic levels depicted in sagittal and coronal projections.

Moving from the central to right lateral in the axial (horizontal) plane, location may be defined as central, right central, right subarticular, right foraminal, or right extraforaminal. The term ‘‘paracentral’’ is less precise than defining ‘‘right central’’ or ‘‘left central,’’ but is useful in describing groups of discs that include both, or when speaking informally, when the side is not significant. For reporting of image observations of a specific disc, ‘‘right central’’ or ‘‘left central’’ should supersede the use of the term ‘‘paracentral.’’ The term ‘‘far lateral’’ is sometimes used synonymously with ‘‘extraforaminal.’’

In the sagittal plane, location may be defined as discal, infrapedicular, suprapedicular, or pedicular. In the coronal plane, anterior, in relationship to the disc, means ventral to the midcoronal plane of the centrum.

Glossary

Note: some terms and definitions included in this Glossary are not recommended as preferred terminology but are included to facilitate the interpretation of vernacular and, in some cases, improper use. Preferred definitions are listed first. Nonstandard definitions are placed in brackets, and by consensus of the organizational task forces, should not be used in the manner described. Some terms are also labeled as colloquial, with further designation as to whether they are considered nonpreferred or nonstandard.

Acute disc herniation: disc herniation of a relatively recent occurrence. Note: paradiscal inflammatory reaction and relatively bright signal of the disc material on T2-weighted images suggest relative acuteness. Such changes may persist for months, however. Thus, absent clinical correlation and/or serial studies, it is not possible to date precisely by imaging when a herniation occurred. An acutely herniated disc material may have brighter signal on T2-weighted MRI sequences than the disc from which the disc material originates [46596468]. Note that a relatively acute herniation can be superimposed on a previously existing herniation. An acute disc herniation may regress spontaneously without specific treatment. See: chronic disc herniation.

Aging disc: disc demonstrating any of the various effects of aging on the disc. Loss of water content from the nucleus occurs before MRI changes, followed by the progression of MRI manifested changes consistent with the progressive loss of water content and increase in collagen and aggregating proteoglycans. See Pfirrmann classification.

Annular fissure: separations between annular fibers, separations of fibers from their vertebral body insertions, or separations of fibers that extend radially, transversely, or concentrically, involving one or many layers of the annular lamellae. Note that the terms ‘‘fissure’’ and ‘‘tear’’ have often been used synonymously in the past. The term ‘‘tear’’ is inappropriate for use in describing imaging findings and should not be used (tear: nonstandard). Neither term suggests injury or implies any knowledge of etiology, neither term implies any relationship to symptoms or that the disc is a likely pain generator, and neither term implies any need for treatment. See also: annular gap, annular rupture, annular tear, concentric fissure, HIZ, radial fissure, transverse fissure.

Annular gap (nonstandard): focal attenuation (CT) or signal (MRI) abnormality, often triangular in shape, in the posterior aspect of the disc, likely representing widening of a radially directed annular fissure, bilateral annular fissures with an avulsion of the intermediate annular fragment, or an avulsion of a focal zone of macerated annulus.

Annular rupture: disruption of fibers of the annulus by sudden violent injury. This is a clinical diagnosis; use of the term is inappropriate for a pure imaging description, which instead should focus on a detailed description of the findings. Ruptured annulus is not synonymous with ‘‘annular fissure,’’ or ‘‘ruptured disc.’’

Annular teartorn annulus (nonstandard): see fissure of the annulus and rupture of annulus.

Anterior displacement: displacement of disc tissues beyond the disc space into the anterior zone.

Anterior zone: peridiscal zone that is anterior to the midcoronal plane of the vertebral body.

Anulus, annulus (abbreviated form of annulus fibrosus): multilaminated fibrous tissue forming the periphery of each disc space, attaching, craniad and caudad, to end plate cartilage and a ring apophyseal bone and blending centrally with the nucleus pulposus. Note: either anulus or annulus is correct spelling. Nomina Anatomica uses both forms, whereas Terminologia Anatomica states ‘‘ anulus fibrosus’’ [22]. Fibrosus has no correct alternative spelling; fibrosis has a different meaning and is incorrect in this context.

Asymmetric bulge: presence of more than 25% of the outer annulus beyond the perimeter of the adjacent vertebrae, more evident in one section of the periphery of the disc than another, but not sufficiently focal to be characterized as a protrusion. Note: asymmetric disc bulging is a morphologic observation that may have various causes and does not imply etiology or association with symptoms. See bulge.

Balloon disc (colloquial, nonstandard): diffuse apparent enlargement of the disc in superior-inferior extent because of bowing of the vertebral end plates due to weakening of the bone as in severe osteoporosis.

Base (of displaced disc): the cross-sectional area of the disc material at the outer margin of the disc space of origin, where disc material beyond the disc space is continuous with disc material within the disc space. In the craniocaudal direction, the length of the base cannot exceed, by definition, the height of the intervertebral space. On axial imaging, base refers to the width at the outer margin of the disc space, of the origin of any disc material extending beyond the disc space.

Black disc (colloquial, nonstandard): see dark disc.

Bulging disc, bulge (noun [n]), bulge (verb [v])

  1. A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, usually greater than 25% (90°) of the circumference of the disc and usually less than 3 mm beyond the edges of the vertebral body apophysis.
  2. (Nonstandard) A disc in which the outer margin extends over a broad base beyond the edges of the disc space.
  3. (Nonstandard) Mild, diffuse, smooth displacement of disc.
  4. (Nonstandard) Any disc displacement at the discal level.

Note: bulging is an observation of the contour of the outer disc and is not a specific diagnosis. Bulging has been variously ascribed to redundancy of the annulus, secondary to the loss of disc space height, ligamentous laxity, response to loading or angular motion, remodeling in response to adjacent pathology, unrecognized and atypical herniation, and illusion from volume averaging on CT axial images. Mild symmetric posterior disc bulging may be a normal finding at L5–S1. Bulging may or may not represent pathologic change, physiologic variant, or normalcy. Bulging is not a form of herniation; discs known to be herniated should be diagnosed as herniation or, when appropriate, as specific types of herniation. See: herniated disc, protruded disc, extruded disc.

Calcified disc: calcification within the disc space, not inclusive of osteophytes at the periphery of the disc space.

Cavitation: spaces, cysts, clefts, or cavities formed within the nucleus and inner annulus from disc degeneration.

See vacuum disc.

Central zone: zone within the vertebral canal between sagittal planes through the medial edges of each facet. Note: the center of the central zone is a sagittal plane through the center of the vertebral body. The zones to either side of the center plane are right central and left central, which are preferred terms when the side is known, as when reporting imaging results of a specific disc. When the side is unspecified, or grouped with both right and left represented, the term paracentral is appropriate.

Chronic disc herniation: a clinical distinction that a disc herniation is of long duration. There are no universally accepted definitions of the intervals that distinguish between acute, subacute, and chronic disc herniations. Serial MRIs revealing disc herniations that are unchanged in appearance over time may be characterized as chronic. Disc herniations associated with calcification or gas on CT may be suggested as being chronic. Even so, the presence of calcification or gas does not rule out an acutely herniated disc. Note that an acute disc herniation may be superimposed on a chronic disc herniation. Magnetic resonance imaging signal characteristics may, on rare occasion, allow differentiation of acute and chronic disc herniations [165964]. In such cases, acutely herniated disc material may appear brighter than the disc of origin on T2-weighted sequences [465961]. Also, see disc-osteophyte complex.

Claw osteophyte: bony outgrowth arising very close to the disc margin, from the vertebral body apophysis, directed, with a sweeping configuration, toward the corresponding part of the vertebral body opposite the disc.

Collagenized disc or nucleus: a disc in which the mucopolysaccharide of the nucleus has been replaced by fibrous tissue.

Communicating disc, communication (n), communicate (v) (nonstandard): communication refers to interruption in the periphery of the disc annulus, permitting free passage of fluid injected within the disc to the exterior of the disc, as may be observed during discography. Not synonymous with ‘‘uncontained.’’ See ‘‘contained disc’’ and ‘‘uncontained disc.’’

Concentric fissure: fissure of the annulus characterized by separation of annular fibers in a plane roughly parallel to the curve of the periphery of the disc, creating fluid-filled spaces between adjacent annular lamellae. See: radial fissures, transverse fissures, HIZ.

Contained herniation, containment (n), contain (v)

  1. Displaced disc tissue existing wholly within an outer perimeter of uninterrupted outer annulus or posterior longitudinal ligament.
  2. (Nonstandard) A disc with its contents mostly, but not wholly, within annulus or capsule.
  3. (Nonstandard) A disc with displaced elements contained within any investiture of the vertebral canal.

A disc that is less than wholly contained by annulus, but under a distinct posterior longitudinal ligament, is contained. Designation as ‘‘contained’’ or ‘‘uncontained’’ defines the integrity of the ligamentous structures surrounding the disc, a distinction that is often but not always possible by advanced imaging. On CT and MRI scans, contained herniations typically have a smooth margin, whereas uncontained herniations most often have irregular margins because the outer annulus and the posterior longitudinal ligament have been penetrated by the disc material [3537]. CT-discography also does not always allow one to distinguish whether the herniated components of a disc are contained, but only whether there is communication between the disc space and the vertebral canal.

Continuity: connection of displaced disc tissue by a bridge of disc tissue, however thin, to tissue within the disc of origin.

Dallas classification (of postdiscography imaging): commonly used grading system for the degree of annular fissuring seen on CT imaging of discs after discography. Dallas Grade 0 is normal; Grade 1: leakage of contrast into the inner one-third of the annulus; Grade 2: leakage of contrast into the inner two-thirds of the annulus; Grade 3: leakage through the entire thickness of the annulus; Grade 4: contrast extends circumferentially; Grade 5: contrast extravasates into the epidural space (See discogram, discography).

Dark disc (colloquial, nonstandard): disc with nucleus showing decreased signal intensity on T2-weighted images (dark), usually because of desiccation of the nucleus secondary to degeneration. Also: black disc (colloquial, nonstandard). See: disc degeneration, Pfirrmann classification.

Degenerated disc, degeneration (n), degenerate (v)

  1. Changes in a disc characterized to varying degrees by one or more of the following: desiccation, cleft formation, fibrosis, and gaseous degradation of the nucleus; mucinous degradation, fissuring, and loss of integrity of the annulus; defects in and/or sclerosis of the end plates; and osteophytes at the vertebral apophyses.
  2. Imaging manifestation of such changes, including [35] standard roentgenographic findings, such as disc space narrowing and peridiscal osteophytes, MRI disc findings (see Pfirrmann classification [61]), CT disc findings (see discogram/discography and Dallas classification [42]), and/or MRI findings of vertebral end plate and marrow reactive changes adjacent to a disc (see Modic classification [38]).

Degenerative disc disease (nonstandard term when used as an imaging description): a condition characterized by manifestations of disc degeneration and symptoms thought to be related to those of degenerative changes. Note: causal connections between degenerative changes and symptoms are often difficult clinical distinctions. The term ‘‘degenerative disc disease’’ carries implications of illness that may not be appropriate if the only or primary indicators of illness are from imaging studies, and thus this term should not be used when describing imaging findings. The preferred term for description of imaging manifestations is ‘‘degenerated disc’’ or ‘‘disc degeneration,’’ rather than ‘‘degenerative disc disease.’’

Delamination: separation of circumferential annular fibers along the planes parallel to the periphery of the disc, characterizing a concentric fissure of the annulus.

Desiccated disc

  1. Disc with reduced water content, usually primarily of nuclear tissues.
  2. Imaging manifestations of reduced water content of the disc, such as decreased (dark) signal intensity on T2-weighted images, or of apparent reduced water content, as from alterations in the concentration of hydrophilic glycosaminoglycans. See also: dark disc (colloquial, nonstandard).

Disc (disk): complex structure composed of nucleus pulposus, annulus fibrosus, cartilaginous end plates, and vertebral body ring apophyseal attachments of annulus. Note: most English language publications use the spelling ‘‘disc’’ more often than ‘‘disk’’ [120226970]. Nomina Anatomica designates the structures as ‘‘disci intervertebrales’’ and Terminologia Anatomica as ‘‘discus intervertebralis/intervertebral disc’’ [2270]. (See ‘‘disc level’’ for naming and numbering of a particular disc).

Disc height: The distance between the planes of the end plates of the vertebral bodies craniad and caudad to the disc. Disc height should be measured at the center of the disc, not at the periphery. If measured at the posterior or anterior margin of the disc on a sagittal image of the spine, this should be clearly specified as such.

Disc level: Level of the disc and vertebral canal between axial planes through the bony end plates of the vertebrae craniad and caudad to the disc being described.

  1. A particular disc is best named by naming the region of the spine and the vertebra above and below it; for example, the disc between the fourth and fifth lumbar vertebral bodies is named ‘‘lumbar 4–5,’’ commonly abbreviated as L4–L5, and the disc between the fifth lumbar vertebral body and the first sacral vertebral body is called ‘‘lumbosacral disc’’ or ‘‘L5–S1.’’ Common anomalies include patients with six lumbar vertebrae or transitional vertebrae at the lumbosacral junction that require, for clarity, narrative explanation of the naming of the discs.
  2. (Nonstandard) A disc is sometimes labeled by the vertebral body above it; for example, the disc between L4 and L5 may be labeled ‘‘the L4 disc’’.
  3. Note: ‘‘a motion segment,’’ numbered in the same way, is a functional unit of the spine, comprising the vertebral body above and below, the disc, the facet joints, and the connecting soft tissues and is most often referenced with regard to the stability of the spine.

Disc of origin: disc from which a displaced fragment originated. Synonym: parent disc. Note: since displaced fragments often contain tissues other than nucleus, disc of origin is preferred to nucleus of origin. Parent disc is synonymous, but more colloquial and nonpreferred.

Disc space: space limited, craniad and caudad, by the end plates of the vertebrae and peripherally by the edges of the vertebral body ring apophyses, exclusive of osteophytes. Synonym: intervertebral disc space. See ‘‘disc’’ level for naming and numbering of discs.

Discogenic vertebral sclerosis: increased bone density and calcification adjacent to the end plates of the vertebrae, craniad and caudad, to a degenerated disc, sometimes associated with intervertebral osteochondrosis. Manifested on MRI as Modic Type III.

Discogram, discography: a diagnostic procedure in which contrast material is injected into the nucleus of the disc with radiographic guidance and observation, often followed by CT/discogram. The procedure is often accompanied by pressure measurements and assessment of pain response (provocative discography). The degree of annular fissuring identified by discography may be defined by the Dallas classification and its modifications (See Dallas classification).

Disc-osteophyte complex: intervertebral disc displacement, whether bulge, protrusion, or extrusion, associated with calcific ridges or ossification. Sometimes called a hard disc or chronic disc herniation (nonpreferred). Distinction should be made between ‘‘spondylotic disc herniation,’’ or ‘‘calcified disc herniation’’ (nonpreferred), the remnants of an old disc herniation; and ‘‘spondylotic bulging disc,’’ a broad-based bony ridge presumably related to chronic bulging disc.

Displaced disc (nonstandard): a disc in which disc material is beyond the outer edges of the vertebral body ring apophyses (exclusive of osteophytes) of the craniad and caudad vertebrae, or, as in the case of intravertebral herniation, has penetrated through the vertebral body end plate.

Note: displaced disc is a general term that does not imply knowledge of the underlying pathology, cause, relationship to symptoms, or need for treatment. The term includes, but is not limited to, disc herniation and disc migration. See: herniated disc, migrated disc.

Epidural membrane: See peridural membrane.

Extraforaminal zone: the peridiscal zone beyond the sagittal plane of the lateral edges of the pedicles, having no well-defined lateral border, but definitely posterior to the anterior zone. Synonym: ‘‘far lateral zone,’’ also ‘‘far-out zone’’ (nonstandard).

Extraligamentous: posterior or lateral to the posterior longitudinal ligament. Note: extraligamentous disc refers to displaced disc tissue that is located posterior or lateral to the posterior longitudinal ligament. If the disc has extruded through the posterior longitudinal ligament, it is sometimes called ‘‘transligamentous’’ or ‘‘perforated’’ and if through the peridural membrane, it is sometimes refined to ‘‘transmembranous.’’

Extruded disc, extrusion (n), extrude (v): a herniated disc in which, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base of the disc material beyond the disc space in the same plane or when no continuity exists between the disc material beyond the disc space and that within the disc space. Note: the preferred definition is consistent with the common image of extrusion, as an expulsion of material from a container through and beyond an aperture. Displacement beyond the outer annulus of the disc material with any distance between its edges greater than the distance between the edges of the base distinguishes extrusion from protrusion. Distinguishing extrusion from protrusion by imaging is best done by measuring the edges of the displaced material and the remaining continuity with the disc of origin, whereas relationship of the displaced portion to the aperture through which it has passed is more readily observed surgically. Characteristics of protrusion and extrusion may coexist, in which case the disc should be subcategorized as extruded. Extruded discs in which all continuity with the disc of origin is lost may be further characterized as ‘‘sequestrated.’’ Disc material displaced away from the site of extrusion may be characterized as ‘‘migrated.’’ See: herniated disc, migrated disc, protruded disc.

Note: An alternative scheme is espoused by some respected radiologists who believe it has better clinical application. This scheme defines extruded disc as synonymous with “uncontained disc” and does not use comparative measurements of the base versus the displaced material. Per this definition, a disc extrusion can be identified by the presence of a continuous line of low signal intensity surrounding the disc herniation. Future study will further determine the validity of this alternative definition. See: contained disc.

Far lateral zone: the peridiscal zone beyond the sagittal plane of the lateral edge of the pedicle, having no well defined lateral border, but definitely posterior to the anterior zone. Synonym: ‘‘extraforaminal zone.’’

Fissure of annulus: see annular fissure.

Foraminal zone: the zone between planes passing through the medial and lateral edges of the pedicles. Note: the foraminal zone is sometimes called the ‘‘pedicle zone’’ (nonstandard), which can be confusing because pedicle zone might also refer to measurements in the sagittal plane between the upper and lower surfaces of a given pedicle that is properly called the ‘‘pedicle level.’’ The foraminal zone is also sometimes called the ‘‘lateral zone’’ (nonstandard), which can be confusing because the ‘‘lateral zone’’ can be confused with ‘‘lateral recess’’ (subarticular zone) and can also mean extraforaminal zone or an area including both the foraminal and extraforaminal zones.

Free fragment

  1. A fragment of disc that has separated from the disc of origin and has no continuous bridge of disc tissue with disc tissue within the disc of origin. Synonym: sequestrated disc.
  2. (Nonstandard) A fragment that is not contained within the outer perimeter of the annulus.
  3. (Nonstandard) A fragment that is not contained within the annulus, posterior longitudinal ligament, or peridural membrane.

Note: ‘‘sequestrated disc’’ and ‘‘free fragment’’ are virtually synonymous. When referring to the condition of the disc, categorization as extruded with subcategorization as sequestrated is preferred, whereas when referring specifically to the fragment, free fragment is preferred.

Gap of annulus: see annular gap.

Hard disc (colloquial): disc displacement in which the displaced portion has undergone calcification or ossification and may be intimately associated with apophyseal osteophytes. Note: the term ‘‘hard disc’’ is most often used in reference to the cervical spine to distinguish chronic hypertrophic and reactive changes at the periphery of the disc from the more acute extrusion of soft, predominantly nuclear tissue. See: chronic disc herniation, disc-osteophyte complex.

Herniated disc, herniation (n), herniated (v): localized or focal displacement of disc material beyond the normal margin of the intervertebral disc space. Note: ‘‘localized’’ or ‘‘focal’’ means, by way of convention, less than 25% (90°) of the circumference of the disc.

Herniated disc material may include nucleus pulposus, cartilage, fragmented apophyseal bone, or annulus fibrosus tissue. The normal margins of the intervertebral disc space are defined, craniad and caudad, by the vertebral body end plates and peripherally by the edges of the vertebral body ring apophyses, exclusive of osteophytic formations. Herniated disc generally refers to displacement of disc tissues through a disruption in the annulus, the exception being intravertebral herniations (Schmorl nodes) in which the displacement is through the vertebral end plate. Herniated discs may be further subcategorized as protruded or extruded. Herniated disc is sometimes referred to as HNP, but the term ‘‘herniated disc’’ is preferred because displaced disc tissues often include cartilage, bone fragments, or annular tissues. The terms ‘‘prolapse’’ and ‘‘rupture’’ when referring to disc herniations are nonstandard and their use should be discontinued. Note: ‘‘herniated disc’’ is a term that does not imply knowledge of the underlying pathology, cause, relationship to symptoms, or need for treatment.

Herniated nucleus pulposus (HNP, nonpreferred): see herniated disc.

High intensity zone (HIZ): area of high intensity on T2-weighted MRIs of the disc, located commonly in the outer annulus. Note: HIZs within the posterior annular substance may indicate the presence of an annular fissure within the annulus, but these terms are not synonymous. An HIZ itself may represent the actual annular fissure or alternatively, may represent vascularized fibrous tissue (granulation tissue) within the substance of the disc in an area adjacent to a fissure. The visualization of an HIZ does not imply a traumatic etiology or that the disc is a source of pain.

Infrapedicular level: the level between the axial planes of the inferior edges of the pedicles craniad to the disc in question and the inferior end plate of the vertebral body above the disc in question. Synonym: superior vertebral notch.

Internal disc disruption: disorganization of structures within the disc. See intraannular displacement

Interspace: see disc space.

Intervertebral chondrosis: see intervertebral osteochondrosis.

Intervertebral disc: see disc.

Intervertebral disc space: see disc space.

Intervertebral osteochondrosis: degenerative process of the disc and vertebral body end plates that is characterized by disc space narrowing, vacuum phenomenon, and vertebral body reactive changes. Synonym: osteochondrosis (nonstandard).

Intraannular displacement: displacement of central, predominantly nuclear, tissue to a more peripheral site within the disc space, usually into a fissure in the annulus. Synonym: (nonstandard) intraannular herniation, intradiscal herniation. Note: intraannular displacement is distinguished from disc herniation, that is, herniation of disc refers to displacement of disc tissues beyond the disc space. Intraannular displacement is a form of internal disruption. When referring to intraannular displacement, it is best not to use the term ‘‘herniation’’ to avoid confusion with disc herniation.

Intraannular herniation (nonstandard): see intraannular displacement.

Intradiscal herniation (nonstandard): see intraannular displacement.

Intradural herniation: disc material that has penetrated the dura so that it lies in an intradural extramedullary location.

Intravertebral herniation: a disc displacement in which a portion of the disc projects through the vertebral end plate into the centrum of the vertebral body. Synonym: Schmorl node.

Lateral recess: that portion of the subarticular zone that is medial to the medial border of the pedicle. It refers to the entire cephalad-caudad region that exists medial to the pedicle, where the same numbered thoracic or lumbar nerve root travels caudally before exiting the nerve root foramen under the caudal margin of the pedicle. It does not refer to the nerve root foramen itself. See also subarticular zone.

Lateral zone (nonstandard): see foraminal zone.

Leaking disc (nonstandard): see communicating disc.

Limbus vertebra: separation of a segment of vertebral ring apophysis. Note: limbus vertebra may be a developmental abnormality caused by failure of integration of the ossifying apophysis to the vertebral body; a chronic herniation (extrusion) of the disc into the vertebral body at the junction of the fusing apophyseal ring, with separation of a portion of the ring with bony displacement; or a fracture through the apophyseal ring associated with intrabody disc herniation. This occurs in children before the apophyseal ring fuses to the vertebral body. In adults, a limbus vertebra should not be confused with an acute fracture. A limbus vertebra does not imply that there has been an injury to the disc or the adjacent apophyseal end plate.

Marginal osteophyte: osteophyte that protrudes from and beyond the outer perimeter of the vertebral end plate apophysis.

Marrow changes (of vertebral body): see Modic classification.

Migrated disc, migration (n), migrate (v)

  • 1.Herniated disc in which a portion of the extruded disc material is displaced away from the fissure in the outer annulus through which it has extruded in either sagittal or axial plane.
  • 2.(Nonstandard) A herniated disc with a free fragment or sequestrum beyond the disc level.

Note: migration refers to the position of the displaced disc material, rather than to its continuity with disc tissue within the disc of origin; therefore, it is not synonymous with sequestration.

Modic classification (Type I, II, and III) [30]: a classification of degenerative changes involving the vertebral end plates and adjacent vertebral bodies associated with disc inflammation and degenerative disc disease, as seen on MRIs. Type I refers to decreased signal intensity on T1-weighted spin echo images and increased signal intensity on T2-weighted images, representing penetration of the end plate by fibrovascular tissue, inflammatory changes, and perhaps edema. Type I changes may be chronic or acute. Type II refers to increased signal intensity on T1-weighted images and isointense or increased signal intensity on T2-weighted images, indicating replacement of normal bone marrow by fat. Type III refers to decreased signal intensity on both T1-and T2-weighted images, indicating reactive osteosclerosis (See: discogenic vertebral sclerosis).

Motion segment: the functional unit of the spine. See disc level.

Nonmarginal osteophyte: an osteophyte that occurs at sites other than the vertebral end plate apophysis. See: marginal osteophyte.

Normal disc: a fully and normally developed disc with no changes attributable to trauma, disease, degeneration, or aging. Note: many congenital and developmental variations may be clinically normal; that is, they are not associated with symptoms, and certain adaptive changes in the disc may be normal considering adjacent pathology; however, classification and reporting for medical purposes is best served if such discs are not considered normal. Note, however, that a disc finding considered not normal does not necessarily imply a cause for clinical signs or symtomatology; the description of any variation of the disc is independent of clinical judgment regarding what is normal for a given patient.

Nucleus of origin (nonpreferred): the central, nuclear portion of the disc of reference, usually used to reference the disc from which the tissue has been displaced. Note: since displaced fragments often contain tissues other than the nucleus, disc of origin is preferred to nucleus of origin. Synonym: disc of origin (preferred), parent nucleus (nonpreferred).

Osteochondrosis: see intervertebral osteochondrosis.

Osteophyte: focal hypertrophy of the bone surface and/or ossification of the soft tissue attachment to the bone.

Paracentral: in the right or left central zone of the vertebral canal. See central zone. Note: the terms ‘‘right central’’ or ‘‘left central’’ are preferable when speaking of a single site when the side can be specified, as when reporting the findings of imaging procedures. ‘‘Paracentral’’ is appropriate if the side is not significant or when speaking of mixed sites.

Parent disc (nonpreferred): see disc of origin.

Parent nucleus (nonpreferred): see nucleus of origin, disc of origin.

Pedicular level: the space between the axial planes through the upper and lower edges of the pedicle. Note: the pedicular level may be further designated with reference to the disc in question as ‘‘pedicular level above’’ or ‘‘pedicular level below’’ the disc in question.

Perforated (nonstandard): see transligamentous.

Peridural membrane: a delicate, translucent membrane that attaches to the undersurface of the deep layer of the posterior longitudinal ligament, and extends laterally and posteriorly, encircling the bony spinal canal outside the dura. The veins of Batson plexus lie on the dorsal surface of the peridural membrane and pierce it ventrally. Synonym: lateral membrane, epidural membrane.

Pfirrmann classification: a grading system for the severity of degenerative changes within the nucleus of the intervertebral disc. A Pfirrmann Grade I disc has a uniform high signal in the nucleus on T2-weighted MRI; Grade II shows a central horizontal line of low signal intensity on sagittal images; Grade III shows high intensity in the central part of the nucleus with lower intensity in the peripheral regions of the nucleus; Grade IV shows low signal intensity centrally and blurring of the distinction between nucleus and annulus; and Grade V shows homogeneous low signal with no distinction between nucleus and annulus.[61]

Prolapsed disc, prolapse (n, v) (nonstandard): the term is variously used to refer to herniated discs. Its use is not standardized and the term does not add to the precision of disc description, so is regarded as nonstandard in deference to ‘‘protrusion’’ or ‘‘extrusion.’’

Protruded disc, protrusion (n), protrude (v): 1. One of the two subcategories of a ‘‘herniated disc’’ (the other being an ‘‘extruded disc’’) in which disc tissue extends beyond the margin of the disc space, involving less than 25% of the circumference of the disc margin as viewed in the axial plane. The test of protrusion is that there must be localized (less than 25% of the circumference of the disc) displacement of disc tissue and the distance between the corresponding edges of the displaced portion must not be greater than the distance between the edges of the base of the displaced disc material at the disc space of origin (See base of displaced disc). While sometimes used as a general term in the way herniation is defined, the use of the term ‘‘protrusion’’ is best reserved for subcategorization of herniation meeting the above criteria. 2. (nonstandard) Any or unspecified type of disc herniation.

Radial fissure: disruption of annular fibers extending from the nucleus outward toward the periphery of the annulus, usually in the craniad-caudad (vertical) plane, although, at times, with axial horizontal (transverse) components. ‘‘Fissure’’ is the preferred term to the nonstandard term ‘‘tear.’’ Neither term implies knowledge of injury or other etiology. Note: Occasionally, a radial fissure extends in the transverse plane to include an avulsion of the outer layers of annulus from the apophyseal ring. See concentric fissures, transverse fissures.

Rim lesion (nonstandard): See limbus vertebra.

Rupture of annulus, ruptured annulus: see annular rupture.

Ruptured disc, rupture (nonstandard): a herniated disc. The term ‘‘ruptured disc’’ is an improper synonym for herniated disc, not to be confused with violent disruption of the annulus related to injury. Its use should be discontinued.

Schmorl node: see intravertebral herniation.

Sequestrated disc, sequestration (n), sequestrate (v); (variant: sequestered disc): an extruded disc in which a portion of the disc tissue is displaced beyond the outer annulus and maintains no connection by disc tissue with the disc of origin. Note: an extruded disc may be subcategorized as ‘‘sequestrated’’ if no disc tissue bridges the displaced portion and the tissues of the disc of origin. If even a tenuous connection by disc tissue remains between a displaced fragment and disc of origin, the disc is not sequestrated. If a displaced fragment has no connection with the disc of origin, but is contained within peridural membrane or under a portion of posterior longitudinal ligament that is not intimately bound with the annulus of origin, the disc is considered sequestrated. Sequestrated and sequestered are used interchangeably. Note: ‘‘sequestrated disc’’ and ‘‘free fragment’’ are virtually synonymous. See: free fragment. When referring to the condition of the disc, categorization as extruded with subcategorization as sequestered is preferred, whereas when referring specifically to the fragment, free fragment is preferred. See sequestrum.

Sequestrum (nonpreferred): refers to disc tissue that has displaced from the disc space of origin and lacks any continuity with disc material within the disc space of origin. Synonym: free fragment (preferred). See sequestrated disc. Note: ‘‘sequestrum’’ (nonpreferred) refers to the isolated free fragment itself, whereas sequestrated disc defines the condition of the disc.

Spondylitis: inflammatory disease of the spine, other than degenerative disease. Note: spondylitis usually refers to noninfectious inflammatory spondyloarthropathies.

Spondylosis: 1. Common nonspecific term used to describe effects generally ascribed to degenerative changes in the spine, particularly those involving hypertrophic changes to the apophyseal end plates and zygapophyseal joints. 2. (nonstandard) Spondylosis deformans, for which spondylosis is a shortened form.

Spondylosis deformans: degenerative process of the spine involving the annulus fibrosus and vertebral body apophysis, characterized by anterior and lateral marginal osteophytes arising from the vertebral body apophyses, while the intervertebral disc height is normal or only slightly decreased. See degeneration, spondylosis.

Subarticular zone: the zone, within the vertebral canal, sagittally between the plane of the medial edges of the pedicles and the plane of the medial edges of the facets and coronally between the planes of the posterior surfaces of the vertebral bodies and the anterior surfaces of the superior facets. Note: the subarticular zone cannot be precisely delineated in two-dimensional depictions because the structures that define the planes of the zone are irregular. The lateral recess is that portion of the subarticular zone defined by the medial wall of the pedicle, where the same numbered nerve root traverses before turning under the inferior wall of the pedicle into the foramen.

Subligamentous: beneath the posterior longitudinal ligament. Note: although the distinction between outer annulus and posterior longitudinal ligament may not always be identifiable, subligamentous has meaning distinct from subannular when the distinction can be made. When the distinction cannot be made, subligamentous is appropriate. Subligamentous contrasts to extraligamentous, transligamentous, or perforated. See extraligamentous, transligamentous.

Submembranous: enclosed within the peridural membrane. Note: with reference to the displaced disc material, characterization of a herniation as submembranous usually infers that the displaced portion is extruded beyond annulus and posterior longitudinal ligament so that only the peridural membrane invests it.

Suprapedicular level: the level within the vertebral canal between the axial planes of the superior end plate of the vertebra caudad to the disc space in question and the superior margin of the pedicle of that vertebra. Synonym: inferior vertebral notch.

Syndesmophytes: thin and vertically oriented bony outgrowths extending from one vertebral body to the next and representing ossification within the outer portion of the annulus fibrosus.

Tear of annulus, torn annulus (nonstandard): see annular tear.

Thompson classification: a five-point grading scale of degenerative changes in the human intervertebral disc, from 0 (normal) to 5 (severe degeneration), based on gross pathologic morphology of midsagittal sections of the lumbar spine.

Traction osteophytes: bony outgrowth arising from the vertebral body apophysis, 2 to 3 mm above or below the edge of the intervertebral disc, projecting in a horizontal direction.

Transligamentous: displacement, usually extrusion, of disc material through the posterior longitudinal ligament. Synonym: (nonstandard) (perforated). See also extraligamentous, transmembranous.

Transmembranous: displacement of extruded disc material through the peridural membrane.

Transverse fissure: fissure of the annulus in the axial (horizontal) plane. When referring to a large fissure in the axial plane, the term is synonymous with a horizontally oriented radial fissure. Often ‘‘transverse fissure’’ refers to a more limited, peripheral separation of annular fibers including attachments to the apophysis. These more narrowly defined peripheral fissures may contain gas visible on radiographs or CT images and may represent early manifestations of spondylosis deformans. See annular fissure, concentric fissure, radial fissure.

Uncontained disc: displaced disc material that is not contained by the outer annulus and/or posterior longitudinal ligament. See discussion under contained disc.

Vacuum disc: a disc with imaging findings characteristic of gas (predominantly nitrogen) in the disc space, usually a manifestation of disc degeneration.

Vertebral body marrow changes: reactive vertebral body signal changes associated with disc inflammation and disc degeneration, as seen on MRIs. See Modic classification.

Vertebral notch (inferior): incisura of the upper surface of the pedicle corresponding to the lower part of the foramen (suprapedicular level).

Vertebral notch (superior): incisura of the under surface of the pedicle corresponding to the upper part of the foramen (infrapedicular level).

Supplementary Appendix

Appendix

A herniated disc most commonly develops as a result of age-related wear and tear or degeneration on the spine. In children and young adults, the intervertebral discs have a much higher water content. As we age, however, the water content of the intervertebral discs decreases and these begin to shrink while the spaces between the vertebra gets narrower, ultimately turning less flexible and becoming more prone to disc herniation. Proper diagnosis and treatment are essential to avoid further symptoms of low back pain. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

References

  1. Fardon, D.F. and Milette, P.C. Nomenclature and classification of lumbar disc pathology: recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine. 2001; 26: E93–E113
  2. Stadnik, T.W., Lee, R.R., Coen, H.L. et al. Annular tear and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology. 1998; 206: 49–55
  3. Mink, J.H. Terminology of lumbar spine disorders, the problem… and a solution. California Managed Imaging Medical Group Publication, Burlingame, CA; 1993
  4. Murtagh, F.R. The importance of being Earnest-about disk nomenclature. Am J Neuroradiol. 2007;28: 1–2
  5. in: E.J. Nordby, M.D. Brown, E.D. Dawson, (Eds.) A glossary on spinal terminology. American Academy of Orthopaedic Surgeons, Chicago; 1985: 31–32
  6. Bonneville, J.F. and Dietemann, J.L. L’imagerie dans les sciatiquesRev Prat (Paris). 1992; 42: 554–566
  7. Brant-Zawadzki, M.N. and Jensen, M.C. Imaging corner: spinal nomenclature. Inter- and intra-observer variability in interpretation of lumbar disc abnormalities: a comparison of two nomenclatures. Spine. 1995; 20: 388–390
  8. Breton, G. Is that a bulging disc, a small herniation, or a moderate protrusion?. Can Assoc Radiol J. 1991; 42: 318
  9. Fardon, D.F., Herzog, R.J., and Mink, J.H. Nomenclature of lumbar disc disorders. in: S.R. Garfin, A.R. Vaccaro (Eds.) Orthopaedic knowledge update: spine. American Academy of Orthopaedic Surgeons,Rosemont, IL; 1997: A3–A14
  10. Milette, P.C. The proper terminology for reporting lumbar intervertebral disc disorders. Am J Neuroradiol. 1997; 18: 1859–1866
  11. Fardon DF, White AH, Wiesel S. Diagnostic terms and conservative treatments favored for lumbar disorders by spine surgeons in North America. Presented at the first annual meeting, North American Spine Society, Lake George, New York, 1986.
  12. Arana, E., Royuela, A., Kovacs, F.M. et al. Lumbar spine: agreement in the interpretation of 1.5T MR images by using the Nordic Modic consensus group classification form. Radiology. 2010; 254: 809–817
  13. Bonneville, J.F. Plaidoyer pour une classification par l’image des hernies discales lombaires: la carte-image. Rev Im Med. 1990; 2: 557–560
  14. Fardon, D.F., Pinkerton, S., Balderston, R. et al. Terms used for diagnosis by English speaking spine surgeons. Spine. 1993; 18: 1–4
  15. Farfan, H.F., Huberdeau, R.M., and Dubow, H.I. Lumbar intervertebral disc degeneration: the influence of geometrical features on the pattern of disc degeneration: a post-mortem study. J Bone Joint Surg [Am]. 1972; 54: 492–510
  16. Milette, P.C., Fontaine, S., Lepanto, L. et al. Differentiating lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity. Spine. 1999; 24: 44–53
  17. Milette, P.C., Melancon, D., Dupuis, P. et al. A simplified terminology for abnormalities of the lumbar disc. Can Assoc Radiol J. 1991; 42: 319–325
  18. Taveras, J.M. Herniated intervertebral disk. A plea for a more uniform terminology. Am J Neuroradiol. 1989; 10: 1283–1284
  19. Thompson, J.P., Pearce, R.H., Schechter, M.T. et al. Preliminary evaluation of a scheme for grading the gross morphology of the human intervertebral disc. Spine. 1990; 15: 411–415
  20. Fardon, D.F., Balderston, R.A., Garfin, S.R. et al. Disorders of the spine, a coding system for diagnoses. Hanley and Belfus, Philadelphia; 1991: 20–22
  21. Herzog, R.J. The radiologic assessment for a lumbar disc herniation. Spine. 1996; 21: 19S–38S
  22. International anatomical nomenclature committee approved by Eleventh International Congress of anatomists. Nomina anatomica. 5th ed. Waverly Press, Baltimore, MD; 1983: A23
  23. Jarvik, J.G., Haynor, D.R., Koepsell, T.D. et al. Interreader reliability for a new classification of lumbar disc abnormalities. Acad Radiol. 1996; 3: 537–544
  24. Ketler, A. and Wilke, H.J. Review of existing grading systems for cervical or lumbar disc and facet joint degeneration. (with Erratum note in Eur Spine J 15(6); 729)Eur Spine J. 2006; 15: 705–718
  25. Kieffer, S.A., Stadlan, E.M., Mohandas, A., and Peterson, H.O. Discographic-anatomical correlation of developmental changes with age in the intervertebral disc. Acta Radiol [Diagn] (Stockholm). 1969; 9: 733–739
  26. Bundschuh, C.V. Imaging of the postoperative lumbosacral spine. Neuroimaging Clin N Am. 1993; 3: 499–516
  27. Bartynski, W.S., Rothfus, W.E., and Kurs-Lasky, M. Post-diskogram CT features of lidocaine-sensitive and lidocaine-insensitive severely painful disks at provocation lumbar diskography. AJNR. 2008; 29: 1455–1460
  28. Ford, L.T., Gilula, L.A., Murphy, W.A., and Gado, M. Analysis of gas in vacuum lumbar disc. AJR. 1977; 128: 1056–1057
  29. Modic, M.T. and Herfkens, R.J. Intervertebral disc: normal age-related changes in MR signal intensity. Radiology. 1990; 177: 332–334
  30. Modic, M.T., Masaryk, T.J., Ross, J.S., and Carter, J.R. Imaging of degenerative disc disease.Radiology. 1988; 168: 177–186
  31. Resnick, D. and Niwayama, G. Degenerative disease of the spine. in: D. Resnick (Ed.) Diagnosis of bone and joint disorders. 3rd ed. WB Saunders, Philadelphia; 1995: 1372–1462
  32. Eckert, C. and Decker, A. Pathological studies of intervertebral discs. J Bone Joint Surg. 1947; 29: 447–454
  33. Marinelli, N.L., Haughton, V.M., and Anderson, P.A. T2 relaxation times correlated with stage of lumbar disc degeneration and patient age. AJNR. 2010; 31: 1278–1282
  34. Yasuma, T., Koh, S., Okamura, T. et al. Histologic changes in aging lumbar intervertebral discs. J Bone Joint Surg [Am]. 1990; 72: 220–229
  35. Oh, K.-J., Lee, J.W., Kwon, E.T. et al. Comparison of MR imaging findings between extraligamentous and subligamentous disk herniations in the lumbar spine. AJNR. 2013; 34: 683–687
  36. United States Department of Health and Human Services. Publication no (PHS) 91-1260, International Classification of Diseases Ninth Revision, clinical modification fifth edition, Washington, DC, 1998; Adapted and published by Practice Management Information Corporation, Los Angeles, and by St. Anthony’s Publishing Company, Alexandria, Virginia, 1999.
  37. Williams, A.L., Haughton, V.M., Daniels, D.L., and Grogan, J.P. Differential CT diagnosis of extruded nucleus pulposus. Radiology. 1983; 148: 141–148
  38. Modic, M.T. Degenerative disorders of the spine. in: Magnetic resonance imaging of the spine. Yearbook Medical, New York; 1989: 83–95
  39. Boden, S.D., Davis, D.O., Dina, T.S. et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg. 1990; 72: 403–408
  40. Yu, S., Haughton, V.M., Sether, L.A., and Wagner, M. Anulus fibrosus in bulging intervertebral disks.Radiology. 1988; 169: 761–763
  41. Yasuma, T., Makino, E., Saito, S., and Inui, M. Histologic development of intervertebral disc herniation. J Bone Joint Surg. 1986; 68A: 1066–1073
  42. Sachs, B.L., Vanharanta, H., Spivey, M.A. et al. Dallas discogram description. A new classification of CT/discography in low-back disorders. Spine. 1987; 12: 287–294
  43. Carragee, E.J., Paragioudakis, S.J., and Khurana, S. Lumbar high-intensity zone and discography in subject without low back problems. Spine. 2000; 25: 2987–2992
  44. Schellhas, K.P., Pollei, S.R., Gundry, C.R. et al. Lumbar disc high intensity zone. Correlation of magnetic resonance imaging and discography. Spine. 1996; 21: 79–86
  45. Munter, F.M., Wasserman, B.A., Wu, H.M., and Yousem, D.M. Serial MR imaging of annular tears in lumbar intervertebral disks. Am J Neuroradiol. 2002; 23: 1105–1109
  46. Quencer, R.M. The abnormal annulus fibrosus: can we infer the acuteness of an annular injury?.Am J Neuroradiol. 2002; 23: 1069
  47. Czervionke, L.F. Lumbar intervertebral disc disease. Neuroimaging Clin N Am. 1993; : 465–485
  48. Rothman, S.L.G. and Chafetz, N.I. An anatomic explanation for overreading disc herniations on MRI imaging studies of the lumbar spine: poster presentation. American Society of Neuroradiology,Chicago, Illinois; 1995
  49. Twomey, L.T. and Taylor, J.R. Age changes in lumbar vertebrae and intervertebral discs. Clin Orthop. 1987; 224: 97–104
  50. Coventry, M.B., Ghormley, R.K., and Kernohan, J.W. The intervertebral disc: its microscopic anatomy and pathology. (233–7)J Bone Joint Surg. 1945; 27: 105–112
  51. Farfan, H.F. Mechanical disorders of the low back. Lea & Febiger, ; 1973: 141
  52. Hirsch, C. and Schajowicz, F. Studies in structural changes in the lumbar annulus fibrosus. Acta Orthop Scand. 1952; 22: 184–231
  53. Ito, T., Yamada, M., Ikuta, F. et al. Histologic evidence of absorption of sequestration-type herniated disc. Spine. 1996; 21: 230–234
  54. Liebscher, T., Haefeli, M., Wuertz, K. et al. Age-related variation in cell density of human lumbar intervertebral disc. Spine. 2011; 36: 153–159
  55. Nathan, H. Osteophytes of the vertebral column. An anatomical study of their development according to age, race, and sex, with consideration as to their etiology and significance. J Bone Joint Surg Am. 1962; 44: 243–268
  56. Sether, L.A., Yu, S., Haughton, V.M., and Fischer, M.E. Intervertebral disk: normal age-related changes in MR signal intensity. Radiology. 1990; 177: 385–388
  57. Twomey, L.T. and Taylor, J.R. Age changes in lumbar intervertebral discs. Acta Orthop Scand. 1985;56: 496–499
  58. Schmorl, G. and Junghanns, H. (American Ed, 1971. Transl. by EF Besemann) (186–98)in: The human spine in health and disease. 2nd. Grune and Stratton, New York; 1971: 141–148
  59. Pritzker, K.P.H. Aging and degeneration in the lumbar intervertebral disk. Orthop Clin North Am. 1977; 8: 65–77
  60. Ross, J.S. Babel 2.0. Radiology. 2010; 254: 640–641
  61. Pfirrmann, C.W., Metzdorf, A., Zanetti, M. et al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine. 2001; 26: 1873–1878
  62. Griffith, J.F., Wang, W.X., and Antonio, G.E. Modified Pfirrmann grading system for lumbar intervertebral disc degeneration. Spine. 2007; 32: E708–E712
  63. Yu, S., Haughton, V.M., Sether, L.A. et al. Criteria for classifying normal and degenerated lumbar intervertebral disks. Radiology. 1989; 170: 323–326
  64. Brock, M., Patt, S., and Mayer, H.M. The form and structure of the extruded disc. Spine. 1992; 17: 1457–1461
  65. Williams, A.L. CT diagnosis of degenerative disc disease. The bulging annulus. Radiol Clin North Am. 1983; 21: 289–300
  66. Masaryk, T.J., Ross, J.S., Modic, M.T. et al. High-resolution MR imaging of sequestered lumbar intervertebral discs. Am J Neuroradiol. 1988; 9: 351–358
  67. Wiltse, L.L., Berger, P.E., and McCulloch, J.A. A system for reporting the size and location of lesions in the spine. Spine. 1997; 22: 1534–1537
  68. Saal, J.A., Saal, J.S., and Herzog, R.J. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine. 1990; 15: 683–686
  69. Fardon DF. Disc nomenclature: current journal practices. Poster presentation, American Orthopaedic Association 110th annual meeting, Boca Raton, FL, 1997.
  70. Federative Committee on Anatomic Terminology. Terminologia anatomica. George Thieme Verlag,Struttgart; 1998: 27
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Additional Topics: Acute Back Pain

Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.

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EXTRA IMPORTANT TOPIC: Sciatica Pain Chiropractic Therapy

Radiculopathies? What Are They?

Radiculopathies? What Are They?

The spine is made of bones called vertebrae, with the spinal cord running through the spinal canal in the center. The cord is made up of nerves. These nerve roots split from the cord and travel between the vertebrae into various areas of the body. When these nerve roots become pinched or damaged, the symptoms that follow are known as, radiculopathy. El Paso, TX. Chiropractor, Dr. Alexander Jimenez breaks down radiculopathies, along with their causes, symptoms and treatment.

The entire length of the spine, at each level, nerves exit through holes in the bone of the spine (foramen) on each side of the spinal column. These nerves are called nerve roots, or radicular nerves and branch out from the spine and supply different parts of the body.

Nerves exiting the cervical spine travel down through the arms, hands, and fingers. This is where neck problems affecting a cervical nerve root can cause pain, as well as, other symptoms through the arms and hands, one form of (radiculopathy). Another is low back problems that affect a lumbar nerve root. This can radiate through the leg and into the foot, another form of (radiculopathy, or sciatica), which creates leg pain and/or foot pain.

The spinal cord does not go into the lumbar spine and because the spinal canal has space in the lower back, problems in the lumbosacral region often cause nerve root problems and not a spinal cord injury. Serious conditions i.e. disc herniation or fracture in the lower back are also not likely to cause permanent loss of motor function in the legs.

  • Cervical Spine – This nerve root is named according to the Lower spinal segment that the nerve root runs between. 
  • Example – The nerve at C5-C6 level is called the C6 nerve root.
  • It’s named like this because as it exits the spine, it passes Over the C6 pedicle (a piece of bone part of the spinal segment).
  • Lumbar Spine – These nerve roots are named according to the Upper spinal segment that the nerve runs between.
  • Example – The nerve at L4-L5 level is called the L4 nerve root.
  • The nerve root is named this way because as it exits the spine it passes Under the L4 pedicle.

Two Nerve Roots

Two nerves cross each disc level

Only one exits the spine (through the foramen) at that level.

Exiting Nerve Root – This is the nerve root exiting the spine at a certain level.

Example: L4 nerve root exits the spine at L4-L5 level.

Traversing Nerve Root – This nerve root goes across the disc and exits the spine at the level below.

Example: L5 nerve is the traversing nerve root at L4-L5 level, and is the exiting nerve root at L5-S1 level.

There is some confusion when a nerve root is compressed by disc herniation or other cause to refer both to the intervertebral level (where the disc is) and to the nerve root that is affected. This depends on where the disc herniation or protrusion is happening. It could impinge upon either the exiting nerve or the traversing nerve.

If The Traversing Nerve Is Affected

Lumbar Radiculopathy

In the lumbar spine, there is a weak area in the disc space right in front of the traversing nerve root, so lumbar discs tend to herniate or leak out and impinge on the traversing nerve.

If The Exiting Nerve Is Affected

Cervical Radiculopathy

The opposite is true in the neck. In the cervical spine, the disc tends to herniate to the side, rather than toward the back and the side. If the disc material herniates to the side, it will compress or impinge the exiting nerve root.

Radiculopathy & Sciatica

Nerve root goes by another name Radicular Nerve, and when a herniated or prolapsed disc presses on a radicular nerve, this is referred to as a radiculopathy. A medical physician might say there is herniated disc at L4-L5, which creates an L5 radiculopathy or an L4 radiculopathy. It all depends on where the disc herniation occurs (the side or the back of the disc) and which nerve is affected. And the term for radiculopathy in the low back is the ever famous Sciatica.

Radiculopathy

  • A pinched nerve can occur at different areas of the spine (cervical, thoracic or lumbar).
  • Common causes are narrowing of the hole where the  nerve roots exit, which can result from stenosis, bone spurs, disc herniation and other conditions.
  • Symptoms vary but often include pain, weakness, numbness and tingling.
  • Symptoms can be managed with nonsurgical treatment, but minimal surgery can also help.

Prevalence & Pathogenesis

radiculopathies chiropractic care el paso tx.

  • A herniated disc can be defined as herniation of the nucleus pulposus through the fibers of the annulus fibrosus.
  • Most disc ruptures occur during the third and fourth decades of life while the nucleus pulposus is still gelatinous.
  • The most likely time of day associated with increased force on the disc is the morning.
  • In the lumbar region, perforations usually arise through a defect just lateral to the posterior midline, where the posterior longitudinal ligament is weakest.

radiculopathies chiropractic care el paso tx.

Epidemology

radiculopathies chiropractic care el paso tx.Lumbar Spine:

  • Symptomatic lumbar disc herniation occurs during the lifetime of approximately 2% of the general population.
  • Approximately 80% of the population will experience significant back pain during the course of a herniated disc.
  • The groups at greatest risk for herniation of intervertebral discs are younger individuals (mean age of 35 years)
  • True sciatica actually develops in only 35% of patients with disc herniation.
  • Not infrequently, sciatica develops 6 to 10 years after the onset of low back pain.
  • The period of localized back pain may correspond to repeated damage to annular fibers that irritates the sinuvertebral nerve but does not result in disc herniation.

Epidemology

Cervical Spine:

  • The average annual incidence of cervical radiculopathies is less than 0.1 per 1000 individuals.
  • Pure soft disc herniations are less common than hard disc abnormalities (spondylosis) as a cause of radicular arm pain.
  • In a study of 395 patients with nerve root abnormalities, radiculopathies occurred in the cervical and lumbar spine in 93 (24%) and 302 (76%), respectively.

Pathogenesis

  • Alterations in intervertebral disc biomechanics and biochemistry over time have a detrimental effect on disc function.
  • The disc is less able to work as a spacer between vertebral bodies or as a universal joint.

Pathogenesis – LUMBAR SPINE

radiculopathies chiropractic care el paso tx.

  • The two most common levels for disc herniation are L4-L5 and L5-S1, which account for 98% of lesions; pathology can occur at L2-L3 and L3-L4 but is relatively uncommon.
    Overall, 90% of disc herniations are at the L4-L5 and L5-S1 levels.
  • Disc herniations at L5-S1 will usually compromise the first sacral nerve root, a lesion at the L4-L5 level will most often compress the fifth lumbar root, and herniation at L3-L4 more frequently involves the fourth lumbar root.

radiculopathies chiropractic care el paso tx.

radiculopathies chiropractic care el paso tx.

radiculopathies chiropractic care el paso tx.

  • Disc herniation may also develop in older patients.
  • Disc tissue that causes compression in elderly patients is composed of the annulus fibrosus and and portions of the cartilaginous endplate (hard disc.)
    The cartilage is avulsed from the vertebral body.
  • Resolution of some of the compressive effects on neural structures requires resorption of the nucleus pulposus.

radiculopathies chiropractic care el paso tx.

  • Disc resorption is part of the natural healing process associated with disc herniation.
  • The enhanced ability to resorb discs has the potential for resolving clinical symptoms more rapidly.
  • Resorption of herniated disc material is associated with a marked increase in infiltrating macrophages and the production of matrix metalloproteinases (MMPs) 3 and 7.
  • Nerlich and associates identified the origins of phagocytic cells in degenerated intervertebral discs.
  • The investigation identified cells that are transformed local cells rather than invaded macrophages.
  • Degenerative discs contain the cells that add to their continued dissolution.

radiculopathies chiropractic care el paso tx.

Pathogenesis – CERVICAL SPINE

  • In the early 1940s, a number of reports appeared in which cervical intervertebral disc herniation with radiculopathies was described.
  • There is a direct correlation between the anatomy of the cervical spine and the location and pathophysiology of disc lesion.

radiculopathies chiropractic care el paso tx.

  • The eight cervical nerve roots exit via intervertebral foramina that are bordered anteromedially by the intervertebral disc and posterolaterally by the zygapophyseal joint.
  • The foramina are largest at C2-C3 and decrease in size until C6-C7.
  • The nerve root occupies 25% to 33% of the volume of the foramen.
  • The C1 root exits between the occiput and the atlas (C1)
  • All lower roots exit above their corresponding cervical vertebrae (the C6 root at the C5-C6 interspace), except C8, which exits between C7 and T1.
  • A differential growth rate affects the relationship of the spinal cord and nerve roots and the cervical spine.

radiculopathies chiropractic care el paso tx.

  • Most acute disc herniations occur posterolaterally and in patients around the forth decade of life, when the nucleus is still gelatinous.
  • The most common areas of disc herniations are C6-C7 and C5-C6.
  • C7-T1 and C3-C4 disc herniations are infrequent ( less than 15 %).
  • Disc herniation of C2-C3 is rare.
  • Patients with upper cervical disc protrusions in the C2-C3 region have symptoms that include suboccipital pain, loss of hand dexterity, and paresthesias over the face and unilateral arm.
  • Unlike lumbar herniated discs, cervical herniated discs may cause myelopathy in addition to radicular pain because of the anatomy of the spinal cord in the cervical region.
  • The uncovertebral prominences play a role in the location of ruptured discs material.
  • The uncovertebral joint tends to guide extruded disc material medially, where cord compression may also occur.

radiculopathies chiropractic care el paso tx.

radiculopathies chiropractic care el paso tx.

  • Disc herniations usually affect the nerve root numbered most caudally for the given disc level; for example, the C3 – C4 disc affects the fourth cervical nerve root; C4- C5, the fifth cervical nerve root; C5 – C6, the sixth cervical nerve root; C6 – C7, the seventh cervical nerve root; and C7 – T1, the eighth cervical nerve root.

radiculopathies chiropractic care el paso tx.

  • Not every herniated disc is symptomatic.
  • The development of symptoms depends on the reserve capacity of the spinal canal, the presence of inflammation, the size of the herniation, and the presence of concomitant disease such as osteophyte formation.
  • In disc rupture, protrusion of nuclear material results in tension on the annular fibers and compressıon of the dura or nerve root causing pain.
  • Also important is the smaller size of the sagittal diameter, the bony cervical spinal canal.
  • Individuals in whom a cervical herniated disc causes motor dysfunction have a complication of cervical disc herniation if the spinal canal is stenotic.

Clinical History – LUMBAR SPINE

  • Clinically, the patient’s major complaint is a sharp, lancinating pain.
  • In many cases there may be a previous history of intermittent episodes of localized low back pain.
  • The pain not only in the back but also radiates down the leg in the anatomic distribution of the affected nerve root.
  • It will usually be described as deep and sharp and progressing from above downward in the involved leg.
  • Its onset may be insidious or sudden and associated with a tearing or snapping sensations of the spine.
  • Occasionally, when sciatica develops, the back pain may resolve because once the annulus has ruptured, it may no longer be under tension.
  • Disc herniation occurs with sudden physical effort when the trunk is flexed or rotated.
  • On occasion, patients with L4-L5 disc herniation have groin pain. In a study of 512 lumbar disc patients, 4.1% had groin pain.
  • Finally, the sciatica may vary in intensity; it may be so severe that patients will be unable to ambulate and they will feel that their back is “locked”.
  • On the other hand, the pain may be limited to a dull ache that increases in intensity with ambulation.
  • Pain is worsened in the flexed position and relieved by extension of the lumbar spine.
  • Characteristically, patients with herniated discs have increased pain with sitting, driving, walking, couching, sneezing, or straining.

Clinical History – CERVICAL SPINE

  • Arm pain, not neck pain, is the patient’ s major complaint.
  • The pain is often perceived as starting in the neck area and then radiating from this point down to shoulder, arm and forearm and usually into the hand.
  • The onset of the radicular pain is often gradual, although it can be sudden and occur in association with a tearing or snapping sensation.
  • As time passes, the magnitude of the arm pain clearly exceeds that of the neck or shoulder pain.
  • The arm pain may also be variable in intensity and preclude any use of the arm; it may range from severe pain to a dull, cramping ache in the arm muscles.
  • The pain is usually severe enough to awaken the patient at night.
  • Additionally, a patient may complain of associated headaches as well as muscle spasm, which can radiate from the cervical spine to below the scapulae.
  • The pain may also radiate to the chest and mimic angina (pseudoangina) or to the breast.
  • Symptoms such as back pain, leg pain, leg weakness, gait disturbance, or incontinence suggest compression of the spinal cord (Myelopathy).

Physical Examination – LUMBAR SPINE

radiculopathies chiropractic care el paso tx.

  • Physical examination will demonstrated a decrease in range of motion of the lumbosacral spine, and patients may list to one side as they try to bend forward.
  • The side of the disc herniation typically corresponds to the location of the scoliotic list.
  • However, the specific level or degree of herniation does not correlate with the degree of list.
  • On ambulation, patients walk with an antalgic gait in which they hold the involved leg flexed so that they put as little weight as possible on the extremity.

radiculopathies chiropractic care el paso tx.

  • Neurologic Examination:
  • The neurologic examination is very important and may yield objective evidence of nerve root compression (We should evaluate of reflex testing, muscle power, and sensation examination of the patient).
  • In addition, a nerve deficit may have little temporal relevance because it may be related to a previous attack at a different level.
  • Compression of individual spinal nerve roots results in alterations in motor, sensory, and reflex function.
  • When the first sacral root is compressed, the patient may have gastrocnemius-soleus weakness and be unable to repeatedly raise up on the toes of that foot.
  • Atrophy of the calf may be apperent, and the ankle (Achilles) reflex is often diminished or absent.
  • Sensory loss, if present, is usually confined to the posterior aspect of the calf and the lateral side of the foot.

radiculopathies chiropractic care el paso tx.

  • Involvement of the fifth lumbar nerve root can lead to weakness in extension of the great toe and, in a few cases, weakness of the everters and dorsiflexors of the foot.
  • A sensory deficit can appear over the anterior of the leg and the dorsomedial aspect of the foot down to the big toe

radiculopathies chiropractic care el paso tx.

  • With compression of the fourth lumbar nerve root, the quadriceps muscle is affected; the patient may note weakness in knee extension, which is often associated with instability.
  • Atrophy of the thigh musculature can be marked. Sensory loss may be apparent over the anteromedial aspect of the thigh, and the patellar tendon reflex can be diminished.

radiculopathies chiropractic care el paso tx.

 

radiculopathies chiropractic care el paso tx.

  • Nerve root sensitivity can be elicited by any method that creates tension.
  • The straight leg-raising (SLR)test is the one most commonly used.
  • This test is performed with the patient supine.

Physical Examination – CERVICAL SPINE

Neurologic Examination:
  • A neurologic examination that shows abnormalities is the most helpful aspect of the diagnostic work-up, although the examination may remain normal despite a chronic radicular pattern.
  • The presence of atrophy helps document the location of the lesion, as well as its chronicity.
  • The presence of subjective sensory changes is often difficult to interpret and requires a coherent and cooperative patient to be of clinical value.

radiculopathies chiropractic care el paso tx.

  • When the third cervical root is compressed, no reflex change and motor weakness can be identified.
  • The pain radiates to the back of the neck and toward the mastoid process and pinna of the ear.
  • Involvement of the fourth cervical nerve root leads to no readily detectable reflex changes or motor weakness.
  • The pain radiates to the back of the neck and superior aspect of the scapula.
  • Occasionally, the pain radiates to the anterior chest wall.
  • The pain is often exacerbated by neck extension.
  • Unlike the third and the fourth cervical nerve roots, the fifth through eighth cervical nerve roots have motor functions.
  • Compression of the fifth cervical nerve root is characterized by weakness of shoulder abduction, usually above 90 degree, and weakness of shoulder extension.
  • The biceps reflexes are often depressed and the pain radiates from the side of the neck to the top of the shoulder.
  • Decreased sensation is often noted in the lateral aspect of the deltoid, which represents the autonomous area of the axillary nerve.

radiculopathies chiropractic care el paso tx.

  • Involvement of the sixth cervical nerve root produces biceps muscles weakness as well as diminished brachioradial reflex.
  • The pain again radiates from the neck down the lateral aspect of the arm and forearm to the radial side of hand (index finger, long finger, and thumb).
  • Numbness occurs occasionally in the tip of the index finger, the autonomous area of the sixth cervical nerve root.

radiculopathies chiropractic care el paso tx.

  • Compression of the seventh cervical nerve root produces reflex changes in the triceps jerk test with associated loss of strength in the triceps muscles, which extend the elbow.
  • The pain from this lesion radiates from the lateral aspect of the neck down the middle of the area to the middle finger.
  • Sensory changes occur often in the tip of the middle finger, the autonomous area for the seventh nerve.
  • Patients should also be tested for scapular winging, which may occur with C6 or C7 radiculopathies.

radiculopathies chiropractic care el paso tx.

  • Finally, involvement of the eighth cervical nerve root by a herniated C7-T1 disc produces significant weakness of the intrinsic musculature of the hand.
  • Such involvement can lead to rapid atrophy of the interosseous muscles because of the small size of these muscles.
  • Loss of the interossei leads to significant loss of fine hand motion.
  • No reflexes are easily found, although the flexor carpi ulnaris reflex may be decreased.
  • The radicular pain from the eighth cervical nerve root radiates to the ulnar border the hand and the ring and little fingers.
  • The tip of the little finger often demonstrates diminished sensation.

radiculopathies chiropractic care el paso tx.

  • Radicular pain secondary to a herniated cervical disc may be relieved by abduction of the affected arm.
  • Although these signs are helpful when present, their absence alone does not rule out a nerve root lesion.

Laboratory Data

radiculopathies chiropractic care el paso tx.

  • Medical screening laboratory test (blood counts, chemistry panels erythrocyte sedimentation rate [ESR]) are normal in patients with a herniated disc.
  • Electro diagnostic Testing
  • Electromyography(EMG)is an electronic extension of the physical examination.
  • The primary use of EMG is to diagnose radiculopathies in cases of questionable neurologic origin.
  • EMG findings may be positive in patients with nerve root impingement.

Radiographic Evaluation – LUMBAR SPINE

  • Plain x-rays may be entirely normal in a patient with signs and symptoms of nerve root impingement.
  • Computed Tomography
  • Radigraphic evaluation by CT scan may demonstrate disc bulging but may not correlate with the level of nerve damage.
  • Magnetic Resonance Imaging
  • MR imaging also allows visualization of soft tissues, including discs in the lumbar spine.
  • Herniated discs are easily detected with MR evaluation.
  • MR imaging is a sensitive technique for the detection of far lateral and anterior disc herniations.

Radiographic Evaluation – CERVICAL SPINE

  • X-rays
  • Plain x-rays may be entirely normal in patients wit han acute herniated cervical disc.
  • Conversely, 70% of asymptomatic women and 95% of asymptomatic men between the ages of 60 and 65 years have evidence of degenerative disc disease on plain roentgenograms.
  • Views to be obtained include anteroposterior, lateral, flexion, and extension.
radiculopathies chiropractic care el paso tx.

radiculopathies chiropractic care el paso tx.

  • Computed Tomography
  • CT permits direct visualization of compression of neural structures and is therefore more precise than myelography.
  • Advantages of CT over myelography include better visualization of lateral abnormalities such as foraminal stenosis and abnormalities caudal to the myelographic block, less radiation exposure, and no hospitalization.
  • Magnetic Resonance
  • MRI allows excellent visualization of soft tissues, including herniated discs in the cervical spine.
  • The test is noninvasive.
  • In a study of 34 patients with cervical lesions, MRI predicted 88% of the surgically proven lesions versus 81% for myelography-CT, 58% for myelography, and 50% for CT alone.

Differential Diagnosis – LUMBAR SPINE

  • The initial diagnosis of a herniated disc is ordinarily made on the basis of the history and physical examination.
  • Plain radiographs of the lumbosacral spine will rarely add to the diagnosis but should be obtained to help rule out other causes of pain such as infection or tumor.
  • Other tests such as MR, CT, and myelography are confirmatory by nature and can be misleading when used as screening tests.

Spinal Stenosis

  • Patient with spinal stenosis may also suffer from back pain that radiates to the lower extremities.
  • Patients with spinal stenosis tend to be older than those in whom herniated discs develop.
  • Characteristically, patients with spinal stenosis experience lower extremity pain (pseudoclaudication=neurogenic claudication) after walking for an unspecified distance.
  • They also complain of pain that is exacerbated by standing or extending the spine.
  • Radiographic evaluation is usually helpful in differentiating individuals with disc herniation from those with bony hypertrophy associated with spinal stenosis.
  • In a study of 1,293 patients, lateral spinal stenosis and herniated intervertebral discs coexisted in 17.7% of individuals.
  • Radicular pain may be caused by more than one pathologic process in an individual.

Facet Syndrome

  • Facet syndrome is another cause of low back pain that may be associated with radiation of pain to structures outside the confines of the lumbosacral spine.
  • Degeneration of articular structures in the facet joint causes pain to develop.
  • In most circumstances, the pain is localized over the area of the affected joint and is aggravated by extension of the spine (standing).
  • A deep , ill-defined, aching discomfort may also be noted in the sacroiliac joint, the buttocks, and the legs.
  • The areas of sclerotome affected show the same embryonic origin as the degenerated facet joint.
  • Patients with pain secondary to facet joint disease may have relief of symptoms with apophyseal injection of a long-acting local anesthetic.
  • The true role of facet joint disease in the production of back and leg pain remains to be determined.
  • Other mechanical causes of sciatica include congentenial abnormalites of the lumbar nerve roots, external compression of the sciatic nerve (wallet in a back pants pocket), and muscular compression of the nerve (piriformis syndrome).
  • In rare circumstances, cervical or thoracic lesion should be considered if the lumbar spine is clear of abnormalities.
  • Medical causes of sciatica (neural tumors or infections, for example) are usually associated with systemic symptoms in addition to nerve pain in a sciatic distribution.

Differential Diagnosis – CERVICAL SPINE

  • No diagnostic criteria exist for the clinical diagnosis of a herniated cervical disc.
  • The provisional diagnosis of a herniated cervical disc is made by the history and physical examination.
  • The plain x-ray is usually nondiagnostic, although occasionally disc space narrowing at the suspected interspace or foraminal narrowing on oblique films is seen.
  • The value of x-rays is to exclude other causes of neck and arm pain, such as infection and tumor.
  • MR imaging and CT-myelography are the best confirmatory examinations for disc herniation.
  • Cervical disc herniations may affect structures other than nerve roots.
  • Disc herniation may cause vessel compression (vertebral artery) associated with vertebrobasilar artery insufficiency and be manifested as blurred vision and dizziness.

radiculopathies chiropractic care el paso tx.

  • Other mechanical causes of arm pain should be excluded.
  • The most common is some form of compression on a peripheral nerve.
  • Such compression can occur at the elbow, forearm, or wrist. An example is compression of the median nerve by the carpal ligament leading to carpal tunnel syndrome.
  • The best diagnostic test to rule out these peripheral neuropathies is EMG.
  • Excessive traction on the arm secondary to heavy weights may cause radicular pain without disc compression of nerve roots.
  • Spinal cord abnormalities must be considered if signs of myelopathy are present in conjunction with radiculopathies.
  • Spinal cord lesions such as syringomyelia are identified by MRI, and motor neuron disease is identified by EMG.
  • Multiple sclerosis should be considered in a patient with radiculopathies if the physical signs indicate lesions above the foramen magnum (optic neuritis).
  • In very rare circumstances, lesions of the parietal lobe corresponding to the arm can mimic the findings of cervical radiculopathies.
Heal A Bulging Disc Through Chiropractic | El Paso, TX.

Heal A Bulging Disc Through Chiropractic | El Paso, TX.

Bulging disc is often thought of as a normal part of the aging process. It causes pain and decreases mobility. Athletes and people who have jobs that are very physical are often prone to bulging discs and other disc problems. Smoking tobacco can also be a contributing factor in spinal discs deteriorating and weakening. Chiropractic has been proven to be an effective treatment to heal a bulging disc and the associated pain.

What Is A Bulging Disc?

heal bulging disc el paso tx.

Bulging discs are often thought to be the same as herniated discs but that is incorrect. A herniated disc involves a crack in the disc’s outer layer. This is called an annulus. Typically, a small part of the disc is affected, allowing the soft material that makes up the nucleus pulposus to protrude. This is different from a bulging disc because, unlike a herniated disc, there is no crack. The disc bulges out of the space but it doesn’t crack and no material protrudes. It also affects more area of the disc than a herniated disc.

While a herniated disc is likely more painful, a bulging disc can also cause pain that can increase over time. Symptoms of a bulging disc include:

  • Tingling, numbness, or muscle weakness in one or both legs
  • Changes in bowel or bladder function
  • Hyper reflexivity in one or both legs
  • Paralysis below the waist
  • Deep pain over the shoulder blade or in the shoulder area
  • Pain when moving the neck
  • Radiating pain in the fingers, forearm, and upper arm

A bulging disc is often diagnosed by a combination of several methods. A physical exam, along with a full history of the problem will often lead to tests like MRI, x-ray, and myelogram with CT scan. From there, your doctor will work with you to find the best course of treatment.

Chiropractic To Help Heal A Bulging Disc

Chiropractic is a preferred treatment method for many patients with bulging disc because it is non-invasive and does not involve drugs or injections. Once you have your diagnosis, you and your chiropractor can work together to find the best way to treat your condition.

Your chiropractor will want to verify your diagnosis so you may go through questions about your medical history, a physical examination, and tests that involve nerve function, reflexes, and muscle tone. Your chiropractor may also order MRI or x-ray as well as other diagnostic testing in order to get a better picture of what is going on.

One of the most popular features of chiropractic care is the whole body approach to wellness. Your chiropractor will look at your entire spine, not just the area that is painful. They will treat your entire spine and provide self-care direction, exercise, and nutritional recommendations so that you can continue to progress and live pain free. Your pain and spinal problems could be the result of spinal misalignment so your chiropractor will seek to get to the root of the problem and treat your entire spine so that you have less pain, your spine can heal, and you have better mobility.

Through focused chiropractic adjustments, your chiropractor will gently use low force techniques to relieve the painful symptoms by manipulating your spine around and at the disc that is bulging. They may use other types of treatments depending on your specific condition and other issues that may be exacerbating your problem.

Chiropractic for bulging discs is safe, effective, and long lasting. If you are having back pain from a bulging disc, you owe it to yourself to seek quality chiropractic care so that you can enjoy less pain, improved mobility, and better quality of life.

Injury Medical Clinic: Non-Surgical Options

Herniated Disc Pain Treatment In El Paso, TX. | Video

Herniated Disc Pain Treatment In El Paso, TX. | Video

Herniated Disc Pain: Araceli Pizana started chiropractic care with Dr. Alex Jimenez due to chronic back pain symptoms associated with a herniated disc. Before finding the right alternative treatment option with Dr. Jimenez, Mrs. Pizana struggled to perform her everyday activities. Araceli Pizana describes how Dr. Alex Jimenez’s exceptional care for his patients ultimately reflects on his ability to improve her overall well-being. Mrs. Pizana recommends chiropractic care for health and wellness.

Herniated Disc Pain & Chiropractic Treatment

Most healthcare professionals agree that degeneration of the intervertebral discs is the main cause of spinal disc herniation, where trauma and/or injury is considered to be the least probable cause. Disc degeneration occurs both with degenerative disc disease and aging. When the degeneration of the intervertebral discs occurs, the soft gel-like center of the disc, known as the nucleus pulposus, pushes through the outer ring of the disc, known as the annulus fibrosus. A tear in the intervertebral disc is what’s known as a disc herniation. Furthermore, the chemical material released can irritate the surrounding structures of the spine causing herniated disc pain.

herniated disc pain in el paso tx.

Dr. Jimenez has teamed with the top surgeons, clinical specialist, medical researchers and premiere rehabilitation providers to bring El Paso the top clinical treatments to our community.  Providing the top non-invasive protocols is our priority.  The clinical insight is what our patients demand in order to give them the appropriate care required.

Our team has takes great pride in bringing our families and injured patients only clinically proven treatments protocols.  By teaching complete holistic wellness as a lifestyle, we also change not only our patients lives but their families as well.  We do this so that we may reach as many El Pasoans who need us, no matter the affordability issues.

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Chiropractic Clinic Extra: Herniated Disc Treatment

Mindfulness for Headache and Cervical Disc Herniation in El Paso, TX

Mindfulness for Headache and Cervical Disc Herniation in El Paso, TX

Stress is a result of the human body’s “fight or flight” response, a prehistoric defense mechanism triggered by the sympathetic nervous system (SNS). Stress is an essential component of survival. When stressors activate the fight or flight response, a mixture of chemicals and hormones are secreted into the blood flow, which prepare the body for perceived danger. Although short-term stress is helpful, however, long-term stress can lead to a variety of health issues. Furthermore, stressors in modern society have changed and it’s become more difficult for people to manage their stress and maintain mindfulness.

 

How Does Stress Affect the Body?

 

Stress can be experienced through three different channels: emotion; body and environment. Emotional stress involves adverse situations which affect our mind and decision making. Bodily stress includes improper nutrition and a lack of sleep. And finally, environmental stress occurs based on external experiences. When you experience any of these types of stressors, the sympathetic nervous system will trigger the “fight or flight” response, releasing adrenaline and cortisol to increase heart rate and heighten our senses to make us more alert in order to face the situation ahead of us.

 

However, if perceived stressors are always present, the SNS’s fight or flight response can remain active. Chronic stress can then lead to a variety of health issues, such as anxiety, depression, muscle tension, neck and back pain, digestive problems, weight gain and sleep problems as well as impaired memory and concentration. In addition, muscle tension along the spine due to stress can cause a spinal misalignment, or subluxation, which may in turn lead to disc herniation.

 

Headache and Disc Herniation from Stress

 

A herniated disc occurs when the soft, gel-like center of an intervertebral disc pushes through a tear in its outer, cartilage ring, irritating and compressing the spinal cord and/or the nerve roots. Disc herniation commonly occurs in the cervical spine, or neck, and in the lumbar spine, or low back. Symptoms of herniated discs depend on the location of the compression along the spine. Neck pain and back pain accompanied by numbness, tingling sensations and weakness along the upper and lower extremities are some of the most common symptoms associated with disc herniation. Headache and migraine are also common symptoms associated with stress and herniated discs along the cervical spine, as a result of muscle tension and spinal misalignment.

 

Mindfulness Interventions for Stress Management

 

Stress management is essential towards improving as well as maintaining overall health and wellness. According to research studies, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR), among others, can safely and effectively help reduce stress. Chiropractic care utilizes spinal adjustments and manual manipulations to carefully restore the original alignment of the spine, relieving pain and discomfort as well as easing muscle tension. Additionally, a chiropractor may include lifestyle modifications to help further improve symptoms of stress. A balanced spine can help the nervous system respond to stress more effectively. MBSR can also help reduce stress, anxiety and depression.

 

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If you are experiencing symptoms of stress with headache or migraine as well as neck and back pain associated with disc herniation, mindfulness interventions such as chiropractic care can be a safe and effective treatment for your stress. Dr. Alex Jimenez’s stress management services can help you achieve overall health and wellness. Seeking the proper mindfulness interventions can get you the relief you deserve. The purpose of the following article is to demonstrate the effects of mindfulness-based stress reduction in patients with tension headache. Don’t just treat the symptoms, get to the source of the issue.

 

Effects of Mindfulness-Based Stress Reduction on Perceived Stress and Psychological Health in Patients with Tension Headache

 

Abstract

 

Background: Programs for improving health status of patients with illness related to pain, such as headache, are often still in their infancy. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in treating chronic pain and stress. This study evaluated efficacy of MBSR in treatment of perceived stress and mental health of client who has tension headache.

 

Materials and Methods: This study is a randomized clinical trial. Sixty patients with tension type headache according to the International Headache Classification Subcommittee were randomly assigned to the Treatment As Usual (TAU) group or experimental group (MBSR). The MBSR group received eight weekly classmates with 12-min sessions. The sessions were based on MBSR protocol. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered in the pre- and posttreatment period and at 3 months follow-up for both the groups.

 

Results: The mean of total score of the BSI (global severity index; GSI) in MBSR group was 1.63 ± 0.56 before the intervention that was significantly reduced to 0.73 ± 0.46 and 0.93 ± 0.34 after the intervention and at the follow-up sessions, respectively (P < 0.001). In addition, the MBSR group showed lower scores in perceived stress in comparison with the control group at posttest evaluation. The mean of perceived stress before the intervention was 16.96 ± 2.53 and was changed to 12.7 ± 2.69 and 13.5 ± 2.33 after the intervention and at the follow-up sessions, respectively (P < 0.001). On the other hand, the mean of GSI in the TAU group was 1.77 ± 0.50 at pretest that was significantly reduced to 1.59 ± 0.52 and 1.78 ± 0.47 at posttest and follow-up, respectively (P < 0.001). Also, the mean of perceived stress in the TAU group at pretest was 15.9 ± 2.86 and that was changed to 16.13 ± 2.44 and 15.76 ± 2.22 at posttest and follow-up, respectively (P < 0.001).

 

Conclusion: MBSR could reduce stress and improve general mental health in patients with tension headache.

 

Keywords: Mental health, tension headache, mindfulness-based stress reduction (MBSR), perceived stress, treatment as usual (TAU)

 

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Dr. Alex Jimenez’s Insight

Chiropractic care is an effective stress management treatment because it focuses on the spine, which is the base of the nervous system. Chiropractic utilizes spinal adjustments and manual manipulations to carefully restore the alignment of the spine in order to allow the body to naturally heal itself. A spinal misalignment, or subluxation, can create muscle tension along the spine and lead to a variety of health issues, including headache and migraine, as well as disc herniation and sciatica. Chiropractic care can also include lifestyle modifications, such as nutritional advice and exercise recommendations, to further enhance its effects. Mindfulness-based stress reduction can also effectively help with stress management and symptoms.

 

Introduction

 

Tension headache constitutes 90% of total headaches. About 3% of the population are suffering from chronic tension headache.[1] Tension headaches are often associated with lower quality of life and high levels of psychological discomforts.[2] In recent years, several meta-analyses evaluating the established pain treatments used today have shown that medical treatments, which may be effective in acute pain, are not effective with chronic pain and may, in fact, be causing further problems. Most of the pain treatments are designed for and useful for acute pain but if used in the long run may create more problems such as substance abuse and avoidance of important activities.[3] A common element in most of the pain treatments is that they emphasize on either avoiding pain or fighting to reduce pain. The pain in tension headache can be intolerable. Painkillers and pain management strategies can increase intolerance and sensitivity to pain. Therefore, the treatments that increase acceptance and tolerance to pain, especially chronic pain, are effective. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in improving physical performance and psychological well-being in patients with chronic pain.[4,5,6,7,8] In the past two decades, Kabat-Zinn et al. in the US successfully used mindfulness for the relief of pain and illness related to pain.[9] Recent studies on acceptance-based methods, such as mindfulness, show improved performance in patients with chronic pain. Mindfulness modulates the pain using nonelaborative awareness of thoughts, feelings and sensations, and an emotionally distanced relationship with internal and external experience.[10] Studies found that MBSR program can significantly alleviate medical illness related to chronic pains such as fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, chronic low back pain, and multiple sclerosis.[7,11,12,13] MBSR has significant changes in pain intensity, anxiety, depression, somatic complaints, well-being, adaptation, quality of sleep, fatigue, and physical functioning.[6,14,15,16,17] But the programs for improving health status of patients with illness related to pain, such as tension headache, are often still in their infancy. Therefore, the study was conducted to assess the effects of MBSR on perceived stress and general mental health in patients with tension headache.

 

Materials and Methods

 

This randomized controlled clinical trial was performed in 2012 in Shahid Beheshti Hospital in Kashan City. The Research Ethics Committee of the Kashan University of Medical Sciences approved this study (IRCT No: 2014061618106N1). The participants of the study included adults with tension headache who were referred by the psychiatrists and neurologists in Kashan. The inclusion criteria were as follows: Having tension headache according to the International Headache Classification Subcommittee, willing to participate in the study, not having a medical diagnosis of organic brain disorder or psychotic disorder, and not having a history of psychological treatment during the preceding 6 months. The patients who did not complete the intervention and missed more than two sessions were excluded from the study. The participants, who signed an informed consent form, completed the measures as a pretest. For estimating the sample size, we referred to another study in which changes in mean of scores of fatigue was 62 ± 9.5 in the pretreatment period and 54.5 ± 11.5 in the posttreatment period.[18] Then, by utilizing the sample size calculation, 33 participants (with attrition risk) in each group with α = 0.95 and 1 – β = 0.9 were segregated. After sample size calculation, 66 patients with tension headache were selected via convenient sampling according to the inclusion criteria. Then, the patients were called and invited to participate in the study. If a patient agreed to participate, then he/she was invited to attend the study-briefing session and if not another patient was selected similarly. Then using a random number table, they were assigned either to the experimental group (MBSR) or to the control group that treated as usual. Finally, 3 patients were excluded from each group and 60 patients were included (30 patients in each group). The TAU group was treated only by antidepressant medication and clinical management. The MBSR group received MBSR training in addition to TAU. The patients in MBSR group were trained for 8 weeks by a clinical psychologist with PhD degree. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered before the first treatment session in the MBSR group, after the eighth session (posttest), and 3 months after the test (follow-up) in both groups. The TAU group was invited to Shahid Beheshti Hospital to fill out the questionnaires. Figure 1 shows a Consolidated Standards of Reporting Trials (CONSORT) diagram depicting the flow of study participants.

 

Figure 1 CONSORT Diagram Depicting Flow of Study Participants

Figure 1: CONSORT diagram depicting flow of study participants.

 

Intervention

 

The intervention group (MBSR) was trained in Shahid Beheshti Hospital. The eight weekly sessions (120 min) were held according to the standard MBSR protocol as developed by Kabat-Zinn.[11] Additional sessions were held for the participants who had missed one or two sessions. At the end of the training and 3 months later (follow-up), both MBSR and TAU groups were invited to Shahid Beheshti Hospital (the place of MBSR trial) and were instructed to complete the questionnaires. During the MBSR sessions, the participants were trained to be aware of their thoughts, feelings, and physical sensations nonjudgmentally. Mindfulness exercises are taught as two forms of meditation practices — formal and informal. Formal type exercises include trained sitting meditation, body scan, and mindful yoga. In informal meditation, attention and awareness are focused not only on daily activities, but also on thoughts, feelings, and physical sensation even they are problematic and painful. The overall content of the sessions were mentioned in Table 1.

 

Table 1 Agendas for Sessions of MBSR

Table 1: Agendas for sessions of mindfulness-based stress reduction.

 

Measurement Tools

 

International Headache Classification Subcommittee Diary Scale for Headache

 

Headache was measured by diary scale for headache.[19] The patients were asked to record the pain severity diary on a 0-10 rating scale. Absence of pain and the most intense disabling headache were characterized by 0 and 10, respectively. The mean of headache severity in a week was calculated by dividing the sum of the severity scores by 7. Moreover, the mean of headache severity in a month was calculated by dividing the sum of the severity scores by 30. The minimum and maximum scores of headache severity were 0 and 10, respectively. Headache diary was given to five patients and a neurologist and a psychiatrist confirmed the content validity of the instrument.[20] The reliability coefficient of Persian version of this scale was calculated as 0.88.[20]

 

Brief symptom Inventory (BSI)

 

Psychological symptoms were assessed with the BSI.[21] The inventory consist 53 items and 9 subscales that assess psychological symptoms. Each item scores between 0 and 4 (for example: I have nausea or upset in my stomach). BSI has a global severity index (GSI) achieved a total score of 53 items. The reliability of the test has reported a score of 0.89.[22] In our study, GSI test–retest estimate was .90 based on a sample of 60 patients with tension headache who completed the BSI.

 

Perceived Stress Scale (PSS)

 

Perceived stress was assessed using the PSS,[21,23] a 10-item scale that assesses the degree of uncontrollable and unpredictable situations of life during the past month (for example: Felt that you were unable to control the important things in your life?). Respondents report the prevalence of an item within the last month on a 5-point scale, ranging from 0 (never) to 4 (very often). Scoring is completed by reverse scoring of four positively worded items[4,5,7,8] and summing all item scores. The scale scores range from 0-40. Higher scores indicate higher levels of stress. It assumes that people depending on their coping resources evaluate level of threatening or challenging events. A higher score indicates a greater degree of perceived stress. Adequate test–retest reliability and convergent and discriminate validity have also been reported.[19] In our study, Cronbach’s alpha coefficients for assessing internal consistency of this scale were calculated to be 0.88.

 

The repeated measures analysis of variance was performed to compare the MBSR and TAU groups on measures of perceived stress and GSI at pretreatment, posttreatment, and 3-month follow-up. Also, Chi-square test was used to compare the demographics in the two groups. P value less than 0.05 was considered significant in all tests.

 

Results

 

Among 66 subjects, 2 participants from the MBSR group were excluded because of missing more than 2 sessions. Also, three participants were excluded because of did not complete the questionnaires in post-test or follow-up who one of them were from MBSR group and three participants from TAU group. Table 2 showed demographic characteristics of the subjects and results of the randomization check. The results of t-test for differences between the MBSR and TAU groups in age variable and Chi-square test in other variables showed that there was no significant difference between demographic variables in two groups and the subjects were randomly assigned to two groups.

 

Table 2 Demographic Characteristics of the Subjects

Table 2: Demographic characteristics of the subjects a,b.

 

Table 3 provides the mean scores and standard deviations of the dependent variables (perceived stress and GSI) and comparison of outcome measures at pretreatment period, post-treatment period, and 3-month follow-up.

 

Table 3 Means, Standard Deviations and Comparison of Outcome Measures

Table 3: Means, standard deviations, and comparison of outcome measures at pretreatment, posttreatment, and follow-up stages in the MBSR and TAU groups a,b.

 

Table 3 shows the more reduction in received stress and GSI in the intervention group (MBSR) compared to TAU group, while the reduction in received stress and GSI were not observed in the TAU group. The results revealed the significant effect of time and interaction between time and type of treatment on the changes of scores (P < 0.001).

 

Figures ​2 and ​3 present mean received stress and GSI scores for MBSR and TAU groups at posttest and follow-up stages.

 

Figure 2 CONSORT Diagram Depicting Flow of Study Participants

Figure 2: CONSORT diagram depicting flow of study participants.

 

Figure 3 Mean of Perceived Stress in MBSR and Control Groups

Figure 3: Mean of perceived stress in MBSR and control groups in pretest, posttest, and follow-up.

 

Discussion

 

This study compared efficacy of MBSR and Treatment As Usual (TAU) in perceived stress and mental health of patients with tension headache. Although MBSR is recognized as an effective treatment for stress symptoms and pain, there is a need to examine its efficacy for the treatment of mental health problems in patients with tension headache, which is one of the common complaints in the population.

 

The findings of our study demonstrate enhanced general mental health in the GSI index of BSI. In some study, significant improvements by MBSR intervention were reported on all indexes of the 36-item Short Form Health Survey (SF-36).[20,24] Studies showed significant reduction in psychological problems in the Symptom Checklist-90-Revised (SCL-90-R) subscale such as anxiety and depression by MBSR after intervention and 1-year follow-up.[5] Reibel et al. showed MBSR in patients with chronic pain reported a decrease in medical symptoms such as anxiety, depression, and pain.[5] It has been shown that tension headache and anxiety are accompanied with deficits in controlled cognitive processing such as sustained attention and working memory.[25] Negative emotions may amplify suffering associated with pain perception.

 

MBSR implements the following mechanisms to improve the patient’s mental status: First, mindfulness leads to increased awareness for what is happening in each moment, with an accepting attitude, without getting caught up in habitual thoughts, emotions, and behavior patterns. The increased awareness then gives rise to new ways to respond and cope in relation to oneself and the world around.[3] Mindfulness establishes a sense of self that is greater than one’s thoughts, feelings, and bodily sensation such as pain. Mindfulness exercises, learned clients develop an “observer–self”. With this ability, they can observe their thoughts and feelings in a nonreactive and nonjudgmental way that previously avoided, that previously avoided thoughts and feelings be observed in a nonreactive and nonjudgmental way. The clients learn to notice thoughts without necessarily acting on them, being controlled by them, or believing them.[3]

 

Second, mindfulness helps the client develop persistence in taking steps in valued directions that are important to them. Most clients with chronic pain want to become pain free rather than living the vital lives of their choice. But the MBSR program trained them to engage in valued action despite the the pain. Studies have shown attention and emotional reaction to pain has an important role in becoming persistent the pain.[26] Emotional and cognitive components can modulate attention to pain and worry about it that could intensify pain and disrupt the patients activities.[27,28]

 

Third, findings from some studies indicate that MBSR can alter the function of the brain that is responsible for affect regulation and the areas that govern how we react to stressful impulses, and this in turn may normalize body functions such as breathing, heart rate, and immune function.[29,30] Mindfulness practice reduces reactivity to distressing thoughts and feelings that comorbid and strengthen pain perception.[31] Also mindfulness may lessen psychophysiological activation related to stress and mood dysfunction by strengthening positive reappraisal and emotion regulation skills.[32]

 

The strength of this study is the use of a new effective psychotherapy in reducing the stress on a complaint that is less studied, but it is a common medical problem. The implications of our study are using a simple psychotherapy that does not make too much cognitive demand and is readily usable as a coping skill for the patient with tension headache. Therefore, the health-care professionals related to this complaint and the patient will be able to use this treatment. Also, MBSR will change the patient’s lifestyle who would be exacerbated by his/her problem. The main limitation of this study was the lack of comparison between MBSR and the gold standard psychotherapies such as cognitive behavior therapy (CBT). It is suggested that future studies need to compare the efficacy of MBSR and other traditional and newer cognitive behavioral therapies in patients with tension headache.

 

Conclusion

 

Our study supports the hypothesis that patients suffering from tension headache can enhance their general mental health by participating in the MBSR program. In summary, the results of the present study suggest that MBSR can reduce pain-related anxiety and interference in daily activities in the short term. The unique features of mindfulness exercises are easy training and no need to complex cognitive abilities.

 

Financial support and sponsorship: Nil.

 

Conflicts of interest: There are no conflicts of interest.

 

Author’s Contribution

 

AO contributed in the conception of the work, conducting the study, and agreed for all aspects of the work. FZ contributed in the conception of the work, revising the draft, approval of the final version of the manuscript and agreed for all aspects of the work.

 

Acknowledgments

 

Authors are grateful to the staff of Shahid Beheshti Hospital and participants. Authors also express their gratitude to Kabat-Zinn from the Center for Mindfulness (CFM) at the University of Massachusetts who graciously provided electronic copies of the MBSR guidelines.

 

In conclusion, while short-term stress is helpful, long-term stress can eventually lead to a variety of health issues, including anxiety and depression as well as neck and back pain, headache and disc herniation. Fortunately, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR) are safe and effective stress management alternative treatment options. Finally, the article above demonstrated evidence-based results that MBSR could reduce stress and improve general mental health in patients with tension headache. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Back Pain

 

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

 

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EXTRA IMPORTANT TOPIC: Managing Workplace Stress

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor

 

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References
1. Trkanjec Z, Aleksic-Shihabi A. Tension-type headaches. Acta Med Croatica. 2008;62:205–10.[PubMed]
2. Zirke N, Seydel C, Szczepek AJ, Olze H, Haupt H, Mazurek B. Psychological comorbidity in patients with chronic tinnitus: Analysis and comparison with chronic pain, asthma or atopic dermatitis patients. Qual Life Res. 2013;22:263–72. [PubMed]
3. Dionne F, Blais MC, Monestes JL. Acceptance and commitment therapy in the treatment of chronic pain. Sante Ment Que. 2013;38:131–52. [PubMed]
4. Cathcart S, Galatis N, Immink M, Proeve M, Petkov J. Brief mindfulness-based therapy for chronic tension-type headache: A randomized controlled pilot study. Behav Cogn Psychother. 2013;42:1–15.[PubMed]
5. Reibel DK, Greeson JM, Brainard GC, Rosenzweig S. Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population. Gen Hosp Psychiatry. 2001;23:183–92.[PubMed]
6. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res. 2004;57:35–43. [PubMed]
7. Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D. Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice. J Psychosom Res. 2010;68:29–36. [PubMed]
8. Kerrigan D, Johnson K, Stewart M, Magyari T, Hutton N, Ellen JM, et al. Perceptions, experiences, and shifts in perspective occurring among urban youth participating in a mindfulness-based stress reduction program. Complement Ther Clin Pract. 2011;17:96–101. [PubMed]
9. Kabat-Zinn J. New York: Dell Publishing; 1990. Full Catastrophe Living; p. 185.
10. Hayes AM, Feldman G. Clarifying the construct of mindfulness in the context of emotion regulation and the process of change in therapy. Clin Psychol-Sci Pr. 2004:255–62.
11. Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating fibromyalgia with mindfulness-based stress reduction: Results from a 3-armed randomized controlled trial. Pain. 2011;152:361–9. [PubMed]
12. Pradhan EK, Baumgarten M, Langenberg P, Handwerger B, Gilpin AK, Magyari T, et al. Effect of Mindfulness-Based Stress Reduction in rheumatoid arthritis patients. Arthritis Rheum. 2007;57:1134–42.[PubMed]
13. Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complement Altern Med. 2012;12:162. [PMC free article] [PubMed]
14. Bazarko D, Cate RA, Azocar F, Kreitzer MJ. The impact of an innovative mindfulness-based stress reduction program on the health and well-being of nurses employed in a corporate setting. J Workplace Behav Health. 2013;28:107–33. [PMC free article] [PubMed]
15. Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. Int J Behav Med. 2005;12:278–85. [PubMed]
16. Lengacher CA, Kip KE, Barta M, Post-White J, Jacobsen PB, Groer M, et al. A pilot study evaluating the effect of mindfulness-based stress reduction on psychological status, physical status, salivary cortisol, and interleukin-6 among advanced-stage cancer patients and their caregivers. J Holist Nurs. 2012;30:170–85. [PubMed]
17. Simpson J, Mapel T. An investigation into the health benefits of mindfulness-based stress reduction (MBSR) for people living with a range of chronic physical illnesses in New Zealand. N Z Med J. 2011;124:68–75. [PubMed]
18. Omidi A, Mohammadi A, Zargar F, Akbari H. Efficacy of mindfulness-based stress reduction on mood States of veterans with post-traumatic stress disorder. Arch Trauma Res. 2013;1:151–4. [PMC free article][PubMed]
19. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–96. [PubMed]
20. Roth B, Robbins D. Mindfulness-based stress reduction and health-related quality of life: Findings from a bilingual inner-city patient population. Psychosom Med. 2004;66:113–23. [PubMed]
21. Brown KW, Ryan RM. The benefits of being present: Mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84:822–48. [PubMed]
22. Astin JA, Shapiro SL, Lee RA, Shapiro DH., Jr The construct of control in mind-body medicine: Implications for healthcare. Altern Ther Health Med. 1999;5:42–7. [PubMed]
23. Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In: Spacapan S, Oskamp S, editors. The Social Psychology of Health. Newbury Park, CA: Sage; 1988. p. 185.
24. Geary C, Rosenthal SL. Sustained impact of MBSR on stress, well-being, and daily spiritual experiences for 1 year in academic health care employees. J Altern Complement Med. 2011;17:939–44.[PubMed]
25. Dick BD, Rashiq S, Verrier MJ, Ohinmaa A, Zhang J. Symptom burden, medication detriment, and support for the use of the 15D health-related quality of life instrument in a chronic pain clinic population. Pain Res Treat 2011. 2011:809071. [PMC free article] [PubMed]
26. McCabe C, Lewis J, Shenker N, Hall J, Cohen H, Blake D. Don’t look now! Pain and attention. Clin Med. 2005;5:482–6. [PMC free article] [PubMed]
27. Bener A, Verjee M, Dafeeah EE, Falah O, Al-Juhaishi T, Schlogl J, et al. Psychological factors: Anxiety, depression, and somatization symptoms in low back pain patients. J Pain Res. 2013;6:95–101.[PMC free article] [PubMed]
28. Lee JE, Watson D, Frey-Law LA. Psychological factors predict local and referred experimental muscle pain: A cluster analysis in healthy adults. Eur J Pain. 2013;17:903–15. [PMC free article] [PubMed]
29. Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med. 2003;65:564–70.[PubMed]
30. Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16:1893–7. [PMC free article] [PubMed]
31. McCracken LM, Jones R. Treatment for chronic pain for adults in the seventh and eighth decades of life: A preliminary study of Acceptance and Commitment Therapy (ACT) Pain Med. 2012;13:860–7.[PubMed]
32. McCracken LM, Gutiérrez-Martínez O. Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy. Behav Res Ther. 2011;49:267–74. [PubMed]
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Cognitive-Behavioral Therapy for Auto Accident Injuries in El Paso, TX

Cognitive-Behavioral Therapy for Auto Accident Injuries in El Paso, TX

Being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. Auto accident injuries, such as whiplash, can be characterized by painful symptoms, including chronic neck pain, however, recent research studies have found that emotional distress resulting from an auto collision could manifest into physical symptoms. Stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident.

 

The researchers of the research studies also determined that cognitive-behavioral therapy may be an effective treatment for emotional distress and psychological issues which may have developed as a result of the auto accident injuries. Additionally, auto accident injuries may also cause stress, anxiety, depression and even PTSD if left untreated for an extended amount of time. The purpose of the article below is to demonstrate the effects of cognitive-behavioral therapy, together with alternative treatment options like chiropractic care and physical therapy. for auto accident injuries, such as whiplash.

 

Neck Exercises, Physical and Cognitive Behavioural-Graded Activity as a Treatment for Adult Whiplash Patients with Chronic Neck Pain: Design of a Randomised Controlled Trial

 

Abstract

 

Background

 

Many patients suffer from chronic neck pain following a whiplash injury. A combination of cognitive, behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders. The objective is to present the design of a randomised controlled trial (RCT) aimed at evaluating the effectiveness of a combined individual physical and cognitive behavioural-graded activity program on self-reported general physical function, in addition to neck function, pain, disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline.

 

Methods/Design

 

The design is a two-centre, RCT-study with a parallel group design. Included are whiplash patients with chronic neck pain for more than 6 months, recruited from physiotherapy clinics and an out-patient hospital department in Denmark. Patients will be randomised to either a pain management (control) group or a combined pain management and training (intervention)group. The control group will receive four educational sessions on pain management, whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months, including guidance in specific neck exercises and an aerobic training programme. Patients and physiotherapists are aware of the allocation and the treatment, while outcome assessors and data analysts are blinded. The primary outcome measures will be Medical Outcomes Study Short Form 36 (SF36), Physical Component Summary (PCS). Secondary outcomes will be Global Perceived Effect (-5 to +5), Neck Disability Index (0-50), Patient Specific Functioning Scale (0-10), numeric rating scale for pain bothersomeness (0-10), SF-36 Mental Component Summary (MCS), TAMPA scale of Kinesiophobia (17-68), Impact of Event Scale (0-45), EuroQol (0-1), craniocervical flexion test (22 mmHg – 30 mmHg), joint position error test and cervical range of movement. The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a standard deviation of 10.

 

Discussion

 

The perspectives of this study are discussed, in addition to the strengths and weaknesses.

 

Trial registration

 

The study is registered in http://www.ClinicalTrials.gov identifier NCT01431261.

 

Background

 

The Danish National Board of Health estimates that 5-6,000 subjects per year in Denmark are involved in a traffic accident evoking whiplash-induced neck pain. About 43% of those will still have physical impairment and symptoms 6 months after the accident [1]. For Swedish society, including Swedish insurance companies, the economic burden is approximately 320 million Euros [2], and this burden is likely to be comparable to that of Denmark. Most studies suggest that patients with Whiplash-Associated Disorders (WAD) report chronic neck symptoms one year after the injury [3]. The main problems in whiplash patients with chronic neck pain are cervical dysfunction and abnormal sensory processing, reduced neck mobility and stability, impaired cervicocephalic kinaesthetic sense, in addition to local and possibly generalised pain [4,5]. Cervical dysfunction is characterised by reduced function of the deep stabilising muscles of the neck.

 

Besides chronic neck pain, patients with WAD may suffer from physical inactivity as a consequence of prolonged pain [6,7]. This influences physical function and general health and can result in a poor quality of life. In addition, WAD patients may develop chronic pain followed by sensitisation of the nervous system [8,9], a lowering of the threshold for different sensory inputs (pressure, cold, warm, vibration and electrical impulses) [10]. This can be caused by an impaired central pain inhibition [11] – a cortical reorganisation [12]. Besides central sensitisation, the group with WAD may have poorer coping strategies and cognitive functions, compared with patients with chronic neck pain in general [13-15].

 

Studies have shown that physical training, including specific exercises targeting the deep postural muscles of the cervical spine, is effective in reducing neck pain [16-18] for patients with chronic neck pain, albeit there is a variability in the response to training with not every patient showing a major change. Physical behavioural-graded activity is a treatment approach with a focus on increasing general physical fitness, reducing fear of movement and increasing psychological function [19,20]. There is insufficient evidence for the long-term effect of treatment of physical and cognitive behavioural-graded activity, especially in chronic neck pain patients. Educational sessions, where the focus is on understanding complex chronic pain mechanisms and development of appropriate pain coping and/or cognitive behavioural strategies, have shown reduced general pain [6,21-26]. A review indicated that interventions with a combination of cognitive, behavioural therapy with physiotherapy including neck exercises is effective in the management of WAD patients with chronic neck pain [27], as also recommended by the Dutch clinical guidelines for WAD [28]. However, the conclusions regarding the guidelines are largely based on studies performed on patients with either acute or sub-acute WAD [29]. A more strict conclusion was drawn for WAD patients with chronic pain in the Bone and Joint Decade 2000-2010 Task Force, stating, that ‘because of conflicting evidence and few high-quality studies, no firm conclusions could be drawn about the most effective non-invasive interventions for patients with chronic WAD” [29,30]. The concept of combined treatment for WAD patients with chronic pain has been used in a former randomised controlled trial [31]. The results indicated that a combination of non-specific aerobic exercises and advice containing standardised pain education and reassurance and encouragement to resume light activity, produced better outcomes than advice alone for patients with WAD 3 months after the accident. The patients showed improvements in pain intensity, pain bothersomeness and functions in daily activities in the group receiving exercise and advice, compared with advice alone. However, the improvements were small and only apparent in the short term.

 

This project is formulated on the expectation that rehabilitation of WAD patients with chronic neck pain must target cervical dysfunctions, training of physical function and the understanding and management of chronic pain in a combined therapy approach. Each single intervention is based upon former studies that have shown effectiveness [6,18,20,32]. This study is the first to also include the long-term effect of the combined approach in patients with chronic neck pain after whiplash trauma. As illustrated in Figure ​Figure1,1, the conceptual model in this study is based upon the hypothesis that training (including both individually-guided specific neck exercises and graded aerobic training) and education in pain management (based on a cognitive behavioural approach) is better for increasing the patients’ physical quality of life, compared with education in pain management alone. Increasing the physical quality of life includes increasing the general physical function and level of physical activity, decreasing fear of movement, reducing post-traumatic stress symptoms, reducing neck pain and increasing neck function. The effect is anticipated to be found immediately after the treatment (i.e. 4 months; short-term effect) as well as after one year (long-term effect).

 

Figure 1 Hypothesis of the Intervention Effect

Figure 1: Hypothesis of the intervention effect for patients with chronic neck pain after a whiplash accident.

 

Using a randomised controlled trial (RCT) design, the aim of this study is to evaluate the effectiveness of: graded physical training, including specific neck exercises and general aerobic training, combined with education in pain management (based on a cognitive behavioural approach) versus education in pain management (based on a cognitive behavioural approach), measured on physical quality of life’, physical function, neck pain and neck functions, fear of movement, post-traumatic symptoms and mental quality of life, in patients with chronic neck pain after whiplash injury.

 

Methods/Design

 

Trial Design

 

The study is conducted in Denmark as an RCT with a parallel group design. It will be a two-centre study, stratified by recruitment location. Patients will be randomised to either the Pain Management group (control) or the Pain Management and Training group (intervention). As illustrated in Figure ​Figure2,2, the study is designed to include a secondary data assessment 12 months after baseline; the primary outcome assessment will be performed immediately after the intervention program 4 months after baseline. The study utilises an allocation concealment process, ensuring that the group to which the patient is allocated is not known before the patient is entered into the study. The outcome assessors and data analysts will be kept blinded to the allocation to intervention or control group.

 

Figure 2 Flowchart of the Patients in the Study

Figure 2: Flowchart of the patients in the study.

 

Settings

 

The participants will be recruited from physiotherapy clinics in Denmark and from The Spine Centre of Southern Denmark, Hospital Lillebælt via an announcement at the clinics and the Hospital. Using physiotherapy clinics spread across Denmark, the patients will receive the intervention locally. The physiotherapy clinics in Denmark receive patients via referral from their general practitioners. The Spine Centre, a unit specialising in treating patients with musculoskeletal dysfunctions and only treating out-patients, receives patients referred from general practitioners and/or chiropractors.

 

Study Population

 

Two hundred adults with a minimum age of 18 years, receiving physiotherapy treatment or having been referred for physiotherapy treatment will be recruited. For patients to be eligible, they must have: chronic neck pain for at least 6 months following a whiplash injury, reduced physical neck function (Neck Disability Index score, NDI, of a minimum of 10), pain primarily in the neck region, finished any medical /radiological examinations, the ability to read and understand Danish and the ability to participate in the exercise program. The exclusion criteria include: neuropathies/ radiculopathies (clinically tested by: positive Spurling, cervical traction and plexus brachialis tests) [33], neurological deficits (tested as in normal clinical practice through a process of examining for unknown pathology), engagement in experimental medical treatment, being in an unstable social and/or working situation, pregnancy, known fractures, depression according to the Beck Depression Index (score > 29) [18,34,35], or other known coexisting medical conditions which could severely restrict participation in the exercise program. The participants will be asked not to seek other physiotherapy or cognitive treatment during the study period.

 

Intervention

 

Control

 

The Pain Management (control) group will receive education in pain management strategies. There will be 4 sessions of 11/2 hours, covering topics regarding pain mechanisms, acceptance of pain, coping strategies, and goal-setting, based upon pain management and cognitive therapy concepts [21,26,36].

 

Intervention

 

The Pain Management plus Training (intervention) group will receive the same education in pain management as those in the control group plus 8 treatment sessions (instruction in neck exercises and aerobic training) with the same period of 4 months length. If the treating physiotherapist estimates additional treatments are needed, the treatment can be extended with 2 more sessions. Neck training: The treatment of neck-specific exercises will be progressed through different phases, which are defined by set levels of neck function. At the first treatment session, patients are tested for cervical neuromuscular function to identify the specific level at which to start neck training. A specific individually tailored exercise program will be used to target the neck flexor and extensor muscles. The ability to activate the deep cervical neck flexor muscles of the upper cervical region to increase their strength, endurance and stability function is trained progressively via the craniocervical training method using a biopressure feedback transducer [18,37]. Exercises for neck-eye coordination, neck joint positioning, balance and endurance training of the neck muscles will be included as well, since it has been shown to reduce pain and improve sensorimotor control in patients with insidious neck pain [17,38]. Aerobic training: The large trunk and leg muscles will be trained with a gradually increasing physical training program. Patients will be allowed to select activities such as walking, cycling, stick walking, swimming, and jogging. The baseline for training duration is set by exercising 3 times at a comfortable level, that does not exacerbate pain and aims at a rated perceived exertion (RPE) level of between 11 and 14 on a Borg scale [39]. The initial duration of training is set 20% below the average time of the three trials. Training sessions are carried out every second day with a prerequisite that pain is not worsened, and that RPE is between 9 and 14. A training diary is used. If patients do not experience a relapse, and report an average RPE value of 14 or less, the exercise duration for the following period (1 or 2 weeks) is increased by 2-5 minutes, up to a maximum of 30 minutes. If the RPE level is 15 or higher, the exercise duration will be reduced to an average RPE score of 11 to 14 every fortnight [20,40]. By using these pacing principles, the training will be graded individually by the patient, with a focus on perceived exertion – with the aim of increasing the patient’ s general physical activity level and fitness.

 

Patients’ compliance will be administered by registration of their participation in the control and intervention group. The patients in the control group will be considered to have completed the pain management if they have attended 3 out of 4 sessions. The patiesnts in the intervention group will be considered to have completed if the patient has attended a minimum of 3 out of 4 pain management sessions and a minimum of 5 out of 8 trainings sessions. Each patient’s home training with neck exercises and aerobic training will be registered by him/her in a logbook. Compliance with 75% of the planned home training will be considered as having completed the intervention.

 

Physiotherapists

 

The participating physiotherapists will be recruited via an announcement in the Danish Physiotherapy Journal. The inclusion criteria consist of: being a qualified physiotherapist, working at a clinic and having at least two years of working experience as a physiotherapist, having attended a course in the described intervention and passed the related exam.

 

Outcome Measures

 

At baseline the participants’ information on age, gender, height and weight, type of accident, medication, development of symptoms over the last two months (status quo, improving, worsening), expectation of treatment, employment and educational status will be registered. As a primary outcome measure, Medical Outcomes Study Short Form 36 (SF36) – Physical Component Summary (PCS) will be used [41,42]. The PCS scales are scored using norm-based methods [43,44] with a mean score of 50 with a standard deviation of 10. The primary outcome with respect to having an effect, will be calculated as a change from baseline [45]. Secondary outcomes contain data on both clinical tests and patient-reported outcomes. Table ​Table11 presents clinical tests for measuring the intervention effect on neuromuscular control of the cervical muscles, cervical function and mechanical allodynia. Table ​Table22 presents the patient-related outcomes from questionnaires used to test for perceived effect of the treatment, neck pain and function, pain bothersomeness, fear of movement, post-traumatic stress and quality of life and potential treatment modifiers.

 

Table 1 Clinical Outcomes Used for Measurement of Treatment Effect

Table 1: Clinical outcomes used for measurement of treatment effect on muscle strategy, function and treatment modifiers.

 

Table 2 Patient Reported Outcomes Used for Measured of Treatment Effect

Table 2: Patient reported outcomes used for measured of treatment effect on pain and function.

 

Patients will be tested at baseline, 4 and 12 months after baseline, except for GPE, which will only be measured 4 and 12 months after baseline.

 

Power and Sample Size Estimation

 

The power and sample size calculation is based on the primary outcome, being SF36-PCS 4 months after baseline. For a two-sample pooled t-test of a normal mean difference with a two-sided significance level of 0.05, assuming a common SD of 10, a sample size of 86 per group is required to obtain a power of at least 90% to detect a group mean difference of 5 PCS points [45]; the actual power is 90.3%, and the fractional sample size that achieves a power of exactly 90% is 85.03 per group. In order to adjust for an estimated 15% withdrawal during the study period of 4 months, we will include 100 patients in each group. For sensitivity, three scenarios were applied: firstly, anticipating that all 2 × 100 patients complete the trial, we will have sufficient power (> 80%) to detect a group mean difference as low as 4 PCS points; secondly, we will be able to detect a statistically significant group mean difference of 5 PCS points with sufficient power (> 80%) even with a pooled SD of 12 PCS points. Thirdly and finally, if we aim for a group mean difference of 5 PCS points, with a pooled SD of 10, we will have sufficient power (> 80%) with only 64 patients in each group. However, for logistical reasons, new patients will no longer be included in the study 24 months after the first patient has been included.

 

Randomisation, Allocation and Blinding Procedures

 

After the baseline assessment, the participants are randomly assigned to either the control group or the intervention group. The randomisation sequence is created using SAS (SAS 9.2 TS level 1 M0) statistical software and is stratified by centre with a 1:1 allocation using random block sizes of 2, 4, and 6. The allocation sequence will be concealed from the researcher enrolling and assessing participants in sequentially numbered, opaque, sealed and stapled envelopes. Aluminium foil inside the envelope will be used to render the envelope impermeable to intense light. After revealing the content of the envelope, both patients and physiotherapists are aware of the allocation and the corresponding treatment. Outcome assessors and data analysts are however kept blinded. Prior to the outcome assessments, the patients will be asked by the research assistant not to mention the treatment to which they have been allocated.

 

Statistical Analysis

 

All the primary data analyses will be carried out according to a pre-established analysis plan; all analyses will be done applying SAS software (v. 9.2 Service Pack 4; SAS Institute Inc., Cary, NC, USA). All descriptive statistics and tests are reported in accordance with the recommendations of the ‘Enhancing the QUAlity and Transparency Of health Research’ (EQUATOR) network; i.e., various forms of the CONSORT statement [46]. Data will be analysed using a two-factor Analysis of Covariance (ANCOVA), with a factor for Group and a factor for Gender, using the baseline value as covariate to reduce the random variation, and increase the statistical power. Unless stated otherwise, results will be expressed as the difference between the group means with 95% confidence intervals (CIs) and associated p-values, based on a General Linear Model (GLM) procedure. All the analyses will be performed using the Statistical Package for Social Sciences (version 19.0.0, IBM, USA) as well as the SAS system (v. 9.2; SAS Institute Inc., Cary, NC, USA). A two-way analysis of variance (ANOVA) with repeated measures (Mixed model) will be performed to test the difference over time between the intervention and the control groups; interaction: Group × Time. An alpha-level of 0.05 will be considered as being statistically significant (p < 0.05, two- sided). The data analysts will be blinded to the allocated interventions for primary analyses.

 

The baseline scores for the primary and secondary outcomes will be used to compare the control and intervention groups. The statistical analyses will be performed on the basis of the intention-to-treat principle, i.e. patients will be analysed in the treatment group to which they were randomly allocated. In the primary analyses, missing data will be replaced with the feasible and transparent ‘Baseline Observation Carried Forward’ (BOCF) technique, and for sensitivity also a multiple imputation technique will apply.

 

Secondarily, to relate the results to compliance, a ‘per protocol’ analysis will be used as well. The ‘per protocol’ population he patients who have ‘completed’ the intervention to which they were allocated, according to the principles described in the intervention section above.

 

Ethical Considerations

 

The Regional Scientific Ethical Committee of Southern Denmark approved the study (S-20100069). The study conformed to The Declaration of Helsinki 2008 [47] by fulfilling all general ethical recommendations.

 

All subjects will receive information about the purpose and content of the project and give their oral and written consent to participate, with the possibility to drop out of the project at any time.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Managing stress, anxiety, depression and symptoms of post traumatic stress disorder, or PTSD, after being involved in an automobile accident can be difficult, especially if the incident caused physical trauma and injuries or aggravated a previously existing condition. In many cases, the emotional distress and the psychological issues caused by the incident may be the source of the painful symptoms. In El Paso, TX, many veterans with PTSD visit my clinic after manifesting worsening symptoms from a previous auto accident injury. Chiropractic care can provide patients the proper stress management environment they need to improve their physical and emotional symptoms. Chiropractic care can also treat a variety of auto accident injuries, including whiplash, head and neck injuries, herniated disc and back injuries.

 

Discussion

 

This study will contribute to a better understanding of treating patients with chronic neck pain following a whiplash accident. The knowledge from this study can be implemented into clinical practice, as the study is based on a multimodal approach, mirroring the approach, which in spite of the current lack of evidence, is often used in a clinical physiotherapy setting. The study may also be included in systematic reviews thereby contributing to updating the knowledge about this population and to enhancing evidence-based treatment.

 

Publishing the design of a study before the study is performed and the results obtained has several advantages. It allows the design to be finalised without its being influenced by the outcomes. This can assist in preventing bias as deviations from the original design can be identified. Other research projects will have the opportunity to follow a similar approach with respect to population, interventions, controls and outcome measurements. The challenges of this study are related to standardising the interventions, treating a non-homogeneous population, defining and standardising relevant outcome measures on a population with long-lasting symptoms and having a population from two different clinical settings. Standardisation of the interventions is obtained by teaching the involved physiotherapists in an instructional course. Population homogeneity will be handled by strict inclusion and exclusion criteria and by monitoring the baseline characteristics of the patients, and differences between groups based on other influences than the intervention/control will be possible to analyse statistically. This research design is composed as an ‘add-on’ design: both groups receive pain education; the intervention group receives additional physical training, including specific neck exercises and general training. Today there is insufficient evidence for the effect of treatment for patients with chronic neck pain following a whiplash accident. All participating patients will be referred for a treatment (control or intervention), as we consider it unethical not to offer some form of treatment, i.e. randomising the control group to a waiting list. The add-on design is chosen as a pragmatic workable solution in such a situation [48].

 

For whiplash patients with chronic pain, the most responsive disability measures (for the individual patient, not for the group as a whole) are considered to be the Patient Specific Functional Scale and the numerical rating scale of pain bothersomeness [49]. By using these and NDI (the most often used neck disability measure) as secondary outcome measures, it is anticipated that patient-relevant changes in pain and disability can be evaluated. The population will be recruited from and treated at two different clinical settings: the out-patient clinic of The Spine Centre, Hospital Lillebælt and several private physiotherapy clinics. To avoid any influence of the different settings on the outcome measures, the population will be block randomised related to the settings, securing equal distribution of participants from each setting to the two intervention groups.

 

Competing Interests

 

The authors declare that they have no competing interests.

 

Authors’ Contributions

 

IRH drafted the manuscript. IRH, BJK and KS participated in the design of the study. All contributed to the design. RC, IRH; BJK and KS participated in the power and sample size calculation and in describing the statistical analysis as well as the allocation and randomization procedure. All authors read and approved the final manuscript. Suzanne Capell provided writing assistance and linguistic corrections.

 

Pre-Publication History

 

The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2474/12/274/prepub

 

Acknowledgements

 

This study has received funding from the Research Fund for the Region of Southern Denmark, the Danish Rheumatism Association, the Research Foundation of the Danish Association of Physiotherapy, the Fund for Physiotherapy in Private Practice, and the Danish Society of Polio and Accident Victims (PTU). The Musculoskeletal Statistics Unit at the Parker Institute is supported by grants from the Oak Foundation. Suzanne Capell provided writing assistance and linguistic correction.

 

The trial is registered in http://www.ClinicalTrials.gov identifier NCT01431261.

 

A Randomized Controlled Trial of Cognitive-Behavioral Therapy for the Treatment of PTSD in the context of Chronic Whiplash

 

Abstract

 

Objectives

 

Whiplash-associated disorders (WAD) are common and involve both physical and psychological impairments. Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes. Trauma-focused cognitive-behavioral therapy (TF-CBT) has shown moderate effectiveness in chronic pain samples. However, to date, there have been no clinical trials within WAD. Thus, this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder (PTSD).

 

Method

 

Twenty-six participants were randomly assigned to either TF-CBT or a waitlist control, and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview, self-report questionnaires, and measures of physiological arousal and sensory pain thresholds.

 

Results

 

Clinically significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at postassessment, with further gains noted at the follow-up. The treatment of PTSD was also associated with clinically significant improvements in neck disability, physical, emotional, and social functioning and physiological reactivity to trauma cues, whereas limited changes were found in sensory pain thresholds.

 

Discussion

 

This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD. Clinical implications of the findings and future research directions are discussed.

 

In conclusion, being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. However, stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident. According to research studies, physical symptoms and emotional distress may be closely connected and treating both physical and emotional injuries could help patients achieve overall health and wellness. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

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Additional Topics: Back Pain

 

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

 

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EXTRA IMPORTANT TOPIC: Managing Workplace Stress

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Car Accident Injury Treatment El Paso, TX Chiropractor

 

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References

1. The National Institute of Public H. Folkesundhedsrapporten, 2007 (engl: Public Health Report, Denmark, 2007) 2007. p. s.112.
2. Whiplash kommisionen och Svenska Lkl. Diagnostik och tidigt omh„ndertagande av whiplashskador (engl: Diagnostics and early treatment of Whiplash Injuries) Sandviken: Sandvikens tryckeri; 2005.
3. Carroll LJ, Hogg-Johnson S, van dV, Haldeman S, Holm LW, Carragee EJ, Hurwitz EL, Cote P, Nordin M, Peloso PM. et al. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;12(4 Suppl):S75–S82. [PubMed]
4. Nijs J, Oosterwijck van J, Hertogh de W. Rehabilitation of chronic whiplash: treatment of cervical dysfunctions or chronic pain syndrome? ClinRheumatol. 2009;12(3):243–251. [PubMed]
5. Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. ManTher. 2004;12(3):125–133. [PubMed]
6. Mannerkorpi K, Henriksson C. Non-pharmacological treatment of chronic widespread musculoskeletal pain. BestPractResClinRheumatol. 2007;12(3):513–534. [PubMed]
7. Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G. Exercises for mechanical neck disorders. CochraneDatabaseSystRev. 2005. p. CD004250. [PubMed]
8. Kasch H, Qerama E, Kongsted A, Bendix T, Jensen TS, Bach FW. Clinical assessment of prognostic factors for long-term pain and handicap after whiplash injury: a 1-year prospective study. EurJNeurol. 2008;12(11):1222–1230. [PubMed]
9. Curatolo M, Arendt-Nielsen L, Petersen-Felix S. Central hypersensitivity in chronic pain: mechanisms and clinical implications. PhysMedRehabilClinNAm. 2006;12(2):287–302. [PubMed]
10. Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?–A preliminary RCT. Pain. 2007;12(1-2):28–34. doi: 10.1016/j.pain.2006.09.030. [PubMed] [Cross Ref]
11. Davis C. Chronic pain/dysfunction in whiplash-associated disorders95. JManipulative Physiol Ther. 2001;12(1):44–51. doi: 10.1067/mmt.2001.112012. [PubMed] [Cross Ref]
12. Flor H. Cortical reorganisation and chronic pain: implications for rehabilitation. JRehabilMed. 2003. pp. 66–72. [PubMed]
13. Bosma FK, Kessels RP. Cognitive impairments, psychological dysfunction, and coping styles in patients with chronic whiplash syndrome14. Neuropsychiatry NeuropsycholBehavNeurol. 2002;12(1):56–65. [PubMed]
14. Guez M. Chronic neck pain. An epidemiological, psychological and SPECT study with emphasis on whiplash-associated disorders9. Acta OrthopSuppl. 2006;12(320):receding-33. [PubMed]
15. Kessels RP, Aleman A, Verhagen WI, van Luijtelaar EL. Cognitive functioning after whiplash injury: a meta-analysis5. JIntNeuropsycholSoc. 2000;12(3):271–278. [PubMed]
16. O’Sullivan PB. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. ManTher. 2000;12(1):2–12. [PubMed]
17. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. JOrthopRes. 2007;12(3):404–412. [PubMed]
18. Falla D, Jull G, Hodges P, Vicenzino B. An endurance-strength training regime is effective in reducing myoelectric manifestations of cervical flexor muscle fatigue in females with chronic neck pain. ClinNeurophysiol. 2006;12(4):828–837. [PubMed]
19. Gill JR, Brown CA. A structured review of the evidence for pacing as a chronic pain intervention. EurJPain. 2009;12(2):214–216. [PubMed]
20. Wallman KE, Morton AR, Goodman C, Grove R, Guilfoyle AM. Randomised controlled trial of graded exercise in chronic fatigue syndrome. MedJAust. 2004;12(9):444–448. [PubMed]
21. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. BehavResTher. 2006;12(1):1–25. [PubMed]
22. Lappalainen R, Lehtonen T, Skarp E, Taubert E, Ojanen M, Hayes SC. The impact of CBT and ACT models using psychology trainee therapists: a preliminary controlled effectiveness trial. BehavModif. 2007;12(4):488–511. [PubMed]
23. Linton SJ, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain. Spine (Phila Pa 1976) 2000;12(21):2825–2831. doi: 10.1097/00007632-200011010-00017. [PubMed] [Cross Ref]
24. Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. AustJPhysiother. 2002;12(4):297–302. [PubMed]
25. Soderlund A, Lindberg P. Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders (WAD)–a randomised group study6. GItalMedLavErgon. 2007;12(1 Suppl A):A5–11. [PubMed]
26. Wicksell RK. Exposure and acceptance in patients with chronic debilitating pain – a behavior therapy model to improve functioning and quality of life. Karolinska Institutet; 2009.
27. Seferiadis A, Rosenfeld M, Gunnarsson R. A review of treatment interventions in whiplash-associated disorders70. EurSpine J. 2004;12(5):387–397. [PMC free article] [PubMed]
28. van der Wees PJ, Jamtvedt G, Rebbeck T, de Bie RA, Dekker J, Hendriks EJ. Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: a systematic review. AustJPhysiother. 2008;12(4):233–241. [PubMed]
29. Verhagen AP, Scholten-Peeters GG, van WS, de Bie RA, Bierma-Zeinstra SM. Conservative treatments for whiplash34. CochraneDatabaseSystRev. 2009. p. CD003338.
30. Hurwitz EL, Carragee EJ, van dV, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Cote P, Hogg-Johnson S. et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;12(4 Suppl):S123–S152. [PubMed]
31. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M. Randomized controlled trial of exercise for chronic whiplash-associated disorders. Pain. 2007;12(1-2):59–68. doi: 10.1016/j.pain.2006.08.030. [PubMed] [Cross Ref]
32. Ask T, Strand LI, Sture SJ. The effect of two exercise regimes; motor control versus endurance/strength training for patients with whiplash-associated disorders: a randomized controlled pilot study. ClinRehabil. 2009;12(9):812–823. [PubMed]
33. Rubinstein SM, Pool JJ, van Tulder MW, Riphagen II, de Vet HC. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. EurSpine J. 2007;12(3):307–319. [PMC free article] [PubMed]
34. Peolsson M, Borsbo B, Gerdle B. Generalized pain is associated with more negative consequences than local or regional pain: a study of chronic whiplash-associated disorders7. JRehabilMed. 2007;12(3):260–268. [PubMed]
35. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. ArchGenPsychiatry. 1961;12:561–571. [PubMed]
36. Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson GL. Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial. Cogn BehavTher. 2008;12(3):169–182. [PubMed]
37. Falla D, Jull G, Dall’Alba P, Rainoldi A, Merletti R. An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion. PhysTher. 2003;12(10):899–906. [PubMed]
38. Palmgren PJ, Sandstrom PJ, Lundqvist FJ, Heikkila H. Improvement after chiropractic care in cervicocephalic kinesthetic sensibility and subjective pain intensity in patients with nontraumatic chronic neck pain. JManipulative Physiol Ther. 2006;12(2):100–106. doi: 10.1016/j.jmpt.2005.12.002. [PubMed] [Cross Ref]
39. Borg G. Psychophysical scaling with applications in physical work and the perception of exertion. ScandJWork EnvironHealth. 1990;12(Suppl 1):55–58. [PubMed]
40. Wallman KE, Morton AR, Goodman C, Grove R. Exercise prescription for individuals with chronic fatigue syndrome. MedJAust. 2005;12(3):142–143. [PubMed]
41. McCarthy MJ, Grevitt MP, Silcocks P, Hobbs G. The reliability of the Vernon and Mior neck disability index, and its validity compared with the short form-36 health survey questionnaire. EurSpine J. 2007;12(12):2111–2117. [PMC free article] [PubMed]
42. Bjorner JB, Damsgaard MT, Watt T, Groenvold M. Tests of data quality, scaling assumptions, and reliability of the Danish SF-36. JClinEpidemiol. 1998;12(11):1001–1011. [PubMed]
43. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. MedCare. 1995;12(4 Suppl):AS264–AS279. [PubMed]
44. Ware JE Jr. SF-36 health survey update. Spine (Phila Pa 1976) 2000;12(24):3130–3139. doi: 10.1097/00007632-200012150-00008. [PubMed] [Cross Ref]
45. Carreon LY, Glassman SD, Campbell MJ, Anderson PA. Neck Disability Index, short form-36 physical component summary, and pain scales for neck and arm pain: the minimum clinically important difference and substantial clinical benefit after cervical spine fusion. Spine J. 2010;12(6):469–474. doi: 10.1016/j.spinee.2010.02.007. [PubMed] [Cross Ref]
46. Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG. CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting parallel group randomised trials. JClinEpidemiol. 2010;12(8):e1–37. [PubMed]
47. Subjects WDoH-EPfMRIH. WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI. WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects. 2008.
48. Dworkin RH, Turk DC, Peirce-Sandner S, Baron R, Bellamy N, Burke LB, Chappell A, Chartier K, Cleeland CS, Costello A. et al. Research design considerations for confirmatory chronic pain clinical trials: IMMPACT recommendations. Pain. 2010;12(2):177–193. doi: 10.1016/j.pain.2010.02.018. [PubMed] [Cross Ref]
49. Stewart M, Maher CG, Refshauge KM, Bogduk N, Nicholas M. Responsiveness of pain and disability measures for chronic whiplash. Spine (Phila Pa 1976) 2007;12(5):580–585. doi: 10.1097/01.brs.0000256380.71056.6d. [PubMed] [Cross Ref]
50. Jull GA, O’Leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. JManipulative Physiol Ther. 2008;12(7):525–533. doi: 10.1016/j.jmpt.2008.08.003. [PubMed] [Cross Ref]
51. Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. ArchPhysMedRehabil. 1994;12(8):895–899. [PubMed]
52. Heikkila HV, Wenngren BI. Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. ArchPhysMedRehabil. 1998;12(9):1089–1094. [PubMed]
53. Treleaven J, Jull G, Grip H. Head eye co-ordination and gaze stability in subjects with persistent whiplash associated disorders. Man Ther. 2010. [PubMed]
54. Williams MA, McCarthy CJ, Chorti A, Cooke MW, Gates S. A systematic review of reliability and validity studies of methods for measuring active and passive cervical range of motion. JManipulative Physiol Ther. 2010;12(2):138–155. doi: 10.1016/j.jmpt.2009.12.009. [PubMed] [Cross Ref]
55. Kasch H, Qerama E, Kongsted A, Bach FW, Bendix T, Jensen TS. Deep muscle pain, tender points and recovery in acute whiplash patients: a 1-year follow-up study. Pain. 2008;12(1):65–73. doi: 10.1016/j.pain.2008.07.008. [PubMed] [Cross Ref]
56. Sterling M. Testing for sensory hypersensitivity or central hyperexcitability associated with cervical spine pain. JManipulative Physiol Ther. 2008;12(7):534–539. doi: 10.1016/j.jmpt.2008.08.002. [PubMed] [Cross Ref]
57. Ettlin T, Schuster C, Stoffel R, Bruderlin A, Kischka U. A distinct pattern of myofascial findings in patients after whiplash injury. ArchPhysMedRehabil. 2008;12(7):1290–1293. [PubMed]
58. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. JManipulative Physiol Ther. 1991;12(7):409–415. [PubMed]
59. Vernon H. The Neck Disability Index: state-of-the-art, 1991-2008. JManipulative Physiol Ther. 2008;12(7):491–502. doi: 10.1016/j.jmpt.2008.08.006. [PubMed] [Cross Ref]
60. Vernon H, Guerriero R, Kavanaugh S, Soave D, Moreton J. Psychological factors in the use of the neck disability index in chronic whiplash patients. Spine (Phila Pa 1976) 2010;12(1):E16–E21. doi: 10.1097/BRS.0b013e3181b135aa. [PubMed] [Cross Ref]
61. Sterling M, Kenardy J, Jull G, Vicenzino B. The development of psychological changes following whiplash injury. Pain. 2003;12(3):481–489. doi: 10.1016/j.pain.2003.09.013. [PubMed] [Cross Ref]
62. Stalnacke BM. Relationship between symptoms and psychological factors five years after whiplash injury. JRehabilMed. 2009;12(5):353–359. [PubMed]
63. Rabin R, de CF. EQ-5D: a measure of health status from the EuroQol Group. AnnMed. 2001;12(5):337–343. [PubMed]
64. Borsbo B, Peolsson M, Gerdle B. Catastrophizing, depression, and pain: correlation with and influence on quality of life and health – a study of chronic whiplash-associated disorders4. JRehabilMed. 2008;12(7):562–569. [PubMed]

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Effectiveness of Mindfulness on Herniated Discs & Sciatica in El Paso, TX

Effectiveness of Mindfulness on Herniated Discs & Sciatica in El Paso, TX

Chronic low back pain is the second most common cause of disability in the United States. Approximately 80 percent of the population will experience back pain at least once throughout their lifetime. The most prevalent causes of chronic low back pain include: herniated discs, sciatica, injuries from lifting heavy objects or any other non-specific spine injury. However, people will often react differently to their symptoms. These differing responses are due to people’s psychological attitudes and outlooks.

 

Chronic Low Back Pain and the Mind

 

Stress has been associated with increased pain but your own personal health beliefs and coping strategies can influence your own perception of pain as well. That’s because psychological vulnerabilities can alter your brain and intensify the pain. Additionally, the pain itself can rewire the brain. When pain first occurs, it impacts the pain-sensitivity brain circuits. When pain becomes persistent, the associated brain activity switches from the pain circuits to circuits that process emotions. That’s why it’s believed that stress, anxiety and depression can cause as well as worsen chronic low back pain.

 

Managing the Scourge of Chronic Low Back Pain

 

Fortunately, several stress management methods and techniques can help improve chronic low back pain. Mindfulness is the most common treatment with the best supporting evidence towards improving and managing chronic pain. A recent study demonstrated that mindfulness-based stress reduction, or MBSR, including mindfulness meditation and other mindfulness interventions, can help reduce back pain and enhance psychological control by increasing brain blood flow to the frontal lobe. Practicing mindfulness involves activating a brain relaxation pathway by intentionally ignoring mental “chatter” and focusing on your breathing. Cognitive behavioral therapy, or CBT can also be helpful for chronic low back pain. Cognitive behavioral therapy can prevent an acute injury from progressing to chronic low back pain. Hypnosis may also help relieve chronic low back pain. However, CBT and hypnosis have weaker evidence to support their effectiveness on back pain.

 

Mind Over Matter

 

So while it may seem that chronic low back pain is all “in your head”, research studies have demonstrated that stress can influence painful symptoms. “Mind” includes “matter,” especially when you consider that the physical “matter” of the brain plays a major role in mindset changes. This is especially true when it comes to the brain-based changes related to low back pain. The purpose of the article below is to demonstrate the effectiveness of mindfulness meditation on chronic low back pain.

 

Effectiveness of Mindfulness Meditation on Pain and Quality of Life of Patients with Chronic Low Back Pain

 

Abstract

 

  • Background and aim: Recovery of patients with chronic low back pain (LBP) is depended on several physical and psychological factors. Therefore, the authors aimed to examine the efficacy of mindfulness based stress reduction (MBSR) as a mind-body intervention on quality of life and pain severity of female patients with nonspecific chronic LBP (NSCLBP).
  • Methods: Eighty-eight patients diagnosed as NSCLBP by physician and randomly assigned to experimental (MBSR+ usual medical care) and the control group (usual medical care only). The subjects assessed in 3 times frames; before, after and 4 weeks after intervention by Mac Gil pain and standard brief quality of life scales. Data obtained from the final sample analyzed by ANCOVA using SPSS software.
  • Results: The findings showed MBSR was effective in reduction of pain severity and the patients who practiced 8 sessions meditation reported significantly lower pain than patients who only received usual medical care. There was a significant effect of the between subject factor group (F [1, 45] = 16.45, P < 0.001) and (F [1, 45] = 21.51, P < 0.001) for physical quality of life and (F [1, 45] = 13.80, P < 0.001) and (F [1, 45] = 25.07, P < 0.001) mental quality of life respectively.
  • Conclusion: MBSR as a mind-body therapy including body scan, sitting and walking meditation was effective intervention on reduction of pain severity and improvement of physical and mental quality of life of female patients with NSCLBP.
  • Keywords: Chronic low back pain, mindfulness based stress reduction, pain, quality of life, SF-12

 

Introduction

 

In nonspecific low back pain (NSLBP) the pain is not related to conditions such as fractures, spondylitis, direct trauma, or neoplastic, infectious, vascular, metabolic, or endocrine-related although it is a cause of limitation in daily activities due to actual pain or fear of pain.[1] Unfortunately, the majority of LBP patients (80–90%) suffers from nonspecific LBP which leads to considerable pain-related disability and limitation in daily activities.[1,2] Chronic LBP is not only prevalent, but is also a source of great physical disability, role impairment, and diminished psychological well-being and quality of life.[1]

 

Prior to the current accepted biopsychosocial model, the biomedical model dominated all illness conceptualizations for almost 300 years and still dominates in the popular imagination. First proposed by Engel (1977) the biopsychosocial model acknowledges biological processes but also highlights the importance of experiential and psychological factors in pain. The famous gate control theory of pain[3] also proposed that the brain plays a dynamic role in pain perception as opposed to being a passive recipient of pain signals. They suggested psychological factors can inhibit or enhance sensory flow of pain signals and thus influence the way brain ultimately responds to painful stimulation.[4] If mind processes can change the way the brain processes pain then this holds tremendous potential for psychological intervention to produce reduced pain signals from the brain.

 

Kabat-Zinn’s et al. (1986) described the process of pain reduction in his paper on mindfulness and meditation. The process of pain reduction occurred by “an attitude of detached observation toward a sensation when it becomes prominent in the field of awareness and to observe with similar detachment the accompanying but independent cognitive processes which lead to evaluation and labeling of the sensation as painful, as hurt.” Thus, by “uncoupling” the physical sensation, from the emotional and cognitive experience of pain, the patient is able to reduce the pain.[5] The patients’ descriptions of distraction from pain, identifying maladaptive coping strategies toward pain and heightened awareness of pain sensation leading to behavioral changes are examples of how pain is unassociated with emotion, cognition, and sensation [Figure 1]. Therefore recently these theories attracted several researchers who are working on pain.

 

Figure 1 Consort Diagram

Figure 1: Consort diagram.

 

Mindfulness meditation has roots in Buddhist Vipassana philosophy and practice and has been independently adopted within clinical psychology in Western societies.[6,7,8,9] Recently in Netherlands Veehof et al. conducted a systematic review of controlled and noncontrolled studies on effectiveness of acceptance-based interventions such as mindfulness-based stress reduction program, acceptance and commitment therapy for chronic pain. Primary outcomes measured were pain intensity and depression. Secondary outcomes measured were anxiety, physical well-being and quality of life.[10] Twenty-two studies randomized controlled studies clinical controlled studies without randomization and noncontrolled studies were included totaling 1235 patients with chronic pain. An effect size on pain of (0.37) was found in the controlled studies. The effect on depression was (0.32). The authors concluded that ACT and mindfulness interventions had similar effects to other cognitive-behavioral therapy interventions and that these types of interventions may be a useful alternative or adjunct to current therapies. Chiesa and Serretti also conducted another systematic review on 10 mindfulness interventions.[11] The main findings were that these interventions produced small nonspecific effects in terms of reducing chronic pain and symptoms of depression. When compared to active control groups (support and education) no additional significant effects were noted.

 

In summary, there is a need for further studies into the specific effects of mindfulness studies on chronic pain. Regarding as the researcher knowledge efficacy of mindfulness has not been explored on quality of life of chronic pain patients in Iran. The authors aimed to examine the impact of mindfulness based stress reduction (MBSR) protocol designed for pain management on quality of life and pain of a homogeneous sample of females with nonspecific chronic LBP (NSCLBP) in comparison of the usual medical care group.

 

Methods

 

Sampling

 

Out of initial female samples aged 30–45 (n = 155) who diagnosed as chronic NSLBP by physicians in physiotherapy centers of Ardebil-Iran at least 6 months before. Only 88 met inclusion criteria and gave consent to participate in the research program. Patients were randomly assigned in small groups to receive MBSR plus medical usual care (experimental group) and medical usual care (control group). Some patients dropped during and after the treatment. The final sample of the study comprised of 48 females.

 

Inclusion Criteria

 

  • Age 30–45 years
  • Being under medical treatments like physiotherapy and medicine
  • Medical problem-history of NSCLBP and persisting pain for at least 6 months
  • Language – Persian
  • Gender – female
  • Qualification – educated at least up to high school
  • Consent and willingness to alternative and complementary therapies for pain management.

 

Exclusion Criteria

 

  • History of spine surgery
  • Combination with other chronic disease
  • Psychotherapy in the last 2 years excluded
  • Unavailability in next 3 months.

 

The proposal of study approved by the scientific committee of “Panjab University,” psychology department and all patients signed consent to participate in the present study. The study approved in India (in the university which researcher done her PhD), but conducted in Iran because researcher is from Iran originally and there was language and culture difference problem. Approval from Institutional Ethics Committee of physiotherapy center of Ardebil was obtained in Iran also to carry out the research.

 

Design

 

The study made use of the pre-post quasi time series experimental design to assess the efficacy of MBSR in 3 times frames (before-after-4 weeks after the program). A MBSR program administered one session per week for explaining techniques, practice, and feedback and share their experience for 8 weeks beside 30–45 min’ daily home practice [Table 1]. The intervention was conducted in three groups included 7–9 participants in each group. The process of framing the program was based on the quid lines provided by Kabat-Zinn, Morone (2008a, 2008b and 2007)[6,12,13,14] and some adaptation done for the patients involved in the study. The control group was not offered any type of intervention in the research project. Consequently, they underwent the normal routines in healthcare including physiotherapy and medicine.

 

Table 1 Content of MBSR Sessions

Table 1: Content of MBSR sessions.

 

Intervention

 

The sessions conducted in a private physiatrist clinic near to physiotherapy centers. Sessions took 8 weeks, and each session lasted for 90 min. Meditation transformed the patients’ awareness through the techniques of breathing and mindfulness. The intervention was conducted in small groups included 7–9 participants in each group. Table 1 for details of session’s content which prepared according books and previous studies.[6,12,13,14]

 

Assessments

 

The questionnaire completed by patients before the intervention, after intervention and 4 weeks after the interventions. The receptor of physiotherapy centers conducted the assessment. The receptors trained before conducting the assessment, and they were blind for the hypothesis of the study. The following are used for assessment of participants:

 

McGill Pain Questionnaire

 

The main component of this scale consists of 15 descriptive adjectives, 11 sensory including: Throbbing, Shooting, Stabbing, Sharp, Cramping, Gnawing, Hot-burning, Aching, Heavy, Tender, Splitting, and four affective including: Tiring-exhausting, Sickening, Fearful, Punishing-cruel, which are rated by the patients according to their severity on a four point scale (0 = none, 1 = mild, 2 = moderate, 3 = severe), yielding three scores. The sensory and affective scores are calculated by adding sensory and affective item values separately, and the total score is the sum of the two above-mentioned scores. In this study, we just used pain rating index with total scores. Adelmanesh et al.,[15] translated and validated Iran version of this questionnaire.

 

Quality of Life (SF-12)

 

The quality of life assessed by the validated SF-12 Health Survey.[16] It was developed as a shorter, quicker-to-complete alternative to the SF-36v2 Health Survey and measures the same eight health constructs. The constructs are: Physical functioning; role physical; bodily pain; general health; vitality; social functioning; role emotional; and mental health. Items have five response choices (for example: All of the time, most of the time, some of the time, a little of the time, none of the time), apart from two questions for which there are three response choices (for the physical functioning domain). Four items are reverse scored. Summed raw scores in the eight domains are transformed to convert the lowest possible score to zero and the highest possible score to 100. Higher scores represent better health and well-being. The standard form SF-12 uses a time frame of the past 4 weeks.[16]

 

The Iranian version of SF-12 in Montazeri et al. (2011) study showed satisfactory internal consistency for both summary measures, that are the Physical Component Summary (PCS) and the Mental Component Summary (MCS); Cronbach’s α for PCS-12 and MCS-12 was 0.73 and 0.72, respectively. The known – group comparison showed that the SF-12 discriminated well between men and women and those who differed in age and educational status (P < 0.001) 2.5.[17]

 

Statistical Analysis

 

The SPSS 20 (Armonk, NY: IBM Corp) was used to analysis of data. For descriptive analysis mean, standard deviation (SD) used. For performing ANCOVA, the pretest scores were used as covariates.

 

Results

 

The mean age was 40.3, SD = 8.2. 45% of females were working and the rest were a house wife. 38% had two children, 55% one child and the rest did have children. All were married and from middle-income families. 9.8% of patients reported very low physical quality of life, and the rest were low (54.8%) and moderate (36.4%). This was 12.4%, 40% and 47.6% very low, low and medium levels of mental quality of life in patients participated in our study (n = 48). The mean and SD of patients in MBSR and control group showed a decrease in pain and increase in mental and physical quality of life [Table 2].

 

Table 2 Mean and SD of Patients

Table 2: Mean and SD of patients in pain, mental and physical quality of life in baseline, after intervention and 4 weeks after intervention.

 

Comparative Results

 

Pain. The results indicated that after adjusting for pretest scores, there was a significant effect of the between subject factor group (F [1, 45] =110.4, P < 0.001) and (F [1, 45] =115.8, P < 0.001). Adjusted post-test scores suggest that the intervention had an effect on increasing the pain scores of the NSCLBP patients who received the MBSR as compared to those who were in the control group and did not receive any mind-body therapy [Table 3].

 

Table 3 The Result of Comparison of Pain and Quality of Life

Table 3: The result of comparison of pain and quality of life of MBSR and control group after intervention (time 1) and 4 weeks after intervention (time 2).

 

Quality of life. The results shows that after adjusting for pretest scores, there was a significant effect of the between subject factor group (F [1, 45] =16.45, P < 0.001) and (F [1, 45] =21.51, P < 0.001). Adjusted post-test scores suggest that the intervention had an effect on increasing the physical quality of life scores of the NSCLBP patients who received the MBSR as compared to those who were in the control group and did not receive any mind-body therapy [Table 3].

 

The results also showed that after adjusting for pretest scores, there was a significant effect of the between subject factor group (F [1, 45] =13.80, P < 0.001) and (F [1, 45] =25.07, P < 0.001). Adjusted post-test scores suggest that the intervention had an effect on increasing the mental quality of life scores of the NSCLBP patients who received the MBSR as compared to those who were in the control group and did not receive any psychological therapy [Table 3].

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Mindfulness is the psychological process which involves activating a brain relaxation pathway by intentionally ignoring mental “chatter”, bringing one’s attention to experiences occurring in the present moment and focusing on your breathing. Mindfulness can commonly be achieved through the practice of meditation and stress management methods and techniques. According to research studies, mindfulness is an effective treatment option which can help decrease chronic low back pain. Researchers have previously compared mindfulness-based stress reduction, or MBSR, with cognitive behavioral therapy to determine whether these mindfulness interventions could improve chronic low back pain. The following article was also conducted to determine if mindfulness meditation is an effective treatment option for chronic low back pain. The results of both research studies were promising, demonstrating that mindfulness can be more effective for chronic low back pain than traditional treatment options as well as the use of drugs and/or medication.

 

Discussion

 

The results showed that the experimental group who were subjected to the MBSR showed a significant improvement in their overall pain severity, physical and mental quality of life scores due to the training received as compared to the control group who received only usual medical care. The program reduced pain perception and enhanced both physical and mental quality of life and impacted on the experimental group clearly in comparison of the usual medical care. Baranoff et al., 2013,[18] Nyklícek and Kuijpers, 2008,[19] and Morone (2) et al., 2008[20] reported the same results.

 

Kabat-Zinn et al. believed the process of pain reduction occurred by “uncoupling” the physical sensation, from the emotional and cognitive experience of pain, the patient is able to reduce the pain.[21] In the current study, the participants uncoupled the different components of the experience of pain. Breathing exercise distract their mind from pain to breathing and mindful living made them aware about maladaptive coping strategies.

 

In the first session, information given about the fundamentals of mindfulness, describing the mindfulness supporting attitudes included being nonjudgmental toward thought, emotions or sensations as they arise, patience, nonstriving, compassion, acceptance and curiosity gave them a wisdom and believe that they are suffering from painful thoughts more than the pain itself.

 

Furthermore, during body scan practice they learned to see their real body conditions, as it truly was, without trying to change the reality. Accepting their chronic illness condition helped them see the other possible abilities in their social and emotional roles. In fact the body scan practice helped them change the relationship with their body and pain. Through direct experience in body scan, one realizes the interconnection between the state of the mind and the body, and thereby increases patients’ self-control over their life. Mindful living techniques also improved their quality of life by teaching them to pay more attention to their daily life necessities, which led to the experience of subtle positive emotions, like peace and joy, self-esteem and confidence. Furthermore, they appreciated positive things. Once they learned to see the persistent pain objectively and observe other sensations in their body, they applied the same principles through mindful living techniques in their everyday life. As a result, they learned how to manage their health and began to engage in their duties mindfully.

 

A number of research studies such as Plews-Ogan et al.,[22] Grossman et al.,[23] and Sephton et al., (2007)[24] showed effectiveness of mindfulness meditation program on quality of life of patients with chronic pain conditions.

 

Conclusion

 

All together the result of this study and previous studies highlighted the effectiveness of complementary and alternative treatment for patients with chronic LBP. Regarding the considerable role of quality of life in professional and personal life designing the effective psychotherapies especially for enhancement of quality of life of patients with chronic LBP strongly suggested by the authors.

 

This study involved with several limitations such as ununiformed usual care received by patients. The provided physiotherapy sessions or methods and medicine prescribed by different physicians in slightly different manner. Although some patients commonly dose not completed physiotherapy sessions. The sample size was small and it was only limited to three centers. This is suggested for future researchers to conduct study with considering physiologic variables such as MRI, NMR and neurologic signals to test the efficacy of MBSR to decrease pain sufferer.

 

In conclusion, more evidence-based larger scale researches with longer-term follow-up need to be done to increase the therapeutic weight and value of MBSR as a part of complementary alternative medicine being preventive and rehabilitation method among CLBP patients.

 

Acknowledgement

 

We are thankful from patients who were corporate with us. Dr. Afzalifard and staff of physiotherapy centers of Ardebil.

 

Footnotes

 

  • Source of support: Nil.
  • Conflict of interest: None declared.

 

In conclusion, mindfulness is the most prevalent treatment with the best supporting evidence towards improving and managing chronic low back pain. Mindfulness interventions, such as mindfulness-based stress reduction and cognitive behavioral therapy, have demonstrated to be effective for chronic low back pain. Furthermore, mindfulness meditation was also demonstrated to effectively help improve as well as manage chronic low back pain caused by stress. However, further research studies are still required to determine a solid outcome measure for mindfulness interventions and chronic pain. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Back Pain

 

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

 

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EXTRA IMPORTANT TOPIC: Managing Workplace Stress

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Choosing Chiropractic? | Familia Dominguez | Patients | El Paso, TX Chiropractor

 

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References
1. Waddell G. London, England: Churchill Livingstone; 1998. The Back Pain Revolution.
2. Kovacs FM, Abraira V, Zamora J, Fernández C. Spanish Back Pain Research Network. The transition from acute to subacute and chronic low back pain: A study based on determinants of quality of life and prediction of chronic disability. Spine (Phila Pa 1976) 2005;30:1786–92. [PubMed]
3. Melzack R, Wall PD. Pain mechanisms: A new theory. Science. 1965;150:971–9. [PubMed]
4. Beverly ET. USA: The Guilford Press; 2010. Cognitive Therapy for Chronic Pain: A Step-by-Step Guide.
5. Kabat-Zinn J, Lipworth L, Burney R, Sellers W. Four-Year Follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clin J Pain. 1986;2:159–73.
6. Wetherell JL, Afari N, Rutledge T, Sorrell JT, Stoddard JA, Petkus AJ, et al. A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain. 2011;152:2098–107. [PubMed]
7. Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review. Clin Psychol Sci Pract. 2003;10:125–43.
8. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4:33–47. [PubMed]
9. Glombiewski JA, Hartwich-Tersek J, Rief W. Two psychological interventions are effective in severely disabled, chronic back pain patients: A randomised controlled trial. Int J Behav Med. 2010;17:97–107.[PubMed]
10. Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis. Pain. 2011;152:533–42. [PubMed]
11. Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: A systematic review of the evidence. J Altern Complement Med. 2011;17:83–93. [PubMed]
12. Morone NE, Greco CM, Weiner DK. Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study. Pain. 2008;134:310–9. [PMC free article][PubMed]
13. Kabat-Zinn J. New York: Dell Publishing; 1990. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness.
14. Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: A structured review. Pain Med. 2007;8:359–75. [PubMed]
15. Adelmanesh F, Arvantaj A, Rashki H, Ketabchi S, Montazeri A, Raissi G. Results from the translation and adaptation of the Iranian Short-Form McGill Pain Questionnaire (I-SF-MPQ): Preliminary evidence of its reliability, construct validity and sensitivity in an Iranian pain population. Sports Med Arthrosc Rehabil Ther Technol. 2011;3:27. [PMC free article] [PubMed]
16. Ware JE, Jr, Kosinski M, Turner-Bowker DM, Gandek B. Lincoln, RI: Quality Metric Incorporated; 2002. How to Score Version 2 of the SF-12® Health Survey (With a Supplement Documenting Version 1)
17. Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item short form health survey (SF-12): A population-based validation study from Tehran, Iran. Health Qual Life Outcomes. 2011;9:12. [PMC free article] [PubMed]
18. Baranoff J, Hanrahan SJ, Kapur D, Connor JP. Acceptance as a process variable in relation to catastrophizing in multidisciplinary pain treatment. Eur J Pain. 2013;17:101–10. [PubMed]
19. Nyklícek I, Kuijpers KF. Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: Is increased mindfulness indeed the mechanism? Ann Behav Med. 2008;35:331–40. [PMC free article] [PubMed]
20. Morone NE, Lynch CS, Greco CM, Tindle HA, Weiner DK. “I felt like a new person.” the effects of mindfulness meditation on older adults with chronic pain: Qualitative narrative analysis of diary entries. J Pain. 2008;9:8 41–8. [PMC free article] [PubMed]
21. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8:163–90. [PubMed]
22. Plews-Ogan M, Owens JE, Goodman M, Wolfe P, Schorling J. A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain. J Gen Intern Med. 2005;20:1136–8. [PMC free article] [PubMed]
23. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res. 2004;57:35–43. [PubMed]
24. Sephton SE, Salmon P, Weissbecker I, Ulmer C, Floyd A, Hoover K, et al. Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: Results of a randomized clinical trial. Arthritis Rheum. 2007;57:77–85. [PubMed]
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Herniated Disc & Sciatica Nonoperative Treatment in El Paso, TX

Herniated Disc & Sciatica Nonoperative Treatment in El Paso, TX

A herniated disc, also known as a slipped or ruptured disc, is a healthcare condition which occurs when a tear in the outer, fibrous ring of an intervertebral disc causes its soft, central portion to bulge out from the damaged, surrounding cartilage. Disc herniations are generally due to the degeneration of the outer ring of an intervertebral disc, known as the anulus fibrosus. Trauma, lifting injuries or straining may also cause a herniated disc. A tear in the intervertebral disc may result in the release of chemicals which may cause irritation and ultimately become the direct cause of severe back pain, even without nerve root compression.

 

Disc herniations also commonly develop following a previously existing disc protrusion, a healthcare condition in which the outermost layers of the anulus fibrosus remain intact, however, these can bulge if the disc is placed under pressure. Unlike a disc herniation, none of the gel-like section escapes the intervertebral disc. Herniated discs often heal on their own within several weeks. Severe disc herniations may require surgery, however, a variety of research studies have demonstrated that nonoperative treatment may help improve and manage the recovery process of a herniated disc without the need for surgical interventions.

 

Surgical vs Nonoperative Treatment for Lumbar Disk Herniation Using The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial

 

Abstract

 

  • Context: Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.
  • Objective: To assess the efficacy of surgery for lumbar intervertebral disk herniation.
  • Design, Setting, and Patients: The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.
  • Interventions: Standard open diskectomy vs nonoperative treatment individualized to the patient.
  • Main Outcome Measures: Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.
  • Results: Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.
  • Conclusions: Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.
  • Trial Registration: clinicaltrials.gov Identifier: NCT00000410

 

Lumbar diskectomy is the most common surgical procedure performed in the United States for patients having back and leg symptoms; the vast majority of the procedures are elective. However, lumbar disk herniation is often seen on imaging studies in the absence of symptoms[1,2] and can regress over time without surgery.[3] Up to 15-fold variation in regional diskectomy rates in the United States[4] and lower rates internationally raise questions regarding the appropriateness of some of these surgeries.[5,6]

 

Several studies have compared surgical and nonoperative treatment of patients with herniated disk, but baseline differences between treatment groups, small sample sizes, or lack of validated outcome measures in these studies limit evidence-based conclusions regarding optimal treatment.[7-12] The Spine Patient Outcomes Research Trial (SPORT) was initiated in March 2000 to compare the outcomes of surgical and nonoperative treatment for lumbar intervertebral disk herniation, spinal stenosis, or degenerative spondylolisthesis.[13] The trial included both a randomized cohort and an observational cohort who declined to be randomized in favor of designating their own treatment but otherwise met all the other criteria for inclusion and who agreed to undergo follow-up according to the same protocol. This article reports intent-to-treat results through 2 years for the randomized cohort.

 

Methods

 

Study Design

 

SPORT was conducted at 13 multidisciplinary spine practices in 11 US states (California, Georgia, Illinois, Maine, Michigan, Missouri, Nebraska, New York, New Hampshire, Ohio, Pennsylvania). The human subjects committee of each participating institution approved a standardized protocol. All patients provided written informed consent. An independent data and safety monitoring board monitored the study at 6-month intervals.[13]

 

Patient Population

 

Patients were considered for inclusion if they were 18 years and older and diagnosed by participating physicians during the study enrollment period as having intervertebral disk herniation and persistent symptoms despite some nonoperative treatment for at least 6 weeks. The content of preenrollment nonoperative care was not prespecified in the protocol but included education/counseling (71%), physical therapy (67%), epidural injections (42%), chiropractic therapy (32%), anti-inflammatory medications (61%), and opioid analgesics (40%).

 

Specific inclusion criteria at enrollment were radicular pain (below the knee for lower lumbar herniations, into the anterior thigh for upper lumbar herniations) and evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise–positive between 30° and 70° or positive femoral tension sign) or a corresponding neurologic deficit (asymmetrical depressed reflex, decreased sensation in a dermatomal distribution, or weakness in a myotomal distribution). Additionally, all participants were surgical candidates who had undergone advanced vertebral imaging (97% magnetic resonance imaging, 3% computed tomography) showing disk herniation (protrusion, extrusion, or sequestered fragment)[14] at a level and side corresponding to the clinical symptoms. Patients with multiple herniations were included if only one of the herniations was considered symptomatic (ie, if only one was planned to be operated on).

 

Exclusion criteria included prior lumbar surgery, cauda equina syndrome, scoliosis greater than 15°, segmental instability (>10° angular motion or >4-mm translation), vertebral fractures, spine infection or tumor, inflammatory spondyloarthropathy, pregnancy, comorbid conditions contraindicating surgery, or inability/unwillingness to have surgery within 6 months.

 

Study Interventions

 

The surgery was a standard open diskectomy with examination of the involved nerve root.[15,16] The procedure agreed on by all participating centers was performed under general or local anesthesia, with patients in the prone or knee-chest position. Surgeons were encouraged to use loupe magnification or a microscope. Using a midline incision reflecting the paraspinous muscles, the interlaminar space was entered as described by Delamarter and McCullough.[15] In some cases the medial border of the superior facet was removed to provide a clear view of the involved nerve root. Using a small annular incision, the fragment of disk was removed as described by Spengler.[16] The canal was inspected and the foramen probed for residual disk or bony pathology. The nerve root was decompressed, leaving it freely mobile.

 

The nonoperative treatment group received “usual care,” with the study protocol recommending that the minimum nonsurgical treatment include at least active physical therapy, education/counseling with home exercise instruction, and nonsteroidal anti-inflammatory drugs, if tolerated. Other nonoperative treatments were listed, and physicians were encouraged to individualize treatment to the patient; all nonoperative treatments were tracked prospectively.[13,17]

 

Study Measures

 

The primary measures were the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) bodily pain and physical function scales[18-21] and the American Academy of Orthopaedic Surgeons MODEMS version of the Oswestry Disability Index (ODI).[22] As specified in the trial protocol, the primary outcomes were changes from baseline in these scales at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment.

 

Secondary measures included patient self-reported improvement, work status, and satisfaction with current symptoms and with care.[23] Symptom severity was measured by the Sciatica Bothersomeness Index (range, 0-24; higher scores represent worse symptoms).[24,25]

 

Recruitment, Enrollment, and Randomization

 

A research nurse at each site identified potential participants and verified eligibility. For recruitment and informed consent, evidence-based videotapes described the surgical and non-operative treatments and the expected benefits, risks, and uncertainties.[26,27] Participants were offered enrollment in either the randomized trial or a concurrent observational cohort, the results of which are reported in a companion article.

 

Enrollment began in March 2000 and ended in November 2004. Baseline variables were collected prior to randomization. Patients self-reported race and ethnicity using National Institutes of Health categories.

 

Computer-generated random treatment assignment based on permuted blocks (randomly generated blocks of 6, 8, 10, and 12)[28] within sites occurred immediately after enrollment via an automated system at each site, ensuring proper allocation concealment. Study measures were collected at baseline and at regularly scheduled follow-up visits. Short-term follow-up visits occurred at 6 weeks and 3 months. If surgery was delayed beyond 6 weeks, additional follow-up data were obtained 6 weeks and 3 months postoperatively. Longer-term follow-up visits occurred at 6 months, 1 year from enrollment, and annually thereafter.

 

Statistical Analyses

 

We originally determined a sample size of 250 patients in each treatment group to be sufficient (with a 2-sided significance level of .05 and 85% power) to detect a 10-point difference in the SF-36 bodily pain and physical functioning scales or a similar effect size in the ODI. This difference corresponded to patients’ reports of being “a little better” in the Maine Lumbar Spine Study (MLSS).[29] The sample size calculation allowed for up to 20% missing data but did not account for any specific levels of nonadherence.

 

The analyses for the primary and secondary outcomes used all available data for each period on an intent-to-treat basis. Predetermined end points for the study included results at each of 6 weeks, 3 months, 6 months, 1 year, and 2 years. To adjust for the possible effect of missing data on the study results, the analysis of mean changes for continuous outcomes was performed using maximum likelihood estimation for longitudinal mixed-effects models under “missing at random” assumptions and including a term for treatment center. Comparative analyses were performed using the single imputation methods of baseline value carried forward and last value carried forward, as well as a longitudinal mixed model controlling for covariates associated with missed visits.[30]

 

For binary secondary outcomes, longitudinal logistic regression models were fitted using generalized estimating equations[31] as implemented in the PROC GENMOD program of SAS version 9.1 (SAS Institute Inc, Cary, NC). Treatment effects were estimated as differences in the estimated proportions in the 2 treatment groups.

 

P<.05 (2-sided) was used to establish statistical significance. For the primary outcomes, 95% confidence intervals (CIs) for mean treatment effects were calculated at each designated time point. Global tests of the joint hypothesis of no treatment effect at any of the designated periods were performed using Wald tests[32] as implemented in SAS. These tests account for the intraindividual correlation due to repeated measurements over time.[32]

 

Nonadherence to randomly assigned treatment may mean that the intention-to-treat analysis underestimates the real benefit of the treatment.[33,34] As a preplanned sensitivity analysis, we also estimated an “as-treated” longitudinal analysis based on comparisons of those actually treated surgically and nonoperatively. Repeated measures of outcomes were used as the dependent variables, and treatment received was included as a time-varying covariate. Adjustments were made for the time of surgery with respect to the original enrollment date to approximate the designated follow-up times. Baseline variables that were individually found to predict missing data or treatment received at 1 year were included to adjust for possible confounding.

 

Results

 

SPORT achieved full enrollment, with 501 (25%) of 1991 eligible patients enrolled in the randomized trial. A total of 472 participants (94%) completed at least 1 follow-up visit and were included in the analysis. Data were available for between 86% and 73% of patients at each of the designated follow-up times (Figure 1).

 

Figure 1 Flow Diagram of the SPORT RCT of Disc Herniation

Figure 1: Flow Diagram of the SPORT Randomized Controlled Trial of Disk Herniation: Exclusion, Enrollment, Randomization, and Follow-up.

 

Patient Characteristics

 

Baseline patient characteristics are shown in Table 1. Overall, the study population had a mean age of 42 years, with majorities being male, white, employed, and having attended at least some college; 16% were receiving disability compensation. All patients had radicular leg pain, 97% in a classic dermatomal distribution. Most of the herniations were at L5-S1, posterolateral, and were extrusions by imaging criteria.[14] The 2 randomized groups were similar at baseline.

 

Table 1 Patient Baseline Demographics

 

Nonoperative Treatments

 

A variety of nonoperative treatments were used during the study (Table 2). Most patients received education/counseling (93%) and anti-inflammatory medications (61%) (nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, or oral steroids); 46% received opiates; more than 50% received injections (eg, epidural steroids); and 29% were prescribed activity restriction. Forty-four percent received active physical therapy during the trial; however, 67% had received it prior to enrollment.

 

Table 2 Nonoperative Treatments

 

Surgical Treatment and Complications

 

Table 3 gives the characteristics of surgical treatment and complications. The median surgical time was 75 minutes (interquartile range, 58-90), with a median blood loss of 49.5 mL (interquar-tile range, 25-75). Only 2% required transfusions. There were no perioperative deaths; 1 patient died from complications of childbirth 11 months after enrollment. The most common intraoperative complication was dural tear (4%). There were no postoperative complications in 95% of patients. Reoperation occurred in 4% of patients within 1 year of the initial surgery; more than 50% of the reoperations were for recurrent herniations at the same level.

 

Table 3 Operative Treatments, Complications and Events

 

Nonadherence

 

Nonadherence to treatment assignment affected both groups, ie, some patients in the surgery group chose to delay or decline surgery, and some in the nonoperative treatment group crossed over to receive surgery (Figure 1). The characteristics of crossover patients that were statistically different from patients who did not cross over are shown in Table 4. Those more likely to cross over to receive surgery tended to have lower incomes, worse baseline symptoms, more baseline disability on the ODI, and were more likely to rate their symptoms as getting worse at enrollment than the other patients receiving nonoperative treatment. Those more likely to cross over to receive nonoperative care were older, had higher incomes, were more likely to have an upper lumbar disk herniation, less likely to have a positive straight leg–raising test result, had less pain, better physical function, less disability on the ODI, and were more likely to rate their symptoms as getting better at enrollment than the other surgery patients.

 

Table 4 Statistically Significant Baseline Demographics

 

Missing Data

 

The rates of missing data were equivalent between the groups at each time point, with no evidence of differential dropout according to assigned treatment. Characteristics of patients with missed visits were very similar to those of the rest of the cohort except that patients with missing data were less likely to be married, more likely to be receiving disability compensation, more likely to smoke, more likely to display baseline motor weakness, and had lower baseline mental component summary scores on the SF-36.

 

Intent-to-Treat Analyses

 

Table 5 shows estimated mean changes from baseline and the treatment effects (differences in changes from baseline between treatment groups) for 3 months, 1 year, and 2 years. For each measure and at each point, the treatment effect favors surgery. The treatment effects for the primary outcomes were small and not statistically significant at any of the points. As shown in Figure 2, both treatment groups showed strong improvements at each of the designated follow-up times, with small advantages for surgery. However, for each primary outcome the combined global test for any difference at any period was not statistically significant. This test accounts for intraindividual correlations as described in the “Methods” section.

 

Figure 2 Mean Scores Over Time

Figure 2: Mean Scores Over Time for SF-36 Bodily Pain and Physical Function Scales and Oswestry Disability Index.

 

Table 5 Treatment Effects for Primary and Secondary Outcomes

Table 5: Treatment Effects for Primary and Secondary Outcomes Based on Intent-to-Treat Analyses*

 

For the secondary outcome of sciatica bothersomeness, Table 5 and Figure 3 show that there were greater improvements in the Sciatica Bothersomeness Index in the surgery group at all designated follow-up times: 3 months (treatment effect, −2.1; 95% CI, −3.4 to −0.9), 1 year (treatment effect, −1.6; 95% CI, −2.9 to −0.4), and 2 years (treatment effect, −1.6; 95% CI, −2.9 to −0.3), with results of the global hypothesis test being statistically significant (P=.003). Patient satisfaction with symptoms and treatment showed small effects in favor of surgery while employment status showed small effects in favor of nonoperative care, but none of these changes was statistically significant. Self-rated progress showed a small statistically significant advantage for surgery (P=.04).

 

Figure 3 Measures Over Time

Figure 3: Measures Over Time for Sciatica Bothersomeness Index, Employment Status, Satisfaction With Symptoms, Satisfaction With Care, and Self-rated Improvement.

 

As-treated analyses based on treatment received were performed with adjustments for the time of surgery and factors affecting treatment crossover and missing data. These yielded far different results than the intent-to-treat analysis, with strong, statistically significant advantages seen for surgery at all follow-up times through 2 years. For example, at 1 year the estimated treatment effects for the SF-36 bodily pain and physical function scales, the ODI, and the sciatica measures were 15.0 (95% CI, 10.9 to 19.2), 17.5 (95% CI, 13.6 to 21.5), −15.0 (95% CI, −18.3 to −11.7), and −3.2 (95% CI, −4.3 to −2.1), respectively.

 

Sensitivity analysis was performed for 4 different analytic methods of dealing with the missing data. One method was based on simple mean changes for all patients with data at a given time point with no special adjustment for missing data. Two methods used single imputation methods—baseline value carried forward and last value carried forward.[32] The latter method used the same mixed-models approach for estimating mean changes as given in Table 5 but also adjusted for factors affecting the likelihood of missing data. Treatment effect estimates at 1 year ranged from 1.6 to 2.9 for the SF-36 bodily pain scale, 0.74 to 1.4 for the physical function scale, −2.2 to −3.3 for the ODI, and −1.1 to −1.6 for the sciatica measures. Given these ranges, there appear to be no substantial differences between any of these methods.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Herniated disc symptoms vary on the location of the condition and on the surrounding soft tissues affected along the spine. Lumbar disc herniations, one of the most common area for herniated discs to occur, are characterized by the compression of the nerve roots along the lower back and can generally cause symptoms of sciatica. Surgery is commonly recommended to treat disc herniations, however, numerous treatment methods can help manage the condition without the need of surgical interventions. A research study conducted on sciatica caused by herniated discs determined that about 73 percent of participants experienced an improvement in symptoms with nonoperative treatment. The results of this article concluded that nonoperative treatment can be as effective as surgery in the treatment of herniated discs.

 

Comment

 

Both operated and nonoperated patients with intervertebral disk herniation improved substantially over a 2-year period. The intent-to-treat analysis in this trial showed no statistically significant treatment effects for the primary outcomes; the secondary measures of sciatica severity and self-reported progress did show statistically significant advantages for surgery. These results must be viewed in the context of the substantial rates of nonadherence to assigned treatment. The pattern of nonadherence is striking because, unlike many surgical studies, both the surgical and nonoperative treatment groups were affected.[35] The most comparable previous trial[8] had 26% crossover into surgery at 1 year, but only 2% crossover out of surgery. The mixing of treatments due to crossover can be expected to create a bias toward the null.[34] The large effects seen in the as-treated analysis and the characteristics of the crossover patients suggest that the intent-to-treat analysis underestimates the true effect of surgery.

 

SPORT findings are consistent with clinical experience in that relief of leg pain was the most striking and consistent improvement with surgery. Importantly, all patients in this trial had leg pain with physical examination and imaging findings that confirmed a disk herniation. There was little evidence of harm from either treatment. No patients in either group developed cauda equina syndrome; 95% of surgical patients had no intraoperative complications. The most common complication, dural tear, occurred in 4% of patients, similar to the 2% to 7% noted in the meta-analysis by Hoffman et al,7 2.2% seen in the MLSS,[29] and 4% in the recent series from Stanford.[36]

 

One limitation is the potential lack of representativeness of patients agreeing to be randomized to surgery or nonoperative care; however, the characteristics of patients agreeing to participate in SPORT were very similar to those in other studies.[29,36] The mean age of 42 years was similar to the mean ages in the MLSS,[29] the series of Spangfort,[37] and the randomized trial by Weber,[8] and only slightly older than those in the recent series from Stanford (37.5 years).[36] The proportion of patients receiving workers’ compensation in SPORT (16%) was similar to the proportion in the Stanford population (19%) but lower than that in the MLSS population (35%), which specifically oversampled patients receiving compensation. Baseline functional status was also similar, with a mean baseline ODI of 46.9 in SPORT vs 47.2 in the Stanford series, and a mean baseline SF-36 physical function score of 39 in SPORT vs 37 in the MLSS.

 

The strict eligibility criteria, however, may limit the generalizability of these results. Patients unable to tolerate symptoms for 6 weeks and demanding earlier surgical intervention were not included, nor were patients without clear signs and symptoms of radiculopathy with confirmatory imaging. We can draw no conclusions regarding the efficacy of surgery in these other groups. However, our entry criteria followed published guidelines for patient selection for elective diskectomy, and our results should apply to the majority of patients facing a surgical decision.[38,39]

 

To fully understand the treatment effect of surgery compared with nonoperative treatment, it is worth noting how each group fared. The improvements with surgery in SPORT were similar to those of prior series at 1 year: for the ODI, 31 points vs 34 points in the Stanford series; for the bodily pain scale, 40 points vs 44 in the MLSS; and for sciatica bothersomeness, 10 points vs 11 in the MLSS. Similarly, Weber[8] reported 66% “good” results in the surgery group, compared with the 76% reporting “major improvement” and 65% satisfied with their symptoms in SPORT.

 

The observed improvements with nonoperative treatment in SPORT were greater than those in the MLSS, resulting in the small estimated treatment effect. The nonoperative improvement of 37, 35, and 9 points in bodily pain, physical function, and sciatica bothersomeness, respectively, were much greater than the improvements of 20, 18, and 3 points reported in the MLSS. The greater improvement with nonoperative treatment in SPORT may be related to the large proportion of patients (43%) who underwent surgery in this group.

 

The major limitation of SPORT is the degree of nonadherence with randomized treatment. Given this degree of crossover, it is unlikely that the intent-to-treat analysis can form the basis of a valid estimate of the true treatment effect of surgery. The “as-treated” analysis with adjustments for possible confounders showed much larger effects in favor of surgical treatment. However, this approach does not have the strong protection against confounding that is afforded by randomization. We cannot exclude the possibility that baseline differences between the as-treated groups, or the selective choice of some but not other patients to cross over into surgery, may have affected these results, even after controlling for important covariates. Due to practical and ethical constraints, this study was not masked through the use of sham procedures. Therefore, any improvements seen with surgery may include some degree of “placebo effect.”

 

Another potential limitation is that the choice of nonoperative treatments was at the discretion of the treating physician and patient. However, given the limited evidence regarding efficacy for most nonoperative treatments for lumbar disk herniation and individual variability in response, creating a limited, fixed protocol for nonoperative treatment was neither clinically feasible nor generalizable. The nonoperative treatments used were consistent with published guidelines.[17,38,39] Compared with the MLSS, SPORT had lower use of activity restriction, spinal manipulation, transcutaneous electrical nerve stimulation, and braces and corsets, and higher rates of epidural steroid injections and use of narcotic analgesics. This flexible nonoperative protocol had the advantages of individualization that considered patient preferences in the choice of nonoperative treatment and of reflecting current practice among multidisciplinary spine practices. However, we cannot make any conclusion regarding the effect of surgery vs any specific nonoperative treatment. Similarly, we cannot adequately assess the relative efficacy of any differences in surgical technique.

 

Conclusion

 

Patients in both the surgery and nonoperative treatment groups improved substantially over the first 2 years. Between-group differences in improvements were consistently in favor of surgery for all outcomes and at all time periods but were small and not statistically significant except for the secondary measures of sciatica severity and self-rated improvement. Because of the high numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis alone.

 

Acknowledgments & Footnotes

 

Ncbi.nlm.nih.gov/pmc/articles/PMC2553805/

 

Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study

 

Abstract

 

Objective: The purpose of this study was to compare the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH).

Methods: One hundred twenty patients presenting through elective referral by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3-4, L4-5, or L5-S1. Forty consecutive consenting patients who met inclusion criteria (patients must have failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. Crossover to the alternate treatment was allowed after 3 months.

Results: Significant improvement in both treatment groups compared to baseline scores over time was observed in all outcome measures. After 1 year, follow-up intent-to-treat analysis did not reveal a difference in outcome based on the original treatment received. However, 3 patients crossed over from surgery to spinal manipulation and failed to gain further improvement. Eight patients crossed from spinal manipulation to surgery and improved to the same degree as their primary surgical counterparts.

Conclusions: Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.

 

In conclusion, a herniated disc causes the soft, central portion of an intervertebral disc to bulge out a tear in its outer, fibrous ring as a result of degeneration, trauma, lifting injuries or straining. Most disc herniations can heal on their own but those considered to be severe may require surgical interventions to treat them. Research studies, such as the one above, have demonstrated that nonoperative treatment may help the recovery of a herniated disc without the need for surgery. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Back Pain

 

According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.

 

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References
1. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am. 1990;72:403–408. [PubMed]
2. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331:69–73.[PubMed]
3. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. Spine. 1989;14:431–437. [PubMed]
4. Weinstein JN, Dartmouth Atlas Working Group . Dartmouth Atlas of Musculoskeletal Health Care.American Hospital Association Press; Chicago, Ill: 2000.
5. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363–370. [PubMed]
6. Weinstein JN, Bronner KK, Morgan TS, Wennberg JE. Trends and geographic variations in major surgery for degenerative diseases of the hip, knee, and spine. Health Aff (Millwood) 2004;(suppl Web exclusive):var81–89. [PubMed]
7. Hoffman RM, Wheeler KJ, Deyo RA. Surgery for herniated lumbar discs: a literature synthesis. J Gen Intern Med. 1993;8:487–496. [PubMed]
8. Weber H. Lumbar disc herniation: a controlled, prospective study with ten years of observation. Spine. 1983;8:131–140. [PubMed]
9. Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy: a prospective, randomized study. J Bone Joint Surg Am. 2004;86:670–679. [PubMed]
10. Gibson JN, Grant IC, Waddell G. The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. Spine. 1999;24:1820–1832. [PubMed]
11. Gibson JN, Grant IC, Waddell G. Surgery for lumbar disc prolapse. Cochrane Database Syst Rev. 2000;(3):CD001350. [PubMed]
12. Jordan J, Shawver Morgan T, Weinstein J, Konstantinou K. Herniated lumbar disc. Clin Evid. 2003 June;:1203–1215.
13. Birkmeyer NJ, Weinstein JN, Tosteson AN, et al. Design of the Spine Patient Outcomes Research Trial (SPORT) Spine. 2002;27:1361–1372. [PMC free article] [PubMed]
14. Fardon DF, Milette PC. Nomenclature and classification of lumbar disc pathology: recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine. 2001;26:E93–E113. [PubMed]
15. Delamarter R, McCullough J. Microdiscectomy and microsurgical laminotomies. In: Frymoyer J, editor. The Adult Spine: Principles and Practice. 2nd ed. Lippincott-Raven Publishers; Philadelphia, Pa: 1996.
16. Spengler DM. Lumbar discectomy: results with limited disc excision and selective foraminotomy. Spine. 1982;7:604–607. [PubMed]
17. Cummins J, Lurie JD, Tosteson T, et al. Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial’s (SPORT) three observational cohorts: disc herniation, spinal stenosis, and degenerative spondylolisthesis. Spine. 2006;31:806–814. [PMC free article][PubMed]
18. Ware JE, Jr, Sherbourne D. The MOS 36-item short-form health survey (SF-36), I: conceptual framework and item selection. Med Care. 1992;30:473–483. [PubMed]
19. Ware JE., Jr . SF-36 Health Survey: Manual and Interpretation Guide. Nimrod Press; Boston, Mass: 1993.
20. McHorney CA, Ware JE, Jr, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36), III: tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40–66. [PubMed]
21. Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study. JAMA. 1989;262:907–913. [PubMed]
22. Daltroy LH, Cats-Baril WL, Katz JN, Fossel AH, Liang MH. The North American Spine Society lumbar spine outcome assessment instrument: reliability and validity tests. Spine. 1996;21:741–749.[PubMed]
23. Deyo RA, Diehl AK. Patient satisfaction with medical care for low-back pain. Spine. 1986;11:28–30.[PubMed]
24. Atlas SJ, Deyo RA, Patrick DL, Convery K, Keller RB, Singer DE. The Quebec Task Force classification for spinal disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis. Spine. 1996;21:2885–2892. [PubMed]
25. Patrick DL, Deyo RA, Atlas SJ, Singer DE, Chapin A, Keller RB. Assessing health-related quality of life in patients with sciatica. Spine. 1995;20:1899–1908. [PubMed]
26. Phelan EA, Deyo RA, Cherkin DC, et al. Helping patients decide about back surgery: a randomized trial of an interactive video program. Spine. 2001;26:206–211. [PubMed]
27. Weinstein JN. Partnership: doctor and patient: advocacy for informed choice vs. informed consent. Spine. 2005;30:269–272. [PubMed]
28. Friedman L, Furberg C, DeMets D. Fundamentals of Clinical Trials. 3rd ed. Springer-Verlag; Cambridge, Mass: 1998. The randomization process; pp. 61–81.
29. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, II: 1-year outcomes of surgical and nonsurgical management of sciatica. Spine. 1996;21:1777–1786. [PubMed]
30. Little R, Rubin D. Statistical Analysis With Missing Data. 2nd ed. John Wiley & Sons; Philadelphia, Pa: 2002.
31. Diggle P, Haeagery P, Liang K, Zeger S. The Analysis of Longitudinal Data. 2nd ed. Oxford University Press; Oxford, England: 2002.
32. Fitzmaurice G, Laird N, Ware J. Applied Longitudinal Analysis. John Wiley & Sons; Philadelphia, Pa: 2004.
33. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134:663–694. [PubMed]
34. Meinert CL. Clinical Trials: Design, Conduct, and Analysis. Oxford University Press; New York, NY: 1986.
35. Kuppermann M, Varner RE, Summitt RL, Jr, et al. Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning: the medicine or surgery (Ms) randomized trial. JAMA. 2004;291:1447–1455. [PubMed]
36. Carragee EJ, Han MY, Suen PW, Kim D. Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am. 2003;85:102–108. [PubMed]
37. Spangfort EV. The lumbar disc herniation: a computer-aided analysis of 2,504 operations. Acta Orthop Scand Suppl. 1972;142:1–95. [PubMed]
38. Agency for Health Care Policy and Research . Acute Low Back Problems in Adults. US Dept of Health & Human Services; Bethesda, Md: 1994.
39. North American Spine Society . North American Spine Society Phase III Clinical Guidelines for Multidisciplinary Spine Care Specialists. NASS; LaGrange, Ill: 2000. Herniated disc.
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Rapid Pain Relief for Herniated Discs in El Paso, TX

Rapid Pain Relief for Herniated Discs in El Paso, TX

Herniated discs are a debilitating condition characterized by pain, numbness and weakness in one or more limbs. While some people may experience no pain at all, those that do may often wish for fast pain relief to avoid long periods of sick leave from their jobs. Many healthcare professionals recommend surgery for patients with persistent and/or worsening herniated disc symptoms but other non-operative treatment options can help treat disc herniations. The purpose of the following article is to demonstrate how a structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery.

 

A Structured Physiotherapy Treatment Model Can Provide Rapid Relief to Patients Who Qualify for Lumbar Disc Surgery: A Prospective Cohort Study

 

Abstract

 

  • Objective: To evaluate a structured physiotherapy treatment model in patients who qualify for lumbar disc surgery.
  • Design: A prospective cohort study.
  • Patients: Forty-one patients with lumbar disc herniation, diagnosed by clinical assessments and magnetic resonance imaging.
  • Methods: Patients followed a structured physiotherapy treatment model, including Mechanical Diagnosis and Therapy (MDT), together with graded trunk stabilization training. Study outcome measures were the Oswestry Disability Index, a visual analogue scale for leg and back pain, the Tampa Scale for Kinesiophobia, the European Quality of Life in 5 Dimensions Questionnaires, the Zung Self-Rating Depression Scale, the Self-Efficacy Scale, work status, and patient satisfaction with treatment. Questionnaires were distributed before treatment and at 3-, 12- and 24-month follow-ups.
  • Results: The patients had already improved significantly (p<0.001) 3 months after the structured physiotherapy treatment model in all assessments: disability, leg and back pain, kinesiophobia, health-related quality of life, depression and self-efficacy. The improvement could still be seen at the 2-year follow-up.
  • Conclusion: This study recommends adopting the structured physiotherapy treatment model before considering surgery for patients with symptoms such as pain and disability due to lumbar disc herniation.
  • Keywords: intervertebral disc displacement; rehabilitation; physical therapy modalities.

 

Introduction

 

Symptoms of lumbar disc herniation are relatively common in the general population, although the prevalence rates vary widely between different studies (1). Symptom severity also varies and, in many patients, pain and loss of function may lead to disability and long periods of sick leave (2). Spontaneous resolution of symptoms after a lumbar disc herniation is regarded as common, which makes it difficult to evaluate the effects of treatment. Furthermore, in studies evaluating spontaneous healing, different physiotherapy treatments are often included, together with pain medication (3–5), which makes it difficult to determine the extent of natural healing. On the other hand, in patients with sciatica, but without confirmed disc herniation on magnetic resonance imaging (MRI), approximately one-third of subjects recover 2 weeks after the onset of sciatica and approximately three-quarters recover after 3 months (6).

 

In contrast to evaluating spontaneous healing, surgery for lumbar disc herniation has been investigated in numerous studies. Surgery has been compared with a variety of treatments, such as education, chiropractic, unspecified physiotherapy, acupuncture, injections and medication (7–10). The non-surgical treatments have, however, been described only in vague terms, and variations in treatments have been used. Previous studies have reported favourable short-term (after 1 year) outcomes for surgery, but no major differences between surgical and other treatments have been demonstrated in the long term (over 2 years) (7, 10, 11). The conclusions that are drawn from the comparison between surgery and non-systematic non-surgical treatments may thus be misleading. This has been confirmed in a systematic review, which concluded that there is conflicting evidence as to whether surgery is more beneficial than nonsurgical care for both short- and long-term follow-up (12).

 

Kinesiophobia has been evaluated in patients after lumbar disc surgery, and almost 50% of patients were classified as having kinesiophobia (13). To our knowledge kinesiophobia has not been evaluated in patients with lumbar disc herniation treated with a structured physiotherapy treatment.

 

There are many different non-surgical treatment methods for patients with low-back pain and sciatica. One common management method is Mechanical Diagnosis and Therapy (MDT), also known as the McKenzie method, which aims to eliminate or minimize pain (14). A systematic review from 2004 of the efficacy of MDT showed that patients with low-back pain treated with MDT reported a greater, more rapid reduction in pain and disability compared with non-steroidal anti-inflammatory drugs (NSAIDs), educational booklets, back massage and back care advice, strength training, spinal mobilization and general exercises (15). In a randomized controlled trial with a 1-year follow-up from 2008, Paatelma and co-workers (16) found that the McKenzie method was only marginally more effective compared with only giving advice to patients with low-back pain. For patients with low-back pain, sciatica and a verified lumbar disc herniation, it has, however, been shown that a selected group of patients who responded to MDT after 5 days of treatment also reported that they were satisfied after 55 weeks (17). The patients started treatment just 12 days after the onset of symptoms and the effects of spontaneous healing cannot therefore be excluded. Taken together, the treatment effects of MDT for patients with a verified lumbar disc herniation appear to require further evaluation.

 

Trunk stabilization exercises, which aim to restore deep trunk muscle control, have been used for the prevention and rehabilitation of low-back pain (18). A randomized controlled trial revealed a reduction in the recurrence of low-back pain episodes after specific trunk stabilization exercises compared with a control group receiving advice and the use of medication (19). Dynamic lumbar stabilization exercises have been found to relieve pain and improve function in patients who have undergone microdiscectomy (20). The effects of trunk stabilization exercises combined with MDT have, however, not been studied in patients with non-operated lumbar disc herniation. MDT is seldom recommended for patients with MRI verified lumbar disc herniation with a broken outer annulus. At our hospital, however, we have several years of good clinical experience of a combination of MDT and trunk stabilization exercises for this category of patients. To our knowledge, no previous study has investigated whether patients with a lumbar disc herniation verified by MRI, symptoms for at least 6 weeks (minimizing effects of spontaneous healing) and who qualified for disc surgery could improve with a structured physiotherapy treatment model including MDT and gradually progressive trunk stabilization exercises. The aim of this study was therefore to evaluate a structured physiotherapy treatment model in patients who qualified for lumbar disc surgery.

 

Material and Methods

 

During the study inclusion period, 150 patients, who were referred to the orthopaedic clinic at Sahlgrenska University Hospital, Gothenburg, from November 2003 to January 2008, were identified as potential participants since disc herniation was confirmed with MRI. Inclusion criteria were: 18–65 years of age; MRI confirming disc herniation explaining the clinical findings; symptoms for at least 6 weeks (minimizing the effects of spontaneous healing) and pain distribution with concomitant neurological disturbances correlated to the affected nerve root. Exclusion criteria were: cauda equina syndrome, previous spinal surgery, other spinal diseases, such as spinal stenosis and spondylolisthesis, and inadequate command of Swedish. However, 70 patients were excluded because of spontaneous resolution of pain and symptoms. The remaining 80 patients met the inclusion criteria and qualified for surgery. Orthopaedic surgeons determined whether the patients qualified for lumbar disc surgery after MRI and physical examination according to the recommendations of the American Academy of Orthopaedic Surgeons for patients with lumbar disc herniation (21).

 

Figure 1 Study Flowchart

Initially, the study was planned as a randomized controlled trial (RCT) between a structured physiotherapy treatment model and surgery, but the number of patients was not sufficient to obtain acceptable power. Eighteen of the 80 patients were initially randomized to physiotherapy, 17 patients were randomized to surgery and 45 patients did not agree to undergo randomization. Twenty-seven of the 45 patients who did not agree to randomization agreed to take part in the structured physiotherapy treatment and 18 patients agreed to undergo surgery. A decision was therefore made solely to present a cohort of 45 patients treated according to the structured physiotherapytreatment protocol (Fig. 1). Patients were given verbal and written information and informed consent was obtained. The study was approved by the Regional Ethical Review Board.

 

Before structured physiotherapy treatment began, 4 patients recovered to the extent that they could no longer be accepted as surgical candidates and they were therefore excluded from the study. The remaining 41 patients treated according to the structured physiotherapy model are presented in this paper.

 

A Structured Physiotherapy Treatment Model

 

Six physiotherapists with credentialed examinations in MDT, which is an examination within the MDT concept after completing 4 courses of 4 days each for evaluating and treating patients with spinal problems. Following completion of these courses, an extensive literature study and practice in evaluating and treating patients is required before the examination can be completed. The physiotherapists involved in the study had 5–20 years of clinical experience of treating patients with back problems and herniated lumbar disc. The inter-examiner reliability of the MDT assessment has been shown to be good if the examiner is trained in the MDT method (22). The physiotherapists examined and treated the patients during a 9-week period (Table I). For the first 2 weeks of treatment, an MDT protocol was followed, based on clinical examinations of individual mechanical and symptomatic responses to positions and movements, with the aim of minimizing pain and with the emphasis on self-management (14). During the third week of treatment, graded trunk stabilization exercises were added to the MDT protocol. The purpose of graded trunk stabilization exercises was to improve muscle control (23). The low-load muscular endurance exercises were gradually increased in intensity on an individual basis with respect to the patients’ reported leg pain and the observed movement control and quality. During treatment, the patients were encouraged to continue exercising on their own at a gym, or to perform some other type of physical training of their own choice after the structured physiotherapy treatment was concluded. Four weeks after the completion of the 9-week physiotherapy treatment period, the patients attended a follow-up visit with the physiotherapist who had treated them. The aim of this visit was to encourage a high level of compliance with respect to continued trunk stabilization exercises and MDT practice (Table I).

 

Table 1 Treatment Procedures

 

Study Outcome Measures

 

The patients were given a battery of questionnaires to complete. Independent examiners, who were not involved in the treatment, distributed the questionnaires before treatment (baseline) and at the 3-, 12- and 24-month follow-ups.

 

The primary outcome measures were pain intensity in the leg, rated using a visual analogue scale (VAS) 0–100 mm (24) and the Oswestry Disability Index (ODI) 0–100 % (25). A score of 0–10 mm on the VAS was defined as no pain according to Öberg et al. (26). An ODI score of 0–20% was defined as minimal or no disability, and a score of over 40% was defined as severe disability (25). These primary outcome measures are commonly used in evaluations after surgery for lowback pain and for assessing patients with lumbar disc herniation (27).

 

Secondary outcome measures included pain intensity in the back rated using a VAS and the degree of kinesiophobia using the Tampa Scale for Kinesiophobia (TSK). The TSK score varies between 17 and 68 and a cut-off more than 37 was defined as a high degree of kinesiophobia (28). Health-Related Quality of Life (HRQoL) in the European Quality of Life in 5 Dimensions Questionnaires (EQ-5D) was used. The EQ-5D includes 2 parts, EQ-5Dindex ranges from 0 to 1.0, where 1.0 is optimal health and EQ-5DVAS is a vertical visual analogue scale ranging from 0 (worst possible health state) to 100 (best possible health state) (29). The Zung Self-Rating Depression Scale (ZDS) ranges from 20–80 and the more depressed the patient is, the higher score (30). The Self-Efficacy Scale (SES) ranges from 8 to 64, with higher scores indicating more positive beliefs (31) was also used. Work status was measured using a 3-grade Likert scale: working full time, full-time sick leave and part-time sick leave. Likewise, patient satisfaction with treatment was measured on a 3-grade Likert scale; satisfied, less satisfied and dissatisfied (32). These secondary outcome measures evaluate bio-psychosocial factors described as important in connection with lumbar disc surgery (33).

 

Table 2 Baseline Characteristics for the 41 Patients

 

Statistical Analyses

 

The results are presented as median values and interquartile range (IQR), except for age, which is presented as the mean and standard deviation (SD). Changes over time within the group were analysed with the Wilcoxon signed-rank test. Statistical significance was set at an alpha level of 0.05.

 

Results

 

The baseline characteristics are shown in Table II. No patient had undergone surgery at the 3-month follow-up. At the 12-month follow-up, 3 patients had undergone surgery and, at the 24-month follow-up, 1 additional patient had been operated on. After surgery, these 4 patients were excluded from further follow-ups (Fig. 1).

 

Change Over Time in Primary Outcome Measures

 

Disability. The patients showed significant improvements (p < 0.001) in ODI at the 3-month follow-up compared with baseline. The median (IQR) score decreased from 42 (27–53) to 14 (8–33). This improvement could still be seen at 12 and 24 months (Table III and Fig. 2). At baseline, 22 patients reported severe disability (54%) and 3 patients reported no disability. The degree of disability decreased at the 3-month follow-up, as only 9 patients (22%) reported severe disability and 26 (64%) reported no disability. At 12- and 24-month follow-ups only 2 patients (5%) reported severe disability. At 12-month followup 26 patients still reported no disability, and at 24-month follow-up 27 patients reported no disability.

 

Figure 2 Visual Analogue Scale Leg Pain and Oswestry Disability Index

 

Leg pain. A significant reduction in patients’ leg pain was found at the 3-month follow-up (p < 0.001) on the VAS compared with baseline. The median (IQR) on the VAS decreased from 60 (40–75) to 9 (2–27). This improvement could still be seen at the 12- and 24-month follow-ups (Table III and Fig. 2). Before treatment, all patients reported leg pain. Three months after treatment, the median on the VAS was 9 mm, i.e. classified as no leg pain (26). Twenty-three patients (56%) reported no leg pain at the 3-month follow-up. At the 12-month follow-up 22 patients reported no leg pain, and after 24 months 24 patients reported no leg pain.

 

Table 3 Changes Over Time in Primary and Secondary Outcome Measures

 

Change in Secondary Outcome Measures Over Time

 

Back pain. A significant improvement in back pain was found at the 3-month follow-up (p < 0.001) on the VAS compared with baseline. This improvement could still be seen at 12 and 24 months (Table III). At baseline, 6 patients (15%) reported no back pain. Three months after treatment began, 20 patients (49%) reported no back pain.

 

Figure 3 Number of Patients Classified with Kinesiophobia at Baseline

 

Kinesiophobia. The degree of kinesiophobia showed a significant improvement at the 3-month follow-up (p < 0.001) and the improvement could be seen throughout the follow-up period (Table III). Before treatment, 25 patients (61%) were classified as having kinesiophobia and 15 patients (37%) had no kinesiophobia, while data for 1 patient was missing. After 3 months, 15 patients (37%) had kinesiophobia and 26 (63%) had no kinesiophobia. At the 12-month follow-up, the number of patients with kinesiophobia had reduced to 4 (11%) (Fig. 3).

 

Health-related quality of life, depression and self-efficacy. All 4 assessments (EQ-5Dindex, EQ-5DVAS, ZDS and SES) showed significant improvements at the 3-month follow-up (p < 0.001). This improvement could still be seen at 12 and 24 months (Table III).

 

Sick leave. At baseline, 22 patients (54%) were on full-time sick leave (Table IV), compared with 9 (22%) patients at the 3-month follow-up. At baseline, 14 patients (34%) were working full time, compared with 22 (54%) at the 3-month follow-up.

 

Table 4 Number of Patients on Sick Leave at Each Follow Up

 

Satisfaction with Treatment

 

At the 3-month follow-up, 32 (78%) of 41 patients were satisfied with the structured physiotherapy treatment. Seven patients were less satisfied and 2 patients were dissatisfied. Both of the dissatisfied patients were later operated. At the 2-year follow-up, the number of satisfied patients was 29 (80%) of 36. Seven patients were less satisfied, but none dissatisfied after structured physiotherapy treatment.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

A disc herniation in the lumbar spine can cause pain, numbness and weakness in the lower back. Because of the severity of the symptoms, many patients seeking fast pain relief consider surgery. However, many non-operative treatment options can help improve as well as manage lumbar herniated disc symptoms. A structured physiotherapy treatment model can provide rapid pain relief to patients who would otherwise qualify for lumbar disc surgery, according to the following article. Patients looking to avoid taking long periods of sick leave from work due to their symptoms may benefit from a structured physiotherapy treatment model. As with any type of injury and/or condition, the use of other treatment options should be properly considered before turning to surgical interventions for fast pain relief.

 

Discussion

 

The principal finding of this study was that patients who qualified for lumbar disc surgery improved to a statistically significant and clinically substantial degree just 3 months after the start of the structured physiotherapy treatment in all assessments: disability, leg and back pain, kinesiophobia, health-related quality of life, depression and self-efficacy. The improvements could still be seen at the 2-year follow-up.

 

The natural course of healing must be considered carefully, especially when evaluating treatment effects in patients with disc herniation. The symptoms often vary over time and many discs heal spontaneously and the symptoms cease. Approximately 75% of patients with sciatica, without an MRI-verified disc herniation, recover within 3 months, and approximately one-third of patients recover within 2 weeks after the onset of sciatica (6). The natural course of sciatica was evaluated in a randomized controlled trial (34), which compared NSAIDs with placebo. The patients were, however, examined within 14 days after the onset of radiating leg pain. After 3 months, 60% of the patients had recovered and, after 12 months, 70% had recovered. In order to minimize the influence of spontaneous healing in the present study, the patients were therefore included only if they had had persistent pain and disability for more than 6 weeks. In fact, the majority of the patients had had pain and disability for more than 3 months. It is therefore most likely that the effects of treatment seen in the present study are, in the majority of patients, an effect of the structured physiotherapy treatment model and not a result of spontaneous healing.

 

In the study by Weber et al. (34), the VAS leg pain mean score was reduced from 54 mm at baseline to 19 mm within 4 weeks for all 183 patients, regardless of treatment. After 1 year, the VAS leg pain mean score was 17 mm. The patients in the present study who were a little worse at baseline (60 mm) reported 9 mm on the VAS leg pain just 3 months after treatment. Consequently, in the present study, the median VAS level had already been reduced to under the no-pain score, defined as 0–10 on the VAS (26), at the 3-month follow-up and this was maintained to the 12- and 24-month follow-ups.

 

Physiotherapy treatment for patients with lumbar disc herniation can lead to improvements. Brötz et al. (17) included a selected group of patients who responded with the centralization of pain after the first 5 daily sessions of treatment according to the MDT method. Centralization of pain is defined as a clinically induced change in the location of pain referred from the spine, that moves from the most distal position toward the lumbar midline (35). However, the patients’ medium duration of symptoms before treatment was only 12 days and the possibility that patients recovered naturally cannot therefore be excluded (17).

 

In a retrospective study, 95 patients were treated with a functional restoration programme (36). The patients achieved significant improvements after a mean treatment period of 8.7 months. The evaluation was performed at discharge only. With a treatment period of this length, it is, however, difficult to differentiate between the effects of treatment and the natural healing process. In the present study, a shorter treatment period was adopted, and large and significant improvements were found after just 3 months and were still present at the 24-month follow-up. It is therefore not likely that the natural healing process was responsible for the positive results in the present study.

 

In a prospective study of 82 consecutive patients with acute severe sciatica, included for conservative management, only a minority of the patients had made a full recovery after 12 months (37). Twenty-five percent of the patients underwent surgery within 4 months and one-third had surgery within 1 year. In spite of the fact that the inclusion criteria in the present study followed the recommendations for surgery (21, 38), no patient required surgery at the 3-month follow-up and, after 12 months, only 3 patients (7%) had undergone surgery. The interpretation of the divergence could be that the structured physiotherapy treatment model used in the present study appeared to influence patients with lumbar disc herniation in a very positive direction. One recommendation is therefore to follow the structured physiotherapy treatment model before considering surgery.

 

In this study, MRI verification of disc herniation was an inclusion criterion. In clinical practice, MRI verification is not mandatory, as it is in surgical treatment, before introducing structured physiotherapy treatment to patients with symptoms from a disc herniation. Consequently, treatment according to the structured physiotherapy treatment model can start early after the commencement of symptoms, as it is not necessary to wait for an MRI. It is possible to speculate that, if treatment with a structured physiotherapy model starts earlier than in the present study, the improvements would be even better, further reducing the risk of persistent pain and accompanying problems. Moreover, the need for MRI is likely to diminish; this, however, should be further evaluated in future studies.

 

One explanation for the good results of this study could be that the patients followed a structured physiotherapy treatment model, comprising MDT and trunk stabilization exercises, allowing for an individual design and progression of the treatment. Similar results were described in a retrospective cohort study (39) using several treatment methods for pain control as well as for exercise training for patients with lumbar disc herniation. The evaluation was not carried out until approximately 31 months after treatment. The results of Saal et al. (39) and of the present study are in agreement, in that structured physiotherapy treatment can reduce symptoms, but symptoms were relieved much more rapidly in the present study.

 

In a multicentre study comprising 501 patients, randomized to surgery or non-operative care, 18% of the patients assigned to non-operative treatment underwent surgery within 6 weeks and 30% had surgery at approximately 3 months (7). The nonoperative treatment group received non-specified ”usual care”, which could include a variety of different treatment methods. In contrast, the patients in the present study were offered a structured physiotherapy treatment model that included both bio-psychological and social components, as described in the International Classification of Functioning, Disability and Health (40).

 

There are many possible explanations for the positive effects seen in this present study, and 5 of these will now be discussed. Firstly, the patients were well informed about the design of the structured physiotherapy treatment model, including the timetable for different phases of the treatment and when the treatment was planned to end. This information enhanced the patients’ opportunity for self-management and gave them an active role in treatment decision-making.

 

Secondly, the patients acquired strategies to deal with their pain by using the different activities and movements in order to reduce pain according to the MDT method (14). The MDT method aims to enhance the patients’ ability to cope with the symptoms, motivate the patient to comply with the treatment and empower them to achieve independence. Leijon et al. (41) have shown that low levels of motivation plus pain are important factors that enhance non-adherence to physical activity. It therefore appears important to reduce pain and increase motivation as early as possible. It is reasonable to believe that, when the patients participated in the evaluation of different activities and exercises, this augmented their opportunity to discover the connection between activities and the following reduction or increase in symptoms. This could have led to the increased self-efficacy and empowerment of the patients. The use of empowerment in physiotherapy has been recommended in a review by Perrault (42), who argues that empowerment improves the intervention.

 

Thirdly, the intensity of exercises was gradually increased on an individual basis with respect to the patients’ reported pain. The objective was to strengthen the patients’ self-efficacy, which also improved significantly in the present study. Fourthly, the trunk stabilization exercises were conducted with the aim of increasing deep trunk muscle control (23). It can be speculated that the physiological effects of training may also have led to reduced pain through increased blood circulation, muscle relaxation and the release of pain-reducing substances, such as endorphins.

 

Finally, one reason for the improvements could be that the physiotherapists were experienced and well educated in the MDT method. Subsequently, the physiotherapists were able to guide the patients during the rehabilitation process. It is, however, not possible to determine whether and how much each of the reasons discussed above contributed to the improvements. It seems reasonable to assume that all 5 factors were operating.

 

In this study, the majority of patients experienced kinesiophobia before treatment started. As early as 3 months after the structured physiotherapy treatment started, the number of patients with kinesiophobia fell dramatically and the majority of patients no longer experienced kinesiophobia. These results are in agreement with those of a study of patients with chronic pain and high kinesiophobia who increased their physical activity level after a pain management programme designed to enable the patients to regain overall function (43).

 

There are some limitations to this study. It is not possible to exclude the possibility that some patients may have improved spontaneously without treatment. Measures were taken to limit this risk by using symptoms for at least 6 weeks as an inclusion criterion. Again, the majority of patients had symptoms for more than 3 months. Another limitation might relate to whether the patients were selected accurately for the study. Clinically experienced orthopaedic surgeons evaluated the clinical findings and the MRI scans and classified the patients as surgical candidates based on recommendations from the American Academy of Orthopaedic Surgeons for intervention for disc herniation published in 1993 (21). The patients included in the present study also fulfilled the recommendations as presented by Bono and co-workers in 2006 (38). The patients can therefore be regarded as serving as their own controls, and comparisons can be made with baseline symptoms and with patients from other studies. An RCT would have been the best way to explore different treatment options; however, we did not reach the number of patients required for an RCT. As the treatment model used in the present study has not been evaluated previously in a group of patients with long-standing pain, with the majority of the patients having pain for more than 3 months due to disc herniation, and, as the results are clinically interesting, it was decided to present the results as a cohort study.

 

In conclusion, this study shows that patients eligible for lumbar disc surgery improved significantly after treatment with the structured physiotherapy model, as early as 3 months after treatment, and the results could still be seen at the 24-month follow-up. Consequently, these patients did not qualify for lumbar disc surgery 3 months after the physiotherapy treatment started. Moreover, the majority of patients had symptoms for more than 3 months at the start of treatment and, for this reason, most of the spontaneous healing ought to have occurred before this study started. This study therefore recommends adoption of the structured physiotherapy treatment model before considering surgery when patients report symptoms such as pain and disability due to lumbar disc herniation.

 

Acknowledgements

 

The authors would like to thank physiotherapists Patrik Drevander, Christina Grundén, Sofia Fridén and Eva Fahlgren for treating the patients and Valter Sundh for statistical support. This study was supported by grants from the Health & Medical Care Committee of the Västra Götaland Region, Renée Eander’s Foundation and Wilhelm & Martina Lundgren’s Foundation of Science.

 

Herniated discs can cause pain, numbness and weakness, a variety of symptoms which may often become so severe, that surgery might seem like the only option for fast relief. However, a structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery, according to the results of the research study. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

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References

1. Konstantinou K, Dunn KM. Sciatica: review of epidemiological
studies and prevalence estimates. Spine (Phila Pa 1976) 2008;
33: 2464–2472.
2. Nygaard OP, Kloster R, Solberg T. Duration of leg pain as a
predictor of outcome after surgery for lumbar disc herniation:
a prospective cohort study with 1-year follow up. J Neurosurg
2000; 92: 131–134.
3. Orief T, Orz Y, Attia W, Almusrea K. Spontaneous resorption
of sequestrated intervertebral disc herniation. World Neurosurg
2012; 77: 146–152.
4. Maigne JY, Rime B, Deligne B. Computed tomographic follow-up
study of forty-eight cases of nonoperatively treated lumbar intervertebral
disc herniation. Spine (Phila Pa 1976) 1992; 17: 1071–1074.
5. Takada E, Takahashi M, Shimada K. Natural history of lumbar disc
hernia with radicular leg pain: spontaneous MRI changes of the
herniated mass and correlation with clinical outcome. J Orthopaed
Surg (Hong Kong) 2001; 9: 1–7.
6. Vroomen PC, de Krom MC, Knottnerus JA. Predicting the outcome
of sciatica at short-term follow-up. Br J Gen Pract 2002;
52: 119–123.
7. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom
B, Skinner JS, et al. Surgical vs nonoperative treatment for lumbar
disk herniation: the Spine Patient Outcomes Research Trial
(SPORT): a randomized trial. JAMA 2006; 296: 2441–2450.
8. Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW.
Prolonged conservative care versus early surgery in patients with
sciatica caused by lumbar disc herniation: two year results of a
randomised controlled trial. BMJ 2008; 336: 1355–1358.
9. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term
outcomes of surgical and nonsurgical management of sciatica secondary
to a lumbar disc herniation: 10 year results from the maine
lumbar spine study. Spine (Phila Pa 1976) 2005; 30: 927–935.
10. Weber H. Lumbar disc herniation. A controlled, prospective
study with ten years of observation. Spine (Phila Pa 1976) 1983;
8: 131–140.
11. Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized
controlled trial with 2 years of follow-up. Spine (Phila Pa 1976)
2006; 31: 2409–2414.
12. Jacobs WC , van Tulder M, Arts M, Rubinstein SM, van Middelkoop
M, Ostelo R, et al. Surgery versus conservative management of
sciatica due to a lumbar herniated disc: a systematic review. Eur
Spine J 2011; 20: 513–522.
13. Svensson GL, Lundberg M, Östgaard HC, Wendt GK. High degree
of kinesiophobia after lumbar disc herniation surgery: a crosssectional
study of 84 patients. Acta Orthop 2011; 82: 732–736.
14. McKenzie R, May S. The lumbar spine: mechanical diagnosis
& therapy. 2nd ed. Spinal Publications New Zealand Limited:
Wellington; 2003.
15. Clare HA, Adams R, Maher CG. A systematic review of efficacy
of McKenzie therapy for spinal pain. Aust J Physiother 2004;
50: 209–216.
16. Paatelma M, Kilpikoski S, Simonen R, Heinonen A, Alen M, Videman
T. Orthopaedic manual therapy, McKenzie method or advice
only for low back pain in working adults: a randomized controlled
trial with one year follow-up. J Rehabil Med 2008; 40: 858–863.
17. Brötz D, Kuker W, Maschke E, Wick W, Dichgans J, Weller M.
A prospective trial of mechanical physiotherapy for lumbar disk
prolapse. J Neurol 2003; 250: 746–749.
18. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic
region: effect and possible mechanisms. J Electromyogr
Kinesiol 2003; 13: 361–370.
19. Hides JA, Jull GA, Richardson CA. Long-term effects of specific
stabilizing exercises for first-episode low back pain. Spine (Phila
Pa 1976) 2001; 26: E243–E248.
20. Yilmaz F, Yilmaz A, Merdol F, Parlar D, Sahin F, Kuran B. Efficacy
of dynamic lumbar stabilization exercise in lumbar microdiscectomy.
J Rehabil Med 2003; 35: 163–167.
21. Nachemson AL. Lumbar disc herniation – conclusions. Acta Orthop
Scand Suppl 1993; 251: 49–50.
22. Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman
T, Alen M. Interexaminer reliability of low back pain assessment
using the McKenzie method. Spine (Phila Pa 1976) 2002; 27:
E207–E214.
23. Richardson CA, Jull GA. Muscle control-pain control. What exercises
would you prescribe? Man Ther 1995; 1: 2–10.
24. Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;
2: 175–184.
25. Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry
low back pain disability questionnaire. Physiotherapy 1980; 66:
271–273.
26. Öberg B, Enthoven P, Kjellman G, Skargren E. Back pain in
primary care: a prospective cohort study of clinical outcome and
healthcare consumption. Adv Physiother 2003; 5: 98.
27. Bombardier C. Outcome assessments in the evaluation of treatment
of spinal disorders: summary and general recommendations. Spine
2000; 25: 3100–3103.
28. Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of
movement/(re)injury in chronic low back pain and its relation to
behavioral performance. Pain 1995; 62: 363–372.
29. EuroQol – a new facility for the measurement of health-related quality
of life. The EuroQol Group. Health Policy 1990; 16: 199–208.
30. Zung WW. A self-rating depression scale. Arch Gen Psychiatry
1965; 12: 63–70.
31. Estlander AM, Vanharanta H, Moneta GB, Kaivanto K. Anthropometric
variables, self-efficacy beliefs, and pain and disability
ratings on the isokinetic performance of low back pain patients.
Spine 1994; 19: 941–947.
32. Strömqvist B, Jönsson B, Fritzell P, Hägg O, Larsson BE, Lind B.
The Swedish National Register for lumbar spine surgery: Swedish
Society for Spinal Surgery. Acta Orthop Scand 2001; 72: 99–106.
33. den Boer JJ, Oostendorp RA, Beems T, Munneke M, Oerlemans
M, Evers AW. A systematic review of bio-psychosocial risk factors
for an unfavourable outcome after lumbar disc surgery. Eur Spine
J 2006; 15: 527–536.
34. Weber H, Holme I, Amlie E. The natural course of acute sciatica
with nerve root symptoms in a double-blind placebo-controlled
trial evaluating the effect of piroxicam. Spine (Phila Pa 1976)
1993; 18: 1433–1438.
35. Werneke M, Hart DL, Cook D. A descriptive study of the centralization
phenomenon. A prospective analysis. Spine (Phila Pa
1976) 1999; 24: 676–683.
36. Hahne AJ, Ford JJ, Hinman RS, Taylor NF, Surkitt LD, Walters
AG, et al. Outcomes and adverse events from physiotherapy
functional restoration for lumbar disc herniation with associated
radiculopathy. Disabil Rehabil 2011; 33: 1537–1547.
37. Balague F, Nordin M, Sheikhzadeh A, Echegoyen AC, Brisby H,
Hoogewoud HM, et al. Recovery of severe sciatica. Spine (Phila
Pa 1976) 1999; 24: 2516–2524.
38. Bono CM, Wisneski R, Garfin SR. Lumbar disc herniations. In:
Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA,
editors. Rothman-Simeone the spine. 5th ed. Saunders Elsevier:
Philadelphia; 2006: p. 979–980.
39. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar
intervertebral disc with radiculopathy. An outcome study. Spine
(Phila Pa 1976) 1989; 14: 431–437.
40. World Health Organisation. International Classification of Functioning,
Disability and Health (ICF). 2001 [cited 2012 Oct 9].
Available from: http://www.who.int/classifications/icf/en/.
41. Leijon ME, Faskunger J, Bendtsen P, Festin K, Nilsen P. Who is
not adhering to physical activity referrals, and why? Scand J Prim
Health Care 2011; 29: 234–240.
42. Perreault K. Linking health promotion with physiotherapy for low
back pain: a review. J Rehabil Med 2008; 40: 401–409.
43. Koho P, Orenius T, Kautiainen H, Haanpaa M, Pohjolainen T, Hurri
H. Association of fear of movement and leisure-time physical
activity among patients with chronic pain. J Rehabil Med 2011;
43: 794–799.

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Amazing Results from Herniated Disc Early Treatment | El Paso, TX

Amazing Results from Herniated Disc Early Treatment | El Paso, TX

A herniated disc is typically a very painful condition, especially if the inner gel-like substance of the intervertebral disc, known as the nucleus pulposus, pushes through the thick, outer ring of cartilage and puts pressure on the sensitive nerves of the spine. Discs are soft, rubbery pads found between each vertebrae of the spine that act as shock-absorbers, allowing the spine to bend and/or flex. An intervertebral disc may begin to rupture as a result of wear-and-tear or due to a sudden injury. Fortunately, most individuals who’ve suffered a herniated disc can find relief from a variety of non-operative treatments before considering surgery. The following article highlights the impact of early treatment for herniated discs in the lumbar spine, or low back.

 

The Impact of Early Recovery on Long-Term Outcomes in a Cohort of Patients Undergoing Prolonged Non-Operative Treatment for Lumbar Disc Herniation: Clinical Article

 

Abstract

 

Object

 

The authors comprehensively studied the recovery of individual patients undergoing treatment for lumbar disc herniation. The primary goal was to gain insight into the variability of individual patient utility scores within a treatment cohort. The secondary goal was to determine how the rates and variability of patient recovery over time, represented by improvement in utility scores, affected long-term patient outcomes.

 

Methods

 

EuroQol Group–5 Dimension (EQ-5D) scores were obtained at baseline and at 2, 4, 8, 12, 26, 38, and 52 weeks for 93 patients treated under a prolonged conservative care protocol for lumbar disc herniation. Gaussian kernel densities were used to estimate the distribution of utility scores at each time point. Logistic regression and multistate Markov models were used to characterize individual patient improvement over time. Fisher exact tests were used to compare the distribution of EQ-5D domain scores.

 

Results

 

The distribution of utility scores was bimodal at 1 year and effectively sorted patients into a “higher” utility group (EQ-5D = 1; 43% of cohort) and a “lower” utility group (EQ-5D ≤ 0.86; 57% of cohort). Fisher exact tests revealed that pain/discomfort, mobility, and usual activities significantly differed between the 2 utility groups (p ≪ 0.001). The utility groups emerged at 8 weeks and were stable for the remainder of the treatment period. Using utility scores from 8 weeks, regression models predicted 1-year outcomes with 62% accuracy.

 

Conclusions

 

This study is the first to comprehensively consider the utility recovery of individual patients within a treatment cohort for lumbar disc herniation. The results suggest that most utility is recovered during the early treatment period. Moreover, the findings suggest that initial improvement is critical to a patient’s long-term outcome: patients who do not experience significant initial recovery appear unlikely to do so at a later time under the same treatment protocol.

 

Abbreviations used in this paper: AUC = area under a receiver-operating curve; EQ-5D = EuroQol Group–5 Dimension. Address correspondence to: Matthew C. Cowperthwaite, Ph.D., The University of Texas at Austin, Texas Advanced Computing Center, J.J. Pickle Research Campus, ROC 1.101, 10100 Burnet Rd., Austin, TX 78758. email: [email protected]

 

Plublished online June 28, 2013; DOI: 10.3171/2013.5.SPINE12992.

 

Introduction

 

Lumbar disc herniation is one of the most common causes of low-back pain and radiculopathy.[4] Treatment for patients with a herniated lumbar disc usually begins with conservative care such as analgesics, epidural steroid injections, and physical therapy,[1,5] with surgery reserved for patients with severe nerve root or cauda equina dysfunction or if conservative therapy is unsuccessful in controlling the symptoms.

 

Several recent studies have compared the effectiveness of conservative care and surgical treatment protocols for treating herniated lumbar discs, and have arrived at varying conclusions.[2,3,9,10,15–18] However, these studies have generally considered outcomes over a period of years, which is a significant length of time for patients who are waiting for their quality of life to improve. In clinical practice, this often leads to the following dilemma: most patients, particularly those with moderate symptoms, would prefer to avoid surgery, but are unwilling to wait an indefinite period of time for their symptoms to resolve. Unsurprisingly, lumbar discectomy is the most frequently performed surgical procedure in the US.[17,18]

 

Moreover, the above-mentioned studies have typically compared the average difference between treatment groups, without regard for individual recovery within the cohort. Additionally, this approach assumes that recovery in the protocols being compared proceeded similarly between observation intervals. To better understand the treatment responses of individual patients and the time frames of their responses, we comprehensively analyzed a cohort of patients undergoing a prolonged conservative care treatment protocol to gain insight into the dynamics of individual patient recovery over time, and whether these recovery dynamics influence long-term outcomes.

 

Methods

 

Study Data Set

 

The data set contained 142 patients randomized to a protocol of prolonged conservative care as part of the Leiden–The Hague Spine Intervention Prognostic Study.[10,15] The Sciatica Trial was reviewed and approved by the Medical Ethics Committee of Leiden University Medical Center.[11] Patients were enrolled into the Sciatica Trial entirely in the Netherlands.

 

In the Sciatica Trial, all patients aged 18 to 65 years, with persistent radicular pain in the L-4, L-5, or S-1 dermatome (with or without mild neurological deficit), severe disabling leg pain (lumbosacral radicular syndrome) lasting 6–12 weeks, and radiologically (MRI) confirmed disc herniation were considered eligible to enroll in the trial. Cauda equina syndrome or severe paresis, prior complaints of lumbosacral radicular syndrome in the previous 12 months, history of same-level unilateral disc surgery, spinal canal stenosis, and degenerative or lytic spondylolisthesis were all exclusion criteria. Cohort demographics and baseline characteristics were previously described; all patients reported both back and leg pain, but leg pain was generally more severe (mean leg pain 67.2 ± 27.7 vs back pain 33.8 ± 29.6, measured on a 100-point, horizontal visual analog scale).[15]

 

The Sciatica Trial used a pragmatic study design: conservative-care management was influenced as little as possible and was supervised by each patient’s general practitioner. Use of analgesics and physical therapy was determined by the treating physician. In this cohort, 46 patients (32%) elected to have surgery before the end of the 1st year; the mean timing of surgery was 12.6 weeks after the start of treatment. The surgical patients and 3 additional subjects with more than 2 missing utility measures were removed from the sample, resulting in a cohort of 93 patients considered in the present study; the crossover patients will be discussed in a separate study (manuscript in preparation). Our results were qualitatively unchanged when the excluded patients were retained in the analyses (data not shown).

 

In the Leiden–The Hague Spine Intervention Prognostic Study the EQ-5D instrument was used to measure patient utility at baseline and at 2, 4, 8, 12, 26, 38, and 52 weeks after enrollment into the study. The average duration of sciatica prior to enrollment was 9.5 weeks.[10,15] Utility is a valuation of a patient’s quality of life on a scale between 0 (as bad as dead) and 1 (perfect health). To estimate utility, the EQ-5D assesses a patient’s functional impairment in 5 domains: mobility, self-care, usual activities, pain, and anxiety.[6] For each domain, patients self-report the scores of 1 (no problems), 2 (some problems), or 3 (extreme problems). Utility scores were computed using the US valuation model,[12] which clearly distinguishes patients reporting no health problems (EQ-5D = 1) from those reporting at least some health problems (EQ-5D ≤ 0.86). Our results are independent of the particular valuation model (not shown). Completeness of the EQ-5D measures during follow-up ranged from 98% at 2 weeks to 90% at 38 weeks.

 

Statistical Analysis

 

All statistical analyses were conducted using the R statistical environment (version 2.9.2; http://www.rproject.org/) with the additional “msm,”[8] “ROCR,”[14] and “rms”[7] packages (all freely available from http://cran.rproject.org). Continuous variables are presented as means (± SEM) and were compared using 2-tailed Student t-tests. Significance was assessed at an α ≤ 0.05 significance level, unless otherwise indicated. Missing EQ-5D measures were imputed using the mean of the measures at adjacent time points; our results are qualitatively similar under forward or backward imputation schemes (not shown).

 

Gaussian kernel density estimates were computed to estimate the distribution of utility scores. The kernel density estimates were estimated using a Silverman’s “rule-of-thumb” bandwidth and a Gaussian smoothing kernel.[13] The left- and right-most points were set to the theoretical minimum and maximum EQ-5D values, respectively, so that the area under the density curve summed to 1.

 

To determine whether specific EQ-5D domains differed between utility groups, Fisher-exact tests were conducted on contingency tables of the number of patients in each utility group that reported scores of 1, 2, or 3. Significance was assessed using a Bonferroni-corrected p value of 0.01.

 

Two-state, continuous-time Markov models were used to study the patterns and probabilities of patients transitioning between a “lower” utility (EQ-5D ≤ 0.86) and a “higher” utility group (EQ-5D = 1). The threshold utility value defining the groups remained fixed over time and was used to assign each patient to a utility group at each observation time. The models were fitted using the “msm” package[14] with piecewise-constant transition intensity matrices (Qt) estimated for each time interval between the points t = 0, 4, 8, 12, 26, 38, 52 (t = 2 was omitted because there were insufficient transitions to yield a robust model). Transition intensities were permitted to change between subsequent observation intervals, but remained homogeneous within each observation interval. The starting transition intensities were based on the observed frequencies of transitions in the data set and were calculated using the formula

 

Article-Formula.jpg

 

in which nij is the observed number of transitions from Group i to Group j over the duration of the study period (T), and nj is the initial number of patients in Group j. The fitted models were robust to the choice of starting transition intensities and yielded qualitatively similar parameter estimates over a range of starting parameters (not shown). The likelihood function was maximized using a Nelder-Mead algorithm, and convergence was visually verified and typically occurred well short of the maximum number of iterations.

 

Logistic regression models were used to test whether utility measurements from earlier time points could predict long-term outcomes. These models only included utility values up to a particular time point as predictors, with the response variable being the patient’s 1-year outcome (higher or lower utility group) modeled as a dichotomous variable; no additional clinical or demographic covariates were included in the models. The models were fitted using the “rms” package[7] and the fit was assessed using chi-square tests (α ≤ 0.05). Separate regression models were created for all utility measurements up to and including those for 2, 4, 8, 12, and 26 weeks; for example, the 8-week model would include utility measurements at 0, 2, 4, and 8 weeks. The AUC statistic was used to assess the performance of the models and was calculated using the ROCR package.[14]

 

Results

 

Delineation of Higher and Lower Utility Groups

 

The distributions of patient utility scores markedly changed over the course of 1 year of conservative care (Fig. 1). At baseline, the majority of patients reported a relatively poor quality of life; the mean EQ-5D score was 0.55 (median 0.60). Two distinct utility groups were found to be present at baseline: a “lower” utility group (EQ-5D ≤ 0.86) and a “higher” utility group (EQ-5D = 1). At 6 months, the lower utility group (n = 62, 67%) was larger than the higher utility group (n = 31, 33%); at 1 year, the lower utility group (n = 53, 57%) had declined, but remained larger than the higher utility group (n = 40, 43%).

 

Figure 1 Distribution of EQ-5D Patient Utilities | El Paso, TX Chiropractor

Figure 1: Distribution of EQ-5D patient utilities at baseline, 6 months, and 1 year. The solid lines depict Gaussian kernel density estimates (right axis) of each distribution. The gray lines outline the histogram with the height of each bar representing the frequency of patients (left axis) in the equal-width bins (0.05) with utility greater than the lower bound and less than or equal to the upper bound. The bounds of both distributions are set to the theoretical minimum and maximum of the EQ-5D utility instrument.

 

EQ-5D Domain Scores Between Groups

 

The average scores in each domain of the EQ-5D (Table 1) suggested that the pain/discomfort (low score = 1.9, high score = 1.0), mobility (low score = 1.4, high score = 1.0), and usual activities (low score = 1.5, high score = 1.0) domains differed most significantly between the high and low utility groups (p ≪ 0.001). The anxiety (low score = 1.2, high score = 1.0) and self-care (low score = 1.1, high score = 1.0) domains differed much less between the 2 utility groups, although they were also significant (p < 0.01).

 

Table 1 Distribution of Scores in Each EQ-5D Domain | El Paso, TX Chiropractor

 

Trajectory of Patient Utility Over Time

 

The series of patient utility scores measured over the study period are referred to as utility “trajectories,” which were studied to understand how patients recovered over the study period. In the study cohort, all patients experienced improvement during at least 1 observation period; only 19.3% (n = 18) never experienced a decline during their recovery. Recovery was variable: 49.5% of the patients (n = 46) experienced at least 2 reversals, which were defined as improvements (declines) immediately followed by declines (improvements) at the next observation. Furthermore, only 29% of patients (n = 27) had stable trajectories with no reversals. Overall, increases in utility were 4 times more common than decreases in utility.

 

The utility of the entire cohort increased by 0.296 (51.8% above baseline; p ≪ 0.001, Wilcoxon Mann-Whitney test) over the year (Fig. 2), but was markedly faster during the first 2 months (0.022/week) than the final 3 months (0.005/week). Over the same time frames, utility scores improved by 0.178 (35.2% above the baseline average) over the first 2 months and by 0.063 (1.3% above the 9-month average) during the final 3 months. The mean utility scores significantly differed between the 2 final utility groups at 8 weeks and remained significant for the rest of the year (p < 0.01, Student t-test; Fig. 2).

 

Figure 2 Graph of Mean Patient Utilities | El Paso, TX Chiropractor

Figure 2: Graph of mean patient utilities at each measurement time point. Error bars represent 95% CIs about the mean. High and low utility group refers to the final group in which the patient belongs at the 1-year time point.

 

Modeling Patient Recovery

 

Given that 2 utility groups were present over the study period, Markov models were used to study the robustness of these groups by estimating the likelihood of patients switching between the groups. The models suggested that the average probability of a patient remaining within their utility group was 97.9% and 97.6% for patients currently in the low and high utility groups, respectively (Fig. 3). The probability of a patient transitioning from the low to the high utility group was 2.1%; the corresponding probability for transitions from the high to the low utility group was 2.3%.

 

Figure 3 Graphs of the Markov Transition Probabilities | El Paso, TX Chiropractor

Figure 3: Graphs of the Markov transition probabilities (per week) for transitions within (lower) and between (upper) utility groups. Each point is centered at the middle of each time interval and represents the maximum-likelihood estimate of the per-week transition probability during the entire interval. Error bars (mean width of the 95% CI was 1.8) were omitted for clarity because the differences were not significant.

 

The models also suggested that the likelihood of a patient transitioning to another utility group declined over the study period. During the first 8 weeks, 2.8% and 3.5% of patients experienced low-to-high and high-to-low transitions, respectively; over the last 3 months, 1.6% and 1.3% of patients experienced low-to-high and high-to-low group transitions, respectively.

 

Predicting Individual Patient Outcome

 

At 8 weeks, logistic regression models could predict a patient’s outcome (final utility group) with modest accuracy (AUC = 0.62, or 62%). The accuracy of the models steadily increased as data from later time points were included; the 26-week model performance was good with an AUC of 0.78 (Fig. 4). The amount of improvement in utility scores from baseline to 8 weeks was also investigated as a predictor of good outcome (higher utility group). Patients with EQ-5D scores that improved by at least 0.30 during the first 8 weeks of treatment were 60% more likely to have a good outcome.

 

Figure 4 Graph Showing the Accuracy of Classifiers Based on Patient Utilities | El Paso, TX Chiropractor

Figure 4: Graph showing the accuracy of classifiers based on patient utilities. The horizontal line is drawn at 0.50, above which models would perform better than randomly assigning patients to utility groups.

 

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Dr. Alex Jimenez’s Insight

Herniated disc commonly develop in the lumbar spine, or lower back. Also referred to as a slipped disc or a ruptured disc, a herniated disc occurs when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding outer ring, known as the annulus fibrosus. The symptoms of a herniated disc are generally specific to the exact level of the spine where the disc herniation occurs and whether or not the nerve tissue has been irritated by the intervertebral disc material leaking out of the inside of the disc. The most common symptoms of a disc herniation include pain, numbness, weakness and tingling sensations as well as causing radiating symptoms along the upper or lower extremities. Depending on the severity of the symptoms, herniated disc treatment can include, drugs and/or medications, epidural injections, physical therapy, chiropractic, and surgery, among others. According to the following article, early treatment can help promote and manage a faster herniated disc recovery from prolonged non-operative treatment methods.

 

Discussion

 

Several studies have sought to compare the relative effectiveness of surgery and conservative care for treatment of a lumbar disc herniation.[4–9,11] Generally, these studies have compared “average” differences between the study cohorts, while the individual trajectories by which patient utility changes over time have received less attention. To our knowledge, this study provides the first comprehensive statistical analysis of individual patient-level utility data from a large cohort of patients randomized to a prolonged conservative-care treatment protocol for lumbar disc herniation.[9]

 

The decision to proceed with surgery is straightforward in patients with severe, disabling symptoms or neurological deficits. Likewise, the decision to continue conservative care is simple for patients with mild symptoms or those who are content to live with their symptoms indefinitely. However, patients with moderate symptoms often present a greater challenge because most patients would prefer to avoid surgery if possible, but are also not content to wait indefinitely for their pain to resolve. These patients often ask for more than just the overall probability they will improve eventually; they usually want to know when they will recover. Moreover, they are usually interested in whether their current symptoms and progress affect the probability and extent of their future improvement.

 

For patients with moderate symptoms, the following observations from our study may be useful. First, the utility scores for individual patients diverged sharply at 8 weeks and were thereafter easily classified as either those reporting no health problems (higher utility, EQ-5D = 1) or those reporting at least some health problems (lower utility, EQ-5D ≤ 0.86). Among the lower utility group, the “pain/discomfort,” “mobility,” and “usual activities” domains of the EQ-5D differed most significantly from the higher utility group, which could potentially represent incompletely treated radiculopathy. Second, most improvement occurred early: almost one-third of the overall improvement in utility came in the first 2 months, while only 1% occurred in the last 3 months. Third, recovery is variable, with most patients (80%) experiencing at least 1 interval of deterioration and only 19% continuously improving without any setbacks. This may provide some reassurance to patients with generally good recovery to “stay the course” without resorting to more invasive measures such as surgery simply because of what may be a brief transient decrease in quality of life. Lastly, the probability of moving into another group was quite low (2%), which may be considered when counseling a patient who is not improving with his or her current treatment regimen.

 

We note the following limitations inherent in this cohort study. First, this is an observational study, and therefore we cannot infer causality for the emergence of the 2 utility groups, and because the individual treatment plans were unknown to us, we cannot comment on any specific type of conservative therapy. However, even if one considers the patients in the low utility group as nonresponders to conservative therapy (which is likely at least partly incorrect), the study does not imply that surgery would necessarily be beneficial in these patients. Second, the EQ-5D scores a patient’s overall health, and therefore unknown comorbid conditions likely account for at least some of the patients residing in the lower utility group and for part of the utility fluctuations. However, in the clinical setting, it should be obvious as to whether a patient’s symptoms are resulting from unresolved radiculopathy or from preexisting comorbidities. Lastly, we excluded crossover patients from our analysis. Crossover patients are likely those with the most severe symptoms and thus our results may be limited to patients with mild to moderate symptoms. However, we believe this exclusion is appropriate because, as mentioned above, the decision to operate is fairly straightforward when a patient has severe symptoms. From a clinical standpoint, patients with moderate symptoms and without neurological deficits after 8 weeks need the most information about the potential time course and extent of their nonoperative recovery to make an informed treatment decision.

 

The focus of the present study is individual utility recovery within a patient cohort rather than comparing average response to different treatment protocols. The goal was to gain insight into the dynamics of utility recovery among individual patients treated conservatively, but our approach could be applied to almost any treatment protocol. Studies of the changes (improvements or declines) in individual utility over time are useful because they may provide insights into a patient’s perception of their current treatment protocol (for example, patients in the low utility group would likely report a poor response to treatment), and also to identify a point at which continuing the same treatment is unlikely to improve a patient’s quality of life. Patients entering a conservative-care treatment protocol are likely to experience an initial period of rapid recovery, followed by a longer phase of more modest recovery. Our results suggest that, once the long-term recovery phase begins, patients are unlikely to spontaneously change their recovery for better or worse under the same treatment protocol. Lastly, patient utility scores early in the treatment process were reasonable predictors of long-term outcomes. This study is a comprehensive characterization of individual patients’ recovery of health utility from a lumbar disc herniation, and provides a unique picture for clinicians taking care of these patients. Our findings suggest that most recovery occurs early during treatment, and this early recovery period is important to long-term outcomes.

 

Conclusions

 

In a cohort of patients undergoing prolonged conservative care for treatment of lumbar disc herniation, 57% of the patients had lingering health problems at 1 year. Utility was recovered most rapidly early in the treatment process, and the majority of utility was also recovered in the initial treatment period. After the initial recovery period, we could identify with reasonable accuracy those patients who would fully recover and those who would not. Over the course of the year, recovery was observed to be highly variable, although most fluctuations were relatively small and only transient. These findings suggest that patients not initially responding to their treatment protocol should consider other options because they are unlikely to respond at a later time. However, patients and clinicians should also be mindful of transient decreases in quality of life, and carefully consider any changes in their treatment plan.

 

Disclosure

 

This work was partially supported by a charitable grant from the St. David’s Foundation Impact Fund to Dr. Cowperthwaite, and does not necessarily represent the views of the Impact Fund or the St. David’s Foundation.

 

Author contributions to the study and manuscript preparation include the following. Conception and design: all authors. Acquisition of data: Cowperthwaite, van den Hout. Analysis and interpretation of data: all authors. Drafting the article: Cowperthwaite. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Cowperthwaite. Statistical analysis: Cowperthwaite, van den Hout. Administrative/technical/material support: Cowperthwaite. Study supervision: Cowperthwaite.

 

In conclusion, early non-operative treatment of lumbar herniated disc can effectively improve as well as manage recovery outcomes in patients with the condition. It’s important for patients with disc herniations in the lumbar spine to comprehend the source of their issue before receiving appropriate treatment for their symptoms. Furthermore, non-operative treatment is effective in most patients, surgical interventions may be considered according to the individual’s recovery outcome. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

 

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References

1. Andersson GB, Brown MD, Dvorak J, Herzog RJ, Kambin P, Malter A, et al.: Consensus summary of the diagnosis and treatment of lumbar disc herniation. Spine (Phila Pa 1976) 21:24 Suppl75S–78S, 1996 Medline
2. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, et al.: The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine (Phila Pa 1976) 21:1777–1786, 1996 Crossref, Medline
3. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, et al.: The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 21:1787–1795, 1996 Crossref, Medline
4. Baldwin NG: Lumbar disc disease: the natural history. Neurosurg Focus 13:2E2, 2002
5. Dawson E, Bernbeck J: The surgical treatment of low back pain. Phys Med Rehabil Clin N Am 9:489–495, x, 1998
6. EuroQol Group: EuroQol—a new facility for the measurement of health-related quality of life. The EuroQol Group Health Policy 16:199–208, 1990 Crossref, Medline
7. Harrell FE: Regression Modeling Strategies: With Applications to Linear Models, Logistic Regression and Survival Analysis New York, Springer, 2001
8. Jackson CH, Sharples LD, Thompson SG, Duffy SW, Couto E: Multistate Markov models for disease progression with classification error. The Statistician 52:193–209, 2003
9. Keller RB, Atlas SJ, Singer DE, Chapin AM, Mooney NA, Patrick DL, et al.: The Maine Lumbar Spine Study, Part I. Background and concepts. Spine (Phila Pa 1976) 21:1769–1776, 1996 Crossref, Medline
10. Peul WC, van den Hout WB, Brand R, Thomeer RTWM, Koes BW: Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 336:1355–1358, 2008 Crossref, Medline
11. Peul WC, van Houwelingen HC, van der Hout WB, Brand R, Eekhof JA, Tans JT, et al.: Prolonged conservative treatment or ‘early’ surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial [ISRCT 26872154]. BMC Musculoskelet Disord 6:8, 2005 Crossref, Medline
12. Shaw JW, Johnson JA, Coons SJ: US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Med Care 43:203–220, 2005 Crossref, Medline
13. Silverman BW: Density Estimation for Statistics and Data Analysis London, Chapman & Hall, 1986
14. Sing T, Sander O, Beerenwinkel N, Lengauer T: ROCR: visualizing classifier performance in R. Bioinformatics 21:3940–3941, 2005
15. van den Hout WB, Peul WC, Koes BW, Brand R, Kievit J, Thomeer RTWM, et al.: Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ 336:1351–1354, 2008 Crossref, Medline
16. Weber H: Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 8:131–140, 1983 Crossref, Medline
17. Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson ANA, et al.: Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 296:2451–2459, 2006 Crossref, Medline
18. Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B, Skinner JS, et al.: Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296:2441–2450, 2006 Crossref, Medline

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Cited By

1. Anurekha Ramakrishnan, MS, K. Michael Webb, MD, and Matthew C. Cowperthwaite, PhD. (2017) One-year outcomes of early-crossover patients in a cohort receiving nonoperative care for lumbar disc herniation. Journal of Neurosurgery: Spine 27:4, 391-396. . Online publication date: 1-Oct-2017. Abstract | Full Text | PDF (2037 KB)
2. Kimberly A Plomp, Una Strand Viðarsdóttir, Darlene A Weston, Keith Dobney, Mark Collard. (2015) The ancestral shape hypothesis: an evolutionary explanation for the occurrence of intervertebral disc herniation in humans. BMC Evolutionary Biology 15:1. . Online publication date: 1-Dec-2015. [Crossref]

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Migraine Pain & Lumbar Herniated Disc Treatment in El Paso, TX

Migraine Pain & Lumbar Herniated Disc Treatment in El Paso, TX

One of the most prevalent causes of lower back pain and sciatica may be due to the compression of the nerve roots in the low back from a lumbar herniated disc, or a ruptured disc in the lumbar spine. Common symptoms of lumbar herniated discs include varying intensities of pain, muscle spasms or cramping, sciatica and leg weakness as well as loss of proper leg function. While these may not appear to be closely associated with each other, a lumbar herniated disc may also affect the cervical spine, manifesting symptoms of migraine and headache. The purpose of the following articles is to educate patients and demonstrate the relation between migraine pain and lumbar herniated disc, further discussing the treatment of these two common conditions.

 

A Critical Review of Manual Therapy Use for Headache Disorders: Prevalence, Profiles, Motivations, Communication and Self-Reported Effectiveness

 

Abstract

 

Background

 

Despite the expansion of conventional medical treatments for headache, many sufferers of common recurrent headache disorders seek help outside of medical settings. The aim of this paper is to evaluate research studies on the prevalence of patient use of manual therapies for the treatment of headache and the key factors associated with this patient population.

 

Methods

 

This critical review of the peer-reviewed literature identified 35 papers reporting findings from new empirical research regarding the prevalence, profiles, motivations, communication and self-reported effectiveness of manual therapy use amongst those with headache disorders.

 

Results

 

While available data was limited and studies had considerable methodological limitations, the use of manual therapy appears to be the most common non-medical treatment utilized for the management of common recurrent headaches. The most common reason for choosing this type of treatment was seeking pain relief. While a high percentage of these patients likely continue with concurrent medical care, around half may not be disclosing the use of this treatment to their medical doctor.

 

Conclusions

 

There is a need for more rigorous public health and health services research in order to assess the role, safety, utilization and financial costs associated with manual therapy treatment for headache. Primary healthcare providers should be mindful of the use of this highly popular approach to headache management in order to help facilitate safe, effective and coordinated care.

 

Keywords: Headache, Migraine, Tension headache, Cervicogenic headache, Manual therapy, Physical therapy, Chiropractic, Osteopathy, Massage

 

Background

 

The co-occurrence of tension headache and migraine is very high [1]. Respectively, they are the second and third most common disorders worldwide with migraine ranking as the seventh highest specific cause of disability globally [2] and the sixteenth most commonly diagnosed condition in the US [3]. These common recurrent headache disorders place a considerable burden upon the personal health, finances and work productivity of sufferers [3–5] with migraine further complicated by an association with cardiovascular and psychiatric co-morbidities [6, 7].

 

Preventative migraine drug treatments include analgesics, anticonvulsants, antidepressants and beta-blockers. Preventative drug treatments for tension-type headaches can include analgesics, NSAIDs, muscle relaxants and botulinum toxin as well as anticonvulsants and antidepressants. While preventative drug treatments are successful for a significant proportion of sufferers, headache disorders are still reported as under-diagnosed and under-treated within medical settings [8–16] with other studies reporting sufferers can cease continuing with preventative headache medications long-term [9, 17].

 

There is a number of non-drug approaches also utilized for the prevention of headaches. These include psychological therapies such as cognitive behavioral therapy, relaxation training and EMG (electromyography) biofeedback. In addition, there is acupuncture, nutritional supplementation (including magnesium, B12, B6, and Coenzyme Q10) and physical therapies. The use of physical therapies is significant, with one recent global survey reporting physical therapy as the most frequently used ‘alternative or complementary treatment’ for headache disorders across many countries [18]. One of the most common physical therapy interventions for headache management is manual therapy (MT), [19–21] which we define here as treatments including ‘spinal manipulation (as commonly performed by chiropractors, osteopaths, and physical therapists), joint and spinal mobilization, therapeutic massage, and other manipulative and body-based therapies’ [22].

 

Positive results have been reported in many clinical trials comparing MT to controls [23–27], other physical therapies [28–30] and aspects of medical care [31–34]. More high quality research is needed however to assess the efficacy of MT as a treatment for common recurrent headaches. Recent systematic reviews of randomized clinical trials of MT for the prevention of migraine report a number of significant methodological short-comings and the need for more high quality research before any firm conclusions can be made [35, 36]. Recent reviews of MT trials for tension-type headache and cervicogenic headache are cautious in reporting positive outcomes and the strong need for further robust research [37–41]. Despite the limited clinical evidence there has been no critical review of the significant use of MT by headache populations.

 

Methods

 

The aim of this study is to report from the peer-reviewed literature; 1) the prevalence of MT use for the treatment of common recurrent headaches and 2) factors associated with this use across several key themes. The review further identifies key areas worthy of further research in order to better inform clinical practice, educators and healthcare policy within this area.

 

Design

 

A comprehensive search of peer-reviewed articles published in English between 2000 and 2015 reporting new empirical research findings of key aspects of MT use among patients with migraine and non-migraine headache disorders was undertaken. Databases searched were MEDLINE, AMED, CINAHL, EMBASE and EBSCO. The key words and phrases used were: ‘headache’, ‘migraine’, ‘primary headache’, ‘cephalgia’, ‘chronic headache’ AND ‘manual therapy’, ‘spinal manipulation’, ‘manipulative therapy’, ‘spinal mobilization’, ‘chiropractic’, ‘osteopathy’, ‘massage’, ‘physical therapy’ or ‘physiotherapy’ AND then ‘prevalence’, ‘utilization’ or ‘profile’ was used for additional searches against the previous terms. The database search was accompanied by a hand search of prominent peer-reviewed journals. All authors accessed the reviewed literature (data) and provided input to analysis.

 

Due to the focus of the review, literature reporting randomized control trials and similar clinical research designs were excluded as were articles identified as letters, correspondence, editorials, case reports and commentaries. Further searches were undertaken of the bibliographies in the identified publications. All identified articles were screened and only those reporting new empirical findings on MT use for headache in adults were included in the review. Articles identified and selected for the review were research manuscripts mostly within epidemiological and health economics studies. The review includes papers reporting MT use pooled with the use of other therapies, but only where MT patients comprised a large proportion (as stated) of the included study population. Results were imported into Endnote X7 and duplicates removed.

 

Search Outcomes, Analyses and Quality Appraisal

 

Figure 1 outlines the literature search process. The initial search identified 3286 articles, 35 of which met the inclusion criteria. Information from each article was organized into a review table (Table 1) to summarise the findings of the included papers. Information is reported under two selected headache groups and within each individual MT profession – chiropractic, physiotherapy, osteopathy and massage therapy – where sufficient detail was available.

 

Figure 1 Flow Chart of Study Selection

Figure 1: Flow Chart of Study Selection.

 

Table 1 Research Based Studies of Manual Therapy Use

Table 1: Research-based studies of manual therapy use for headache disorders.

 

An appraisal of the quality of the articles identified for review was conducted using a quality scoring system (Table 2) developed for the critical appraisal of health literature used for prevalence and incidence of health problems [42] adapted from similar studies [43–45]. This scoring system was applicable to the majority of study designs involving surveys and survey-based structured interviews (29 of the 35 papers) but was not applicable to a small number of included studies based upon clinical records, secondary analysis or practitioner characteristics.

 

Table 2 Description of Quality Criteria and Scoring

 

Two separate authors (CM and JA) independently searched and scored the articles. Score results were compared and any differences were further discussed and resolved by all the authors. The quality score of each relevant article is reported in Table 3.

 

Table 3 Quality Score for Selected Studies

 

Results

 

The key findings of the 35 articles were grouped and evaluated using a critical review approach adapted from previous research [46, 47]. Based on the limited information available for other headache types, prevalence findings are reported within one of two categories – either as ‘migraine’ for papers reporting studies where the population was predominately or entirely made up of migraine patients or as ‘headache’ for papers where the study population was predominately other headache types (including tension-type headaches, cluster headaches, cervicogenic headache) and/or where the headache type was not clearly stated. Ten papers reported findings examining prevalence rates for the ‘migraine’ category alone, 18 papers reported findings examining prevalence for the ‘headache’ category alone and 3 papers reported findings for both categories. Based on the nature of the information available, prevalence use was categorised by manual therapy providers. The extracted data was then analysed and synthesized into four thematic categories: prevalence; profile and motivations for MT use; concurrent use and order of use of headache providers; and self-reported evaluation of MT treatment outcomes.

 

Prevalence of MT Use

 

Thirty-one of the reviewed articles with a minimum sample size (>100) reported findings regarding prevalence of MT use. The prevalence of chiropractic use for those with migraine ranged from 1.0 to 36.2% (mean: 14.4%) within the general population [19–21, 48–52] and from 8.9 to 27.1% (mean: 18.0%) within headache-clinic patient populations [53, 54]. The prevalence of chiropractic use for those reported as headache ranged from 4 to 28.0% (mean: 12.9%) within the general population [20, 48, 51, 55–57]; ranged from 12.0 to 22.0% (mean: 18.6%) within headache/pain clinic patient populations [58–60] and from 1.9 to 45.5% (mean: 9.8%) within chiropractic patient populations [61–69].

 

The prevalence use of physiotherapy for those with migraine ranged from 9.0 to 57.0% (mean: 24.7%) within the general population [19, 20, 48, 52] and from 4.9 to 18.7% (mean: 11.8%) within headache-clinic patient populations [54, 70]. The prevalence use of physiotherapy for those reported as headache ranged from 12.2 to 52.0% (mean: 32.1%) within the general population [20, 48] and from 27.8 to 35.0%% (mean: 31.4%) within headache/pain clinic populations [60, 70].

 

Massage therapy use for those with migraine ranged from 2.0 to 29.7% (mean: 15.6%) within the general population [49, 50, 71] and from 10.1 to 56.4% (mean: 33.9%) within headache-clinic populations [53, 54, 72, 73]. Massage/acupressure use for those reported as headache within headache/pain clinic patient populations ranged from 12.0 to 54.0% (mean: 32.5%) [58–60, 70].

 

Osteopathy use for those with migraine was reported as 1% within the general population [49]; as 2.7% within a headache-clinic patient population [53] and as 1.7% within an osteopathy patient population [74]. For headache the prevalence was 9% within a headache/pain clinic population [60] and ranged from 2.7 to 10.0% (mean: 6.4%) within osteopathy patient populations [74, 75].

 

The combined prevalence rate of MT use across all MT professions for those with migraine ranged from 1.0 to 57.0% (mean: 15.9%) within the general population; ranged from 2.7 to 56.4% (mean: 18.4%) within headache-clinic patient populations and was reported as 1.7% in one MT patient population. The combined prevalence rate of MT use across all MT professions for those reported as headache ranged from 4.0 to 52.0% (mean: 17.7%) within the general population; ranged from 9.0 to 54.0% (mean: 32.3%) within headache-clinic patient populations and from 1.9 to 45.5% (mean: 9.25%) within MT patient populations.

 

Profile and Motivations for MT Use

 

While patient socio-demographic profiles were not reported within headache populations that were exclusively using MT, several studies report these findings where MT users made up a significant percentage of the non-medical headache treatments utilized by the study population (range 40% – 86%: mean 63%). While findings varied for level of income [58, 70] and level of education, [70, 72, 73] this patient group were more likely to be older [70, 72], female [20], have a higher rate of comorbid conditions [58, 70, 76] and a higher rate of previous medical visits [20, 58, 70] when compared to the non-user group. Overall, this group were reported to have a higher level of headache chronicity or headache disability than non-users [20, 54, 58, 70, 72, 77].

 

Several studies within headache-clinic populations report patient motivations for the use of complementary and alternative headache treatments where MT users made up a significant proportion of the study population (range 40% – 86%: mean 63%) [58, 70, 72, 78]. From these studies the most common motivation reported by study patients was ‘seeking pain relief’ for headache which accounted for 45.4% – 84.0% (mean: 60.5%) of responses. The second most common motivation was patient concerns regarding the ‘safety or side effects’ of medical headache treatment, accounting for 27.2% – 53.0% (mean: 43.8%) of responses [58, 70, 72]. ‘Dissatisfaction with medical care’ accounted for 9.2% – 35.0% (mean: 26.1%) of responses [58, 70, 72].

 

A limited number of reviewed papers (all from Italy) report on the source of either the referral or recommendation to MT for headache treatment [53, 58, 59]. From these studies, referral from a GP to a chiropractor ranged from 50.0 to 60.8% (mean: 55.7%), while referral from friends/relatives ranged from 33.0 to 43.8% (mean: 38.7%) and self-recommendation ranged from 0 to 16.7% (mean: 5.6%). For massage therapy, referral from a GP ranged from 23.2 to 50.0% (mean: 36.6%), while referral from friends/relatives ranged from 38.4 to 42.3% (mean: 40.4%) and self-recommendation ranged from 7.7 to 38.4% (mean: 23.1%). For acupressure, referral from a GP ranged from 33.0 to 50.0% (mean: 41.5%), while referral from friends/relatives was reported as 50% and self-recommendation ranged from 0 to 16.6% (mean: 8.3%). One study reported findings for osteopathy where referral from both GP’s and friends/relatives was reported as 42.8% and self-recommendation was reported as 14.4%. Overall, the highest proportion of referrals within these studies was from GPs to chiropractors for chronic tension-type headache (56.2%), cluster headache (50%) and migraine (60.8%).

 

Concurrent Use and Order of Use of Headache Providers and Related Communication of MT Users

 

Several studies report on the concurrent use of medical headache management with complementary and alternative therapies. In those studies where the largest percentage of the patient population were users of MT’s (range 57.0% – 86.4%: mean 62.8%), [58, 70, 78] concurrent use of medical care ranged between 29.5% and 79.0% (mean: 60.0%) of the headache patient population.

 

These studies further report on the level of patient non-disclosure to medical providers regarding the use of MT for headache. Non-disclosure ranged between 25.5 and 72.0% (mean: 52.6%) of the patient population, with the most common reason for non-disclosure reported as the doctor ‘never asking’, ranging from 37.0 to 80.0% (mean: 58.5%). This was followed by a patient belief that ‘it was not important for the doctor to know’ or ‘none of the doctor’s business’, ranging from 10.0 to 49.8% (mean: 30.0%). This was followed by a belief that either ‘the doctor would not understand’ or ‘would discourage’ these treatments, ranging from 10.0 to 13.0% (mean: 11.5%) [53, 77].

 

One large international study reported the ordering of the typical provider of headache care by comparing findings between several countries for migraine patients [21]. Primary care providers followed by neurologists were reported as the first and second providers for migraine treatment for nearly all countries examined. The only exception was Australia, where those with chronic migraine selected chiropractors as typical providers at equal frequency to neurologists (14% for both) while those with episodic migraine selected chiropractors at a greater frequency to neurologists (13% versus 5%). Comparatively, chiropractors were selected as the typical provider for those with chronic migraine by 10% in USA and Canada, 1% in Germany and 0% for UK and France. Chiropractors were selected as the typical provider for those with episodic migraine by 7% in USA, 6% in Germany, 4% in Canada and by 1% in both the UK and France.

 

Self-Reported Effectiveness of MT Treatment Outcomes

 

Several headache and pain-clinic population studies provide findings for the self-reported effectiveness of MT headache treatment. For chiropractic, patient self-reporting of partially effective or fully effective headache relief ranged from 27.0 to 82.0% (mean: 45.0%) [53, 58–60, 78]. For massage therapy, patient self-reporting of partially effective or fully effective headache relief ranged from 33.0 to 64.5% (mean: 45.2%)[53, 58, 60, 73, 78], and for acupressure this ranged from 33.4 to 50.0% (mean: 44.5%) [53, 58, 59]. For osteopathy and physiotherapy, one study reported effectiveness as 17 and 36% respectively [60].

When results are combined across all MT professions the reporting of MT as either partially or fully effective ranged from 17.0 to 82.0% (mean 42.5%) [53, 58–60, 73, 78]. In addition, one general population study provides findings for the self-reported effectiveness for chiropractic and physiotherapy at 25.6 and 25.1% respectively for those with primary chronic headache and 38 and 38% respectively for those with secondary chronic headache [79].

 

Discussion

 

This paper provides the first critical integrative review on the prevalence and key factors associated with the use of MT treatment for headaches within the peer-reviewed literature. While study methodological limitations and lack of data prevent making strong conclusions, these findings raise awareness of issues of importance to policy-makers, educators, headache providers and future research.

 

Our review found that MT use was generally higher within medical headache-clinic populations when compared to general populations. However, the use of individual MT providers does vary between different regions and this is likely due to a number of factors including variation in public access, healthcare funding and availability of MT providers. For example, the use of physiotherapy for some headache types may be relatively higher in parts of Europe [20, 60] while the use of chiropractors for some headache types may be relatively higher in Australia and the USA [19, 21]. Overall, the prevalence use of MT for headache appears to be substantial and likely to be the most common type of physical therapy utilized for headache in many countries [19–21, 49]. More high quality epidemiological studies are needed to measure the prevalence of MT use across different headache types and sub-types, both within the general population and clinical populations.

 

Beyond prevalence, data is more limited regarding who, how and why headache patients seek MT. From the information available however, the healthcare needs of MT headache patients may be more complex and multi-disciplinary in nature compared to those under usual medical care alone. Socio-demographic findings suggest that users of MT and other complementary and alternative therapies have a higher level of headache disability and chronicity compared to non-users. This finding may correlate with the higher prevalence of MT users within headache-clinic populations and a history of more medical appointments. This may also have implications for future MT trial designs both in terms of the selection of trial subjects from inside versus outside MT clinical settings and the decision to test singular MT interventions versus MT in combination with other interventions.

 

Limited information suggests that a pluralistic approach toward the use of medical and non-medical headache treatments such as MT is common. While findings suggest MT is sought most often for reasons of seeking headache relief, the evidence to support the efficacy of MT for headache relief is still limited. MT providers must remain mindful of the quality of the evidence for a given intervention for a given headache disorder and to inform patients where more effective or safer treatment interventions are available. More research is needed to assess these therapies individually and through multimodal approaches and for studies to include long-term follow-up.

 

Information limited to Italy, suggests referral from GPs for MT headache treatment can be common in some regions, while this is less likely to widespread given the issue of patient non-disclosure to medical doctors regarding the use of this treatment in other studies. High quality healthcare requires open and transparent communication between patients and providers and between the providers themselves. Non-disclosure may adversely influence medical management should unresponsive patients require further diagnostic investigations [80] or the implementation of more effective approaches to headache management [81] or prevents discussion in circumstances where MT may be contraindicated [82]. Primary headache providers may benefit from paying particular attention to the possibility of non-disclosure of non-medical headache treatments. Open discussion between providers and patients about the use of MT for headache and the associated outcomes may improve overall patient care.

 

Future Research

 

Despite the strong need for more high quality research to assess the efficacy of MT as a treatment for headache, the substantial use of MT brings attention to the need for more public health and health services research within this area of headache management. The need for this type of research was identified in a recent global report on the use of headache-related healthcare resources [18]. Furthering this information can lead to improvements in healthcare policy and the delivery of healthcare services.

 

The substantial use of physical therapies such as MT has been under-reported within many of the national surveys reporting headache-related healthcare utilization [3, 5, 83–85]. Regardless, the role of physical therapies in headache management continues to be assessed, often within mainstream and integrated headache management settings [86–89]. Continuing this research may further our understanding of the efficacy and outcomes associated with a more multidisciplinary approach to headache management.

 

Further to this is the need for more research to understand the healthcare utilization pathways associated with those patients who use MT in their headache management. Little is known about the sociodemographic background, types of headaches, level of headache disability and comorbidities more common to this patient population. In turn, such information can provide insights that may be valuable to provider clinical decision-making and provider education.

 

Limitations

 

The design and findings of our review has a number of limitations. The design of the review was limited by a search within English language journals only. As a result, some research on this topic may have been missed. While the quality scoring system adopted for this review requires further validation, the data we collected was limited by the low to moderate quality of available papers which averaged 6.4 out of 10 points (Table 3). The low scoring was largely due to significant methodological issues and the small sample size associated with much of the collected papers. Much of the data on this topic was heterogeneous in nature (telephone, postal surveys and face-to-face interviews). There was a lack of validated practitioner and patient questionnaires to report findings, such as for questions on prevalence, where the time frames utilized varied between ‘currently’, ‘last 12 months’ and ‘ever’.

 

Data on the prevalence of MT use for headache was limited particularly within individual MT provider populations when compared to data found within the general population and headache-clinic populations. Many studies assessed the use of MT for headache without identifying headache types. Only one study inside an MT population had reported the percentage of patients attending for reasons of migraine alone (osteopathy). The prevalence of MT use for headache was reported most within chiropractic patient population studies, however information was limited on the types of headache. We found no studies reporting the prevalence of headache patients within physiotherapy or massage therapy patient populations using our search terms.

 

A lack of data for some themes necessitated providing findings pooled with users of other non-medical headache providers. Data within many geographical regions was very limited with the most limited data was on the source of referral to MT headache providers (three papers from Italy only). These limitations support the call for more research to be focused exclusively within MT populations and different regional areas before stronger conclusions can be drawn.

 

Conclusion

 

The needs of those with headache disorders can be complex and multi-disciplinary in nature. Beyond clinical research, more high quality public health and health services research is needed to measure and examine a number of issues of significance to the delivery and use of MT’s within headache management. With unmet needs still remaining for many who suffer recurrent headaches, clinicians should remain cognizant of the use of MT’s and remain open to discussing this approach to headache management in order to ensure greater safety, effectiveness and coordination of headache care.

 

Acknowledgements

 

Not applicable.

 

Funding

 

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors while the first author on this paper receives a PhD scholarship made available by the Australian Chiropractors’ Association.

 

Availability of Data and Materials

 

Not applicable (all data is reported in article).

 

Authors’ Contributions

 

CM, JA and DS designed the paper. CM carried out the literature search, data collection and selection. CM and DS provided the analysis and interpretation. CM and JA wrote the drafts. All authors contributed to the critical review and intellectual content. All authors read and approved the final manuscript.

 

Competing Interests

 

The authors declare that they have no competing interests.

 

Consent for Publication

 

Not applicable.

 

Ethics Approval and Consent to Participate

 

Not applicable.

 

Publisher’s Note

 

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

 

Abbreviations

 

  • MT Manual therapy
  • EMG Electromyography

 

Contributor Information

 

Ncbi.nlm.nih.gov/pmc/articles/PMC5364599/

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

A staggering 15% of the population suffers from migraines, a debilitating condition which affects an individual’s ability to engage in everyday activities. Although widely misunderstood by researches today, I believe that migraine pain can be a symptom of a much bigger underlying health issue. Lumbar herniated discs, or ruptured discs in the lumbar spine, are a common cause of lower back pain and sciatica. When the soft, gel-like center of a lumbar herniated disc compresses the nerve roots of the low back, it can result in symptoms of pain and discomfort, numbness and weakness in the lower extremities. What’s more, a lumbar herniated disc can unbalance the structure and function of the entire spine, eliciting symptoms along the cervical spine that could ultimately trigger migraines. People who constantly experience migraine pain often have to carefully go about their day in hopes of avoiding the blaze of another painful episode. Fortunately, many migraine pain and lumbar herniated disc treatment methods are available to help improve as well as manage the symptoms. Other treatment options can also be considered before surgical interventions.

 

Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT)

 

Abstract

 

Study Design

 

Concurrent prospective randomized and observational cohort studies.

 

Objective

 

To assess the 8-year outcomes of surgery vs. non-operative care.

 

Summary of Background Data

 

Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical to non-operative treatment remain controversial.

 

Methods

 

Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting SPORT eligibility criteria enrolled into prospective randomized (501 participants) and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual non-operative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain (BP) and Physical Function (PF) scales and the modified Oswestry Disability Index (ODI – AAOS/Modems version) assessed at 6 weeks, 3 and 6 months, and annually thereafter.

 

Results

 

Advantages were seen for surgery in intent-to-treat analyses for the randomized cohort for all primary and secondary outcomes other than work status; however, with extensive non-adherence to treatment assignment (49% patients assigned to non-operative therapy receiving surgery versus 60% of patients assigned to surgery) these observed effects were relatively small and not statistically significant for primary outcomes (BP, PF, ODI). Importantly, the overall comparison of secondary outcomes was significantly greater with surgery in the intent-to-treat analysis (sciatica bothersomeness [p > 0.005], satisfaction with symptoms [p > 0.013], and self-rated improvement [p > 0.013]) in long-term follow-up. An as-treated analysis showed clinically meaningful surgical treatment effects for primary outcome measures (mean change Surgery vs. Non-operative; treatment effect; 95% CI): BP (45.3 vs. 34.4; 10.9; 7.7 to 14); PF (42.2 vs. 31.5; 10.6; 7.7 to 13.5) and ODI (−36.2 vs. −24.8; −11.2; −13.6 to −9.1).

 

Conclusion

 

Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operatively treated patients; there was little to no degradation of outcomes in either group (operative and non-operative) from 4 to 8 years.

 

Keywords: SPORT, intervertebral disc herniation, surgery, non-operative care, outcomes

 

Introduction

 

Lumbar discectomy for relief of sciatica in patients with intervertebral disc herniation (IDH) is a well-researched and common indication for spine surgery, yet rates of this surgery exhibit considerable geographic variation.[1] Several randomized trials and large prospective cohorts have demonstrated that surgery provides faster pain relief and perceived recovery in patients with herniated disc.[2–6] The effect of surgery on longer term outcomes remains less clear.

 

In a classic RCT evaluating surgery versus non-operative treatment for lumbar IDH, Weber et al. showed a greater improvement in the surgery group at 1 year that was statistically significant; there was also greater improvement for surgery at 4 years, although not statistically significant, but no apparent difference in outcomes at 10 years.[2] However, a number of patients in the non-operative group eventually underwent surgery over that time, complicating the interpretation of the long-term results. The Maine Lumbar Spine Study, a prospective observational cohort, found greater improvement at one year in the surgery group that narrowed over time, but remained significantly greater in the surgical group for sciatica bothersomeness, physical function, and satisfaction, but no different for work or disability outcomes.[3] This paper reports 8-year results from the Spine Patient Outcomes Research Trial (SPORT) based on the continued follow-up of the herniated disc randomized and observational cohorts.

 

Methods

 

Study Design

 

SPORT is a randomized trial with a concurrent observation cohort conducted in 11 US states at 13 medical centers with multidisciplinary spine practices. The human subjects committees at each participating institution approved a standardized protocol for both the observational and the randomized cohorts. Patient inclusion and exclusion criteria, study interventions, outcome measures, and follow-up procedures have been reported previously.[5–8]

 

Patient Population

 

Men and women were eligible if they had symptoms and confirmatory signs of lumbar radiculopathy persisting for at least six weeks, disc herniation at a corresponding level and side on imaging, and were considered surgical candidates. The content of pre-enrollment non-operative care was not pre-specified in the protocol.[5–7] Specific enrollment and exclusion criteria are reported elsewhere.[6,7]

 

A research nurse at each site identified potential participants, verified eligibility and used a shared decision making video for uniformity of enrollment. Participants were offered enrollment in either the randomized trial or the observational cohort. Enrollment began in March of 2000 and ended in November of 2004.

 

Study Interventions

 

The surgery was a standard open discectomy with examination of the involved nerve root.[7,9] The non-operative protocol was “usual care” recommended to include at least: active physical therapy, education/counseling with home exercise instruction, and non-steroidal anti-inflammatory drugs if tolerated. Non-operative treatments were individualized for each patient and tracked prospectively.[5–8]

 

Study Measures

 

Primary endpoints were the Bodily Pain (BP) and Physical Function (PF) scales of the SF-36 Health Survey[10] and the AAOS/Modems version of the Oswestry Disability Index (ODI)[11] as measured at 6 weeks, 3 and 6 months, and annually thereafter. If surgery was delayed beyond six weeks, additional follow-up data was obtained 6 weeks and 3 months post-operatively. Secondary outcomes included patient self-reported improvement; work status; satisfaction with current symptoms and care;[12] and sciatica severity as measured by the sciatica bothersomeness index.[13,14] Treatment effect was defined as the difference in the mean changes from baseline between the surgical and non-operative groups.

 

Statistical Considerations

 

Initial analyses compared means and proportions for baseline patient characteristics between the randomized and observational cohorts and between the initial treatment arms of the individual and combined cohorts. The extent of missing data and the percentage of patients undergoing surgery were calculated by treatment arm for each scheduled follow-up. Baseline predictors of time until surgical treatment (including treatment crossovers) in both cohorts were determined via a stepwise proportional hazards regression model with an inclusion criterion of p < 0.1 to enter and p > 0.05 to exit. Predictors of missing follow-up visits at yearly intervals up to 8 years were separately determined via stepwise logistic regression. Baseline characteristics that predicted surgery or a missed visit at any time-point were then entered into longitudinal models of primary outcomes. Those that remained significant in the longitudinal models of outcome were included as adjusting covariates in all subsequent longitudinal regression models to adjust for potential confounding due to treatment selection bias and missing data patterns.[15] In addition, baseline outcome, center, age and gender were included in all longitudinal outcome models.

 

Primary analyses compared surgical and non-operative treatments using changes from baseline at each follow-up, with a mixed effects longitudinal regression model including a random individual effect to account for correlation between repeated measurements within individuals. The randomized cohort was initially analyzed on an intent-to-treat basis.[6] Because of cross-over, additional analyses were performed based on treatments actually received. In these as-treated analyses, the treatment indicator was a time-varying covariate, allowing for variable times of surgery. Follow-up times were measured from enrollment for the intent-to-treat analyses, whereas for the as-treated analysis the follow-up times were measured from the beginning of treatment (i.e. the time of surgery for the surgical group and the time of enrollment for the non-operative group), and baseline covariates were updated to the follow-up immediately preceding the time of surgery. This procedure has the effect of including all changes from baseline prior to surgery in the estimates of the non-operative treatment effect and all changes after surgery in the estimates of the surgical effect. The six-point sciatica scales and binary outcomes were analyzed via longitudinal models based on generalized estimating equations[16] with linear and logit link functions respectively, using the same intent-to-treat and adjusted as-treated analysis definitions as the primary outcomes. The randomized and observational cohorts were each analyzed to produce separate as-treated estimates of treatment effect. These results were compared using a Wald test to simultaneously test all follow-up visit times for differences in estimated treatment effects between the two cohorts.[15] Final analyses combined the cohorts.

 

To evaluate the two treatment arms across all time-periods, the time-weighted average of the outcomes (area under the curve) for each treatment group was computed using the estimates at each time period from the longitudinal regression models and compared using a Wald test.[15]

 

Kaplan-Meier estimates of re-operation rates at 8 years were computed for the randomized and observational cohorts and compared via the log-rank test.[17,18]

 

Computations were done using SAS procedures PROC MIXED for continuous data and PROC GENMOD for binary and non-normal secondary outcomes (SAS version 9.1 Windows XP Pro, Cary, NC). Statistical significance was defined as p < 0.05 based on a two-sided hypothesis test with no adjustments made for multiple comparisons. Data for these analyses were collected through February 4, 2013.

 

Results

 

Overall, 1,244 SPORT participants with lumbar intervertebral disc herniation were enrolled (501 in the randomized cohort, and 743 in the observational cohort) (Figure 1). In the randomized cohort, 245 were assigned to surgical treatment and 256 to non-operative treatment. Of those randomized to surgery, 57% had surgery by 1 year and 60% by 8 years. In the group randomized to non-operative care, 41% of patients had surgery by 1 year and 48% by 8 years. In the observational cohort, 521 patients initially chose surgery and 222 patients initially chose non-operative care. Of those initially choosing surgery, 95% received surgery by 1 year; at 8 years 12 additional patients had undergone primary surgery. Of those choosing non-operative treatment, 20% had surgery by 1 year and 25% by 8 years. In both cohorts combined, 820 patients received surgery at some point during the first 8 years; 424 (34%) remained non-operative. Over the 8 years, 1,192 (96%) of the original enrollees completed at least 1 follow-up visit and were included in the analysis (randomized cohort: 94% and observational cohort 97%); 63% of initial enrollees supplied data at 8 years with losses due to dropouts, missed visits, or deaths (Figure 1).

 

Figure-1-Exclusion-Enrollment-Randomization-and-Follow-Up

Figure 1: Exclusion, enrollment, randomization and follow-up of trial participants.

 

Patient Characteristics

 

Baseline characteristics have been previously reported and are summarized in Table 1.[5,6,8] The combined cohorts had an overall mean age of 41.7 with slightly more men than women. Overall, the randomized and observational cohorts were similar. However, patients in the observational cohort had more baseline disability (higher ODI scores), were more likely to prefer surgery, more often rated their problem as worsening, and were slightly more likely to have a sensory deficit. Subjects receiving surgery over the course of the study were: younger; less likely to be working; more likely to report being on worker’s compensation; had more severe baseline pain and functional limitations; fewer joint and other co-morbidities; greater dissatisfaction with their symptoms; more often rated their condition as getting worse at enrollment; and were more likely to prefer surgery. Subjects receiving surgery were also more likely to have a positive straight leg test, as well as more frequent neurologic, sensory, and motor deficits. Radiographically, their herniations were more likely to be at the L4–5 and L5-S1 levels and to be posterolateral in location.

 

Table 1 Patient Baseline Demographic Characteristics, Comorbidities and Health Status Measures

Table 1: Patient baseline demographic characteristics, comorbidities and health status measures according to study cohort and treatment received.

 

Surgical Treatment and Complications

 

Overall surgical treatment and complications were similar between the two cohorts (Table 2). The average surgical time was slightly longer in the randomized cohort (80.5 minutes randomized vs. 74.9 minutes observational, p=0.049). The average blood loss was 75.3cc in the randomized cohort vs. 63.2cc in the observational, p=0.13. Only 6 patients total required intra-operative transfusions. There were no perioperative mortalities. The most common surgical complication was dural tear (combined 3% of cases). Re-operation occurred in a combined 11% of cases by 5 years, 12% by 6 years, 14% by 7 years, and 15% by 8 years post-surgery. The rates of reoperation were not significantly different between the randomized and observational cohorts. Eighty-seven of the 119 re-operations noted the type of re-operation; approximately 85% of these (74/87) were listed as recurrent herniations at the same level. One death occurred within 90 days post-surgery related to heart surgery at another institution; the death was judged to be unrelated and was reported to the Institutional Review Board and the Data and Safety Monitoring Board.

 

Table 2 Operative Treatments, Complications and Events

Cross-Over

 

Non-adherence to treatment assignment affected both treatment arms: patients chose to delay or decline surgery in the surgical arm and crossed over to surgery in the non-operative arm. (Figure 1) Statistically significant differences of patients crossing over to non-operative care within 8 years of enrollment were that they were older, had higher incomes, less dissatisfaction with their symptoms, more likely to have a disc herniation at an upper lumbar level, more likely to express a baseline preference for non-operative care, less likely to perceive their symptoms as getting worse at baseline, and had less baseline pain and disability (Table 3). Patients crossing over to surgery within 8 years were more dissatisfied with their symptoms at baseline; were more likely to perceive they were getting worse at baseline; more likely to express a baseline preference for surgery; and had worse baseline physical function and more self-rated disability.

 

Table 3 Statistically Significant Predictors of Adherence to Treatment

Table 3: Statistically significant predictors of adherence to treatment among RCT patients.

 

Main Treatment Effects

 

Intent-to-Treat Analysis In the intention-to-treat analysis of the randomized cohort, all measures over 8 years favored surgery but there were no statistically significant treatment effects in the primary outcome measures (Table 4 and Figure 2). In the overall intention-to-treat comparison between the two treatment groups over time (area-under the curve), secondary outcomes were significantly greater with surgery in the intention-to-treat analysis (sciatica bothersomeness (p=0.005), satisfaction with symptoms (p=0.013), and self-rated improvement (p=0.013)) (Figure 3) Improvement in sciatica bothersomeness index was also statistically significant in favor of surgery at most individual time point comparisons (although non-significant in years 6 and 7) (Table 4).

 

Figure-2-Primary-Outcomes-in-the-Randomized-and-Observational-Cohorts

Figure 2: Primary outcomes (SF-36 Bodily Pain and Physical Function, and Oswestry Disability Index) in the randomized and observational cohorts during 8 years of follow-up.

 

Figure-3-Secondary-Outcomes-in-the-Randomized-and-Observational-Cohorts.

Figure 3: secondary outcomes (Sciatica Bothersomeness, Satisfaction with Symptoms, and Self-rated Global Improvement) in the randomized and observational cohorts during 8 years of follow-up.

 

Table 4 Primary Analysis Results for Years 1 to 8

Table 4: Primary analysis results for years 1 to 8. Intent-to-treat for the randomized cohort and adjusted* analyses according to treatment received for the randomized and observational cohorts combined.

 

As-Treated Analysis The adjusted as-treated effects seen in the randomized and observational were similar. Accordingly, the cohorts were combined for the final analyses. Treatment effects for the primary outcomes in the combined as-treated analysis were clinically meaningful and statistically significant out to 8 years: SF-36 BP 10.9 p < 0.001 (95% CI 7.7 to 14); SF-36 PF 10.6 p<0.001 (95% CI 7.7 to 13.5); ODI −11.3 p<0.001 (95% CI −13.6 to −9.1) (Table 4). The footnote for Table 4 describes the adjusting covariates selected for the final model.

 

Results from the intent-to-treat and as-treated analyses of the two cohorts are compared in Figure 2. In the combined analysis, treatment effects were statistically significant in favor of surgery for all primary and secondary outcome measures (with the exception of work status which did not differ between treatment groups) at each time point (Table 4 and Figure 3).

 

Loss-to-Follow-Up

 

At the 8-year follow-up, 63% of initial enrollees supplied data, with losses due to dropouts, missed visits, or deaths. Table 5 summarized the baseline characteristics of those lost to follow-up compared to those retained in the study at 8-years. Those who remained in the study at 8 years were – somewhat older; more likely to be female, white, college educated, and working at baseline; less likely to be disabled, receiving compensation, or a smoker; less symptomatic at baseline with somewhat less bodily pain, better physical function, less disability on the ODI, better mental health, and less sciatica bothersomeness. These differences were small but statistically significant. Table 6 summarizes the short-term outcomes during the first 2 years for those retained in the study at 8 years compared to those lost to follow-up. Those lost to follow-up had worse outcomes on average; however this was true in both the surgical and non-operative groups with non-significant differences in treatment effects. The long-term outcomes are therefore likely to be somewhat over-optimistic on average in both groups, but the comparison between surgical and non-operative outcomes appear likely to be un-biased despite the long-term loss to follow-up.

 

Table 5 Patient Baseline Demographic Characteristics, Comorbidities and Health Status Measures

Table 5: Patient baseline demographic characteristics, comorbidities, and health status measures according to patient follow-up status as of 02/01/2013 when the IDH8yr data were pulled.

 

Table 6 Time Weighted Average of Treatment Effects

Table 6: Time-weighted average of treatment effects at 2 years (AUC) from adjusted* as-treated randomized and observational cohorts combined primary outcome analysis, according to treatment received and patient follow-up status.

 

Discussion

 

In patients with a herniated disc confirmed by imaging and leg symptoms persisting for at least 6 weeks, surgery was superior to non-operative treatment in relieving symptoms and improving function. In the as-treated analysis, the treatment effect for surgery was seen as early as 6 weeks, appeared to reach a maximum by 6 months and persisted over 8 years; it is notable that the non-operative group also improved significantly and this improvement persisted with little to no degradation of outcomes in either group (operative and non-operative) between 4 and 8 years. In the longitudinal intention-to-treat analysis, all the outcomes showed small advantages for surgery, but only the secondary outcomes of sciatica bothersomeness, satisfaction with symptoms, and self-rated improvement were statistically significant. The persistent small benefit in the surgery group over time has made the overall intention-to-treat comparison more statistically significant over time despite high levels of cross-over. The large effects seen in the as-treated analysis after adjustments for characteristics of the crossover patients suggest that the intent-to-treat analysis may underestimate the true effect of surgery since the mixing of treatments due to crossover can be expected to create a bias toward the null in the intent-to-treat analyses.[4,19] Loss to follow-up among patients who were somewhat worse at baseline and with worse short-term outcomes probably leads to overly-optimistic estimated long-term outcomes in both surgery and non-operative groups but unbiased estimates of surgical treatment effects.

 

Comparisons to Other Studies

 

There are no other long-term randomized studies reporting the same primary outcome measures as SPORT. The results of SPORT primary outcomes at 2 years were quite similar to those of Peul et al but longer follow up for the Peul study is necessary for further comparison.[4,20] In contrast to the Weber study, the differences in the outcomes in SPORT between treatment groups remained relatively constant between 1 and 8 years of follow-up. One of the factors in this difference may be the sensitivity of the outcome measures – for example, sciatica bothersomeness, which was significantly different out to 8 years in the intention-to-treat, may be a more sensitive marker of treatment success than the general outcome measure used by Weber et al.[2]

 

The long-term results of SPORT are similar to the Maine Lumbar Spine Study (MLSS).[21] The MLSS reported statistically significantly greater improvements at 10 years in sciatica bothersomeness for the surgery group (−11.9) compared to the nonsurgical groups (−5.8) with a treatment effect of −6.1 p=0.004; in SPORT the improvement in sciatica bothersomeness in the surgical group at 8 years was similar to the 10 year result in MLSS (−11) though the non-operative cohort in SPORT did better than their MLSS counterparts (−9.1) however the treatment effect in SPORT, while smaller, remained statistically significant (−1.5; p<0.001) due to the much larger sample size. Greater improvements in the non-operative cohorts between SPORT and MLSS may be related to differences in non-operative treatments over time, differences between the two cohorts since the MLSS and did not require imaging confirmation of IDH.

 

Over the 8 years there was little evidence of harm from either treatment. The 8-year rate of re-operation was 14.7%, which is lower than the 25% reported by MLSS at 10 years.[22]

 

Limitations

 

Although our results are adjusted for characteristics of cross over patients and control for important baseline covariates, the as-treated analyses presented do not share the strong protection from confounding that exists for an intent-to-treat analysis.[4–6] However, However, intent-to-treat analyses are known to be biased in the presence of noncompliance at the level observed in SPORT, and our adjusted as-treated analyses have been shown to produce accurate results under reasonable assumptions about the dependence of compliance on longitudinal outcomes.[23] Another potential limitation is the heterogeneity, of the non-operative treatment interventions, as discussed in our prior papers.[5,6,8] Finally, attrition in this long-term follow-up study meant that only 63% of initial enrollees supplied data at 8 years with losses due to dropouts, missed visits, or deaths; based on analyses at baseline and at short-term follow-up, this likely leads to somewhat overly-optimistic estimated long-term outcomes in both treatment groups but an unbiased estimation of surgical treatment effect.

 

Conclusions

 

In the intention-to-treat analysis, small, statistically insignificant surgical treatment effects were seen for the primary outcomes but statistically significant advantages for sciatica bothersomeness, satisfaction with symptoms, and self-rated improvement were seen out to 8 years despite high levels of treatment cross-over. The as-treated analysis combining the randomized and observational cohorts, which carefully controlled for potentially confounding baseline factors, showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 8 years compared to patients treated non-operatively. The non-operative group, however, also showed substantial improvements over time, with 54% reporting being satisfied with their symptoms and 73% satisfied with their care after 8 years.

 

Acknowledgments

 

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (U01-AR45444; P60-AR062799) and the Office of Research on Women’s Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention grant funds were received in support of this work. Relevant financial activities outside the submitted work: consultancy, grants, stocks.

 

This study is dedicated to the memories of Brieanna Weinstein and Harry Herkowitz, leaders in their own rights, who simply made the world a better place.

 

Footnotes

 

Other comorbidities include: stroke, diabetes, osteoporosis, cancer, fibromyalgia, cfs, PTSD, alcohol, drug dependency, heart, lung, liver, kidney, blood vessel, nervous system, hypertension, migraine, anxiety, stomach, bowel

 

In conclusion, individuals who suffer from migraine pain require the most effective type of treatment in order to help improve as well as manage their symptoms, particularly if their migraines were elicited from a lumbar herniated disc. The purpose of the following articles was to associate the two conditions with each other and demonstrate the results of the research above. Various treatment options can be considered before surgery for migraine pain and lumbar herniated disc treatment. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

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References
1. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Has the prevalence of migraine and tension-type headache changed over a 12-year period? a Danish population survey. Eur J Epidemiol. 2005;20:243–9. doi: 10.1007/s10654-004-6519-2. [PubMed] [Cross Ref]
2. Vos T, Flaxman A, Naghavi M. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380:2163–96. doi: 10.1016/S0140-6736(12)61729-2. [PubMed] [Cross Ref]
3. Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the united states: updated statistics from government health surveillance studies. Headache. 2015;55:21–34. doi: 10.1111/head.12482. [PubMed] [Cross Ref]
4. Lanteri-Minet M. Economic burden and costs of chronic migraine. Curr Pain Headache Rep. 2014;18:385. doi: 10.1007/s11916-013-0385-0. [PubMed] [Cross Ref]
5. Bloudek L, Stokes M, Buse D, Wilcox T, Lipton R, Goadsby P, Varon S, Blumenfeld A, Katsarava Z, Pascual J, et al. Cost of healthcare for patients with migraine in five European countries: results from the international burden of migraine study (IBMS) J Headache Pain. 2012;13:361–78. doi: 10.1007/s10194-012-0460-7. [PMC free article] [PubMed] [Cross Ref]
6. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A. Migraine and psychiatric comorbidity: a review of clinical findings. J Headache Pain. 2011;12:115–25. doi: 10.1007/s10194-010-0282-4. [PMC free article] [PubMed] [Cross Ref]
7. Kurth T, Chabriat H, Bousser M-G. Migraine and stroke: a complex association with clinical implications. Lancet Neurol. 2012;11:92–100. doi: 10.1016/S1474-4422(11)70266-6. [PubMed] [Cross Ref]
8. Lipton R, Goadsby P, Sawyer J, Blakeborough P, Stewart W. Migraine: diagnosis and assessment of disability. Rev Contemp Pharmaco. 2000;11:63–73.
9. Diamond S, Bigal ME, Silberstein S, Loder E, Reed M, Lipton RB. Patterns of diagnosis and acute and preventive treatment for migraine in the united states: results from the American migraine prevalence and prevention study. Headache. 2007;47:355–63. [PubMed]
10. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed M, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343–9. doi: 10.1212/01.wnl.0000252808.97649.21. [PubMed] [Cross Ref]
11. Berger A, Bloudek LM, Varon SF, Oster G. Adherence with migraine prophylaxis in clinical practice. Pain Pract. 2012;12:541–9. doi: 10.1111/j.1533-2500.2012.00530.x. [PubMed] [Cross Ref]
12. Peres MFP, Silberstein S, Moreira F, Corchs F, Vieira DS, Abraham N, Gebeline-Myers C. Patients’ preference for migraine preventive therapy. Headache. 2007;47:540–5. doi: 10.1111/j.1526-4610.2007.00757.x. [PubMed] [Cross Ref]
13. Nicholson RA, Rooney M, Vo K, O’Laughlin E, Gordon M. Migraine care among different ethnicities: Do disparities exist? Headache. 2006;46:754–65. doi: 10.1111/j.1526-4610.2006.00453.x. [PMC free article] [PubMed] [Cross Ref]
14. Lafata JE, Tunceli O, Cerghet M, Sharma KP, Lipton RB. The use of migraine preventive medications among patients with and without migraine headaches. Cephalalgia. 2010;30:97–104. doi: 10.1111/j.1468-2982.2009.01909.x. [PubMed] [Cross Ref]
15. Cevoli S, D’Amico D, Martelletti P, Valguarnera F, Del Bene E, De Simone R, Sarchielli P, Narbone MC, Testa L, Genco S, et al. Underdiagnosis and undertreatment of migraine in Italy: a survey of patients attending for the first time 10 headache centres. Cephalalgia. 2009;29:1285–93. doi: 10.1111/j.1468-2982.2009.01874.x. [PubMed] [Cross Ref]
16. Stark RJ, Valenti L, Miller GC. Management of migraine in Australian general practice. Med J Aust. 2007;187:142. [PubMed]
17. Lipton RB, Buse DC, Serrano D, Holland S, Reed ML. Examination of unmet treatment needs among persons with episodic migraine: results of the American migraine prevalence and prevention (AMPP) study. Headache. 2013;53:1300–11. doi: 10.1111/head.12154. [PubMed] [Cross Ref]
18. WHO Lifting the Burden 2011: http://www.who.int/mental_health/management/who_atlas_headache_disorders.pdf?ua=1. Retrieved 8 August 2015
19. Bigal ME, Serrano D, Reed M, Lipton RB. Chronic migraine in the population Burden, diagnosis, and satisfaction with treatment. Neurology. 2008;71:559–66. doi: 10.1212/01.wnl.0000323925.29520.e7. [PubMed] [Cross Ref]
20. Kristoffersen ES, Grande RB, Aaseth K, Lundqvist C, Russell MB. Management of primary chronic headache in the general population: the Akershus study of chronic headache. J Headache Pain. 2012;13:113–20. doi: 10.1007/s10194-011-0391-8. [PMC free article] [PubMed] [Cross Ref]
21. Sanderson JC, Devine EB, Lipton RB, Bloudek LM, Varon SF, Blumenfeld AM, Goadsby PJ, Buse DC, Sullivan SD. Headache-related health resource utilisation in chronic and episodic migraine across six countries. J Neurol Neurosurg Psychiatry. 2013;84:1309–17. doi: 10.1136/jnnp-2013-305197. [PMC free article] [PubMed] [Cross Ref]
22. Biology of Manual Therapies (R21) National Institute of Health, 2014: http://grants.nih.gov/grants/guide/pa-files/PA-14-167.html Retrieved 11 August 2015
23. Marcus D, Scharff L, Mercer S, Turk D. Nonpharmacological treatment for migraine: incremental utility of physical therapy with relaxation and thermal biofeedback. Cephalalgia. 1998;18:266–72. doi: 10.1046/j.1468-2982.1998.1805266.x. [PubMed] [Cross Ref]
24. Lawler SP, Cameron LD. A randomized, controlled trial of massage therapy as a treatment for migraine. Ann Behav Med. 2006;32:50–9. doi: 10.1207/s15324796abm3201_6. [PubMed] [Cross Ref]
25. Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther. 2000;23:91–5. doi: 10.1016/S0161-4754(00)90073-3. [PubMed] [Cross Ref]
26. Hoyt W, Shaffer F, Bard D, Benesler J, Blankenhorn G, Gray J, Hartman W, Hughes L. Osteopathic manipulation in the treatment of muscle-contraction headache. J Am Osteopath Assoc. 1979;78:322–5. [PubMed]
27. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976) 2002;27:1835–43. doi: 10.1097/00007632-200209010-00004. [PubMed] [Cross Ref]
28. Haas M, Spegman A, Peterson D, Aickin M, Vavrek D. Dose-Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized Controlled Trial. Spine J. 2010;10:117–28. [PMC free article] [PubMed]
29. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576–9. doi: 10.1001/jama.280.18.1576. [PubMed] [Cross Ref]
30. Parker GB, Pryor DS, Tupling H. Why does migraine improve during a clinical trial? Further results from a trial of cervical manipulation for migraine. Aust N Z J Med. 1980;10:192–8. doi: 10.1111/j.1445-5994.1980.tb03712.x. [PubMed] [Cross Ref]
31. Hsieh LL-C, Liou H-H, Lee L-H, Chen TH-H, Yen AM-F. Effect of acupressure and trigger points in treating headache: a randomized controlled trial. Am J Chin Med. 2010;38:1–14. doi: 10.1142/S0192415X10007634. [PubMed] [Cross Ref]
32. Boline P, Kassack K, Bronfort G, Nelson C, Anderson A. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. 1995;18:148–54. [PubMed]
33. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther. 1998;21:511–9. [PubMed]
34. Castien RF, Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2011;31:133–43. doi: 10.1177/0333102410377362. [PubMed] [Cross Ref]
35. Chaibi A, Tuchin P, Russell M. Manual therapies for migraine: a systematic review. J Headache Pain. 2011;12:127–33. doi: 10.1007/s10194-011-0296-6. [PMC free article] [PubMed] [Cross Ref]
36. Posadzki P, Ernst E. Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials. Cephalalgia. 2011;31:964–70. doi: 10.1177/0333102411405226. [PubMed] [Cross Ref]
37. Posadzki P, Ernst E. Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials. Complement Ther Med. 2012;20:232–9. doi: 10.1016/j.ctim.2011.12.001. [PubMed] [Cross Ref]
38. Racicki S, Gerwin S, DiClaudio S, Reinmann S, Donaldson M. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. J Man Manip Ther. 2013;21:113–24. doi: 10.1179/2042618612Y.0000000025. [PMC free article] [PubMed] [Cross Ref]
39. Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. 2012;13:351–9. doi: 10.1007/s10194-012-0436-7. [PMC free article] [PubMed] [Cross Ref]
40. Chaibi A, Russell MB. Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. J Headache Pain. 2014;15:67. doi: 10.1186/1129-2377-15-67. [PMC free article] [PubMed] [Cross Ref]
41. Mesa-Jiménez JA, Lozano-López C, Angulo-Díaz-Parreño S, Rodríguez-Fernández ÁL, De-la-Hoz-Aizpurua JL, Fernández-de-las-Peñas C. Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials. Cephalalgia. 2015;35:1323–32. doi: 10.1177/0333102415576226. [PubMed] [Cross Ref]
42. Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW. Critical appraisal of the health research literature prevalence or incidence of a health problem. Chronic Dis Inj Can. 1998;19:170. [PubMed]
43. Fejer R, Kyvik KO, Hartvigsen J. The Prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine. 2006;15:834–48. doi: 10.1007/s00586-004-0864-4. [PMC free article] [PubMed] [Cross Ref]
44. Bishop F, Prescott P, Chan Y, Saville J, von Elm E, Lewith G. Complementary medicine use by men with prostate cancer: a systematic review of prevalence studies. Prostate Cancer Prostatic Dis. 2011;14:1–13. doi: 10.1038/pcan.2010.38. [PubMed] [Cross Ref]
45. Adams J, Barbery G, Lui C-W. Complementary and alternative medicine use for headache and migraine: a critical review of the literature. Headache. 2013;53:459–73. doi: 10.1111/j.1526-4610.2012.02271.x. [PubMed] [Cross Ref]
46. Adams J, Chi-Wai L, Sibbritt D, Broom A, Wardle J, Homer C. Attitudes and referral practices of maternity care professionals with regard to complementary and alternative medicine: an integrative review. J Adv Nurs. 2011;67:472–83. doi: 10.1111/j.1365-2648.2010.05510.x. [PubMed] [Cross Ref]
47. Solomon D, Adams J. The use of complementary and alternative medicine in adults with depressive disorders. A critical integrative review. J Affect Disord. 2015;179:101–13. doi: 10.1016/j.jad.2015.03.031. [PubMed] [Cross Ref]
48. Vuković V, Plavec D, Lovrencić Huzjan A, Budisić M, Demarin V. Treatment of migraine and tension-type headache in Croatia. J Headache Pain. 2010;11:227–34. doi: 10.1007/s10194-010-0200-9. [PMC free article] [PubMed] [Cross Ref]
49. Cooke LJ, Becker WJ. Migraine prevalence, treatment and impact: the canadian women and migraine study. Can J Neurol Sci. 2010;37:580–7. doi: 10.1017/S0317167100010738. [PubMed] [Cross Ref]
50. Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alternative medicine use among adults with migraines/severe headaches. Headache. 2011;51:1087–97. doi: 10.1111/j.1526-4610.2011.01917.x. [PMC free article] [PubMed] [Cross Ref]
51. Wells RE, Phillips RS, Schachter SC, McCarthy EP. Complementary and alternative medicine use among US adults with common neurological conditions. J Neurol. 2010;257:1822–31. doi: 10.1007/s00415-010-5616-2. [PMC free article] [PubMed] [Cross Ref]
52. Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Secular changes in health care utilization and work absence for migraine and tension-type headache: a population based study. Eur J Epidemiol. 2005;20:1007–14. doi: 10.1007/s10654-005-3778-5. [PubMed] [Cross Ref]
53. Rossi P, Di Lorenzo G, Malpezzi MG, Faroni J, Cesarino F, Di Lorenzo C, Nappi G. Prevalence, pattern and predictors of use of complementary and alternative medicine (CAM) in migraine patients attending a headache clinic in Italy. Cephalalgia. 2005;25:493–506. doi: 10.1111/j.1468-2982.2005.00898.x. [PubMed] [Cross Ref]
54. Minen MT, Seng EK, Holroyd KA. Influence of family psychiatric and headache history on migraine-related health care utilization. Headache. 2014;54:485–92. doi: 10.1111/head.12300. [PubMed] [Cross Ref]
55. Xue C, Zhang A, Lin V, Myers R, Polus B, Story D. Acupuncture, chiropractic and osteopathy use in Australia: a national population survey. BMC Public Health. 2008;8:105. doi: 10.1186/1471-2458-8-105. [PMC free article] [PubMed] [Cross Ref]
56. Gaumer G. Factors associated with patient satisfaction with chiropractic care: survey and review of the literature. J Manipulative Physiol Ther. 2006;29:455–62. doi: 10.1016/j.jmpt.2006.06.013. [PubMed] [Cross Ref]
57. Ndetan HT, Bae S, Evans MW, Jr, Rupert RL, Singh KP. Characterization of health status and modifiable risk behavior among United States adults using chiropractic care as compared with general medical care. J Manipulative Physiol Ther. 2009;32:414–22. doi: 10.1016/j.jmpt.2009.06.012. [PubMed] [Cross Ref]
58. Rossi P, Di Lorenzo G, Faroni J, Malpezzi MG, Cesarino F, Nappi G. Use of complementary and alternative medicine by patients with chronic tension-type headache: results of a headache clinic survey. Headache. 2006;46:622–31. doi: 10.1111/j.1526-4610.2006.00412.x. [PubMed] [Cross Ref]
59. Rossi P, Torelli P, Di Lorenzo C, Sances G, Manzoni GC, Tassorelli C, Nappi G. Use of complementary and alternative medicine by patients with cluster headache: results of a multi-centre headache clinic survey. Complement Ther Med. 2008;16:220–7. doi: 10.1016/j.ctim.2007.05.002. [PubMed] [Cross Ref]
60. Ossendorf A, Schulte E, Hermann K, Hagmeister H, Schenk M, Kopf A, Schuh-Hofer S, Willich SN, Berghöfer A. Use of complementary medicine in patients with chronic pain. Eur J Integrative Med. 2009;1:93–8. doi: 10.1016/j.eujim.2009.05.002. [Cross Ref]
61. Brown BT, Bonello R, Fernandez-Caamano R, Eaton S, Graham PL, Green H. Consumer characteristics and perceptions of chiropractic and chiropractic services in Australia: results from a cross-sectional survey. J Manipulative Physiol Ther. 2014;37:219–29. doi: 10.1016/j.jmpt.2014.01.001. [PubMed] [Cross Ref]
62. Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Davis RB, Cramer E, Milliman B, Booker J, et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. J Am Board Fam Med. 2002;15:463–72. [PubMed]
63. Jackson P. Summary of the 2000 ACA professional survey on chiropractic practice. J Am Chiro Assn. 2001;38:27–30.
64. French S, Charity M, Forsdike K, Gunn J, Polus B, Walker B. Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice. Med J Aust. 2013;10:687–91. [PubMed]
65. Ailliet L, Rubinstein SM, de Vet HCW. Characteristics of chiropractors and their patients in Belgium. J Manipulative Physiol Ther. 2010;33:618–25. doi: 10.1016/j.jmpt.2010.08.011. [PubMed] [Cross Ref]
66. Coulter I, Hurwitz E, Adams A, Genovese B, Hays R, Shekelle P. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine (Phila Pa 1976) 2002;27:291–8. doi: 10.1097/00007632-200202010-00018. [PubMed] [Cross Ref]
67. Rubinstein S, Pfeifle CE, van Tulder MW, Assendelft WJJ. Chiropractic patients in the Netherlands: A descriptive study. J Manipulative Physiol Ther. 2000;23:557–63. doi: 10.1067/mmt.2000.109675. [PubMed] [Cross Ref]
68. Hartvigsen J, Bolding-Jensen O, Hviid H, Grunnet-Nilsson N. Danish chiropractic patients then and now—a comparison between 1962 and 1999. J Manipulative Physiol Ther. 2003;26:65–9. doi: 10.1067/mmt.2003.14. [PubMed] [Cross Ref]
69. Brown B, Bonello R, Fernandez-Caamano R, Graham P, Eaton S, Green H. Chiropractic in Australia : a survey of the general public. Chiropractic J Aust. 2013;43:85–92.
70. Gaul C, Eismann R, Schmidt T, May A, Leinisch E, Wieser T, Evers S, Henkel K, Franz G, Zierz S. Use of complementary and alternative medicine in patients suffering from primary headache disorders. Cephalalgia. 2009;29:1069–78. doi: 10.1111/j.1468-2982.2009.01841.x. [PubMed] [Cross Ref]
71. Malone CD, Bhowmick A, Wachholtz AB. Migraine: treatments, comorbidities, and quality of life, in the USA. J Pain Res. 2015;8:537–47. doi: 10.2147/JPR.S88207. [PMC free article] [PubMed] [Cross Ref]
72. Gaul C, Schmidt T, Czaja E, Eismann R, Zierz S. Attitudes towards complementary and alternative medicine in chronic pain syndromes: a questionnaire-based comparison between primary headache and low back pain. BMC Complement Altern Med. 2011;11:1–8. doi: 10.1186/1472-6882-11-89. [PMC free article] [PubMed] [Cross Ref]
73. Karakurum Goksel B, Coskun O, Ucler S, Karatas M, Ozge A, Ozkan S. Use of complementary and alternative medicine by a sample of Turkish primary headache patients. Agri Dergisi. 2014;26:1–7. [PubMed]
74. Morin C, Aubin A. Primary reasons for osteopathic consultation: a prospective survey in quebec. PLoS One. 2014;9:e106259. doi: 10.1371/journal.pone.0106259. [PMC free article] [PubMed] [Cross Ref]
75. Orrock PJ. Profile of members of the Australian osteopathic association: part 2 – the patients. Int J Osteopath Med. 2009;12:128–39. doi: 10.1016/j.ijosm.2009.06.001. [Cross Ref]
76. Bethell C, Kemper KJ, Gombojav N, Koch TK. Complementary and conventional medicine use among youth with recurrent headaches. Pediatrics. 2013;132:e1173–e83. doi: 10.1542/peds.2013-1816. [PMC free article] [PubMed] [Cross Ref]
77. Lambert TD, Morrison KE, Edwards J, Clarke CE. The use of complementary and alternative medicine by patients attending a UK headache clinic. Complement Ther Med. 2010;18:128–34. doi: 10.1016/j.ctim.2010.05.035. [PubMed] [Cross Ref]
78. von Peter S, Ting W, Scrivani S, Korkin E, Okvat H, Gross M, Oz C, Balmaceda C. Survey on the use of complementary and alternative medicine among patients with headache syndromes. Cephalalgia. 2002;22:395–400. doi: 10.1046/j.1468-2982.2002.00376.x. [PubMed] [Cross Ref]
79. Kristoffersen ES, Aaseth K, Grande RB, Lundqvist C, Russell MB. Self-reported efficacy of complementary and alternative medicine: the Akershus study of chronic headache. J Headache Pain. 2013;13:113–20. doi: 10.1007/s10194-011-0391-8. [PMC free article] [PubMed] [Cross Ref]
80. Sobri M, Lamont A, Alias N, Win M. Red flags in patients presenting with headache: clinical indications for neuroimaging. Br J Radiol. 2014;76(908):532–35. [PubMed]
81. Carville S, Padhi S, Reason T, Underwood M, Group GD. Diagnosis and management of headaches in young people and adults: summary of NICE guidance. BMJ. 2012;345:e5765. doi: 10.1136/bmj.e5765. [PubMed] [Cross Ref]
82. Puentedura EJ, March J, Anders J, Perez A, Landers MR, Wallmann HW, Cleland JA. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? a review of 134 case reports. J Man Manip Ther. 2012;20:66–74. doi: 10.1179/2042618611Y.0000000022. [PMC free article] [PubMed] [Cross Ref]
83. Becker C, Brobert GP, Almqvist PM, Johansson S, Jick SS, Meier CR. Migraine incidence, comorbidity and health resource utilization in the UK. Cephalalgia (Wiley-Blackwell) 2008;28:57–64. doi: 10.1111/j.1468-2982.2007.01469.x. [PubMed] [Cross Ref]
84. Brandes JL. Global trends in migraine care: results from the MAZE survey. CNS Drugs. 2002;16:13–8. doi: 10.2165/00023210-200216001-00003. [PubMed] [Cross Ref]
85. Radtke A, Neuhauser H. Prevalence and burden of headache and migraine in Germany. Headache. 2009;49:79–89. doi: 10.1111/j.1526-4610.2008.01263.x. [PubMed] [Cross Ref]
86. Zeeberg P, Olesen J, Jensen R. Efficacy of multidisciplinary treatment in a tertiary referral headache centre. Cephalalgia (Wiley-Blackwell) 2005;25:1159–67. doi: 10.1111/j.1468-2982.2005.00980.x. [PubMed] [Cross Ref]
87. Wallasch T-M, Angeli A, Kropp P. Outcomes of a headache-specific cross-sectional multidisciplinary treatment program. Headache. 2012;52:1094–105. doi: 10.1111/j.1526-4610.2012.02189.x. [PubMed] [Cross Ref]
88. Wallasch T-M, Hermann C. Validation of criterion-based patient assignment and treatment effectiveness of a multidisciplinary modularized managed care program for headache. J Headache Pain. 2012;13:379–87. doi: 10.1007/s10194-012-0453-6. [PMC free article] [PubMed] [Cross Ref]
89. Gaul C, Visscher CM, Bhola R, Sorbi MJ, Galli F, Rasmussen AV, Jensen R. Team players against headache: multidisciplinary treatment of primary headaches and medication overuse headache. J Headache Pain. 2011;12:511–9. doi: 10.1007/s10194-011-0364-y. [PMC free article] [PubMed] [Cross Ref]
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References
1. Dartmouth Atlas Working Group. Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospital Association Press; 2000.
2. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine. 1983;8:131–40. [PubMed]
3. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine. 1996;21:1777–86. [PubMed]
4. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245–56. [PubMed]
5. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. Jama. 2006;296:2451–9. [PMC free article] [PubMed]
6. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. Jama. 2006;296:2441–50. [PMC free article] [PubMed]
7. Birkmeyer NJ, Weinstein JN, Tosteson AN, et al. Design of the Spine Patient outcomes Research Trial (SPORT) Spine. 2002;27:1361–72. [PMC free article] [PubMed]
8. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT) Spine (Phila Pa 1976) 2008;33:2789–800. [PMC free article] [PubMed]
9. Delamarter R, McCullough J. Microdiscectomy & Microsurgical Laminotomies. In: Frymoyer J, editor. The Adult Spine: Principles and Practice. 2. Philadelphia: Lippincott-Raven Publishers; 1996.
10. McHorney CA, Ware JE, Jr, Lu JF, et al. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40–66. [PubMed]
11. Daltroy LH, Cats-Baril WL, Katz JN, et al. The North American Spine Society lumbar spine outcome assessment Instrument: reliability and validity tests. Spine. 1996;21:741–9. [PubMed]
12. Deyo RA, Diehl AK. Patient satisfaction with medical care for low-back pain. Spine. 1986;11:28–30. [PubMed]
13. Atlas SJ, Deyo RA, Patrick DL, et al. The Quebec Task Force classification for Spinal Disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis. Spine. 1996;21:2885–92. [PubMed]
14. Patrick DL, Deyo RA, Atlas SJ, et al. Assessing health-related quality of life in patients with sciatica. Spine. 1995;20:1899–908. discussion 909. [PubMed]
15. Fitzmaurice G, Laird N, Ware J. Applied Longitudinal Analysis. Philadelphia, PA: John Wiley & Sons; 2004.
16. Diggle PJ, Liang K-Y, Zeger SL. Analysis of Longitudinal Data. Oxford, England, UK: Oxford University Press; 1994.
17. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. Journal of the American Statistical Association. 1958;53:457–81.
18. Peto R, Peto J. Asymptotically Efficient Rank Invariant Test Procedures. Journal of the Royal Statistical Society Series a-General. 1972;135:185.
19. Meinert CL. Clinical Trials: Design, Conduct, and Analysis. New York, NY: Oxford University Press, Inc; 1986.
20. Peul WC, van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. Bmj. 2008;336:1355–8. [PMC free article] [PubMed]
21. Atlas SJ, Keller RB, Chang Y, et al. Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study. Spine. 2001;26:1179–87. [PubMed]
22. Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine. 2005;30:927–35. [PubMed]
23. Sitlani CM, Heagerty PJ, Blood EA, et al. Longitudinal structural mixed models for the analysis of surgical trials with noncompliance. Statistics in medicine. 2012;31:1738–60. [PMC free article] [PubMed]
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Migraine and Cervical Disc Herniation Treatment In El Paso, TX Chiropractor

Migraine and Cervical Disc Herniation Treatment In El Paso, TX Chiropractor

Migraine is a debilitating condition characterized by a headache of varying intensity, often accompanied by nausea and sensitivity to light and sound. While researchers today still don’t understand the true reason behind this primary headache disorder, many healthcare professionals believe a misalignment of the cervical spine can lead to migraine. However, new evidence-based research studies have determined that cervical disc herniation, a health issue associated with the intervertebral discs of the upper spine, may also cause head pain. The purpose of the following article is to educate patients and help them understand the source of their symptoms as well as to demonstrate several types of treatment effective for migraine and cervical disc herniation.

 

Manual Therapies for Primary Chronic Headaches: a Systematic Review of Randomized Controlled Trials

 

Abstract

 

This is to our knowledge the first systematic review regarding the efficacy of manual therapy randomized clinical trials (RCT) for primary chronic headaches. A comprehensive English literature search on CINHAL, Cochrane, Medline, Ovid and PubMed identified 6 RCTs all investigating chronic tension-type headache (CTTH). One study applied massage therapy and five studies applied physiotherapy. Four studies were considered to be of good methodological quality by the PEDro scale. All studies were pragmatic or used no treatment as a control group, and only two studies avoided co-intervention, which may lead to possible bias and makes interpretation of the results more difficult. The RCTs suggest that massage and physiotherapy are effective treatment options in the management of CTTH. One of the RCTs showed that physiotherapy reduced headache frequency and intensity statistical significant better than usual care by the general practitioner. The efficacy of physiotherapy at post-treatment and at 6 months follow-up equals the efficacy of tricyclic antidepressants. Effect size of physiotherapy was up to 0.62. Future manual therapy RCTs are requested addressing the efficacy in chronic migraine with and without medication overuse. Future RCTs on headache should adhere to the International Headache Society’s guidelines for clinical trials, i.e. frequency as primary end-point, while duration and intensity should be secondary end-point, avoid co-intervention, includes sufficient sample size and follow-up period for at least 6 months.

 

Keywords: Randomized clinical trials, Primary chronic headache, Manual therapies, Massage, Physiotherapy, Chiropractic

 

Introduction

 

Primary chronic headaches i.e. chronic migraine (CM), chronic tension-type headache (CTTH) and chronic cluster headache has significant health, economic and social costs. About 3% of the general population suffers from chronic headache with female predominance [1]. The International Classification of Headache Disorders III β (ICDH-III β) defines CM as ≥15 headache days/month for at least 3 months with features of migraine in ≥8 days/month, CTTH is defined as on average ≥15 days/month with tension-type headache for at least 3 months, and chronic cluster headache as attacks at least every other day for more than 1 year without remission, or with remissions lasting <1 month [2].

 

About 80% consult their primary physician for primary chronic headache [3], and pharmacological management is considered first line of treatment. However, the risk is that it may cause overuse of acute headache medication due to frequent headache attacks. 47% of those with primary chronic headache in the general Norwegian population overused acute headache medication [1,4]. Considering the high use of acute medication, both prophylactic medication and non-pharmacological management should therefore be considered in the management [5,6]. Prophylactic medication is used only by 3% in the general Norwegian population, while 52% have tried physiotherapy and 28% have tried chiropractic spinal manipulative therapy [3]. Non-pharmacological management has furthermore the advantage of few and usually minor transient adverse events and no pharmacological interaction/adverse event [7].

 

Previous systematic reviews have focused on RCTs for tension-type headache, migraine and/or cervicogenic headache, but not on efficacy on primary chronic headache [5,6,8-11]. Manual therapy is a physical treatment used by physiotherapists, chiropractors, osteopaths and other practitioners to treat musculoskeletal pain and disability, and includes massage therapy, joint mobilization and manipulation [12].

 

This is to our knowledge the first systematic review assessing the efficacy of manual therapy randomized controlled trials (RCT) for primary chronic headache using headache frequency as primary end-point and headache duration and intensity as secondary end-points.

 

Review

 

Methods

 

The English literature search was done on CINHAL, Cochrane, Medline, Ovid and PubMed. Search words were; migraine, chronic migraine, tension-type headache, chronic tension-type headache, cluster headache, chronic cluster headache combined with the words; massage therapy, physiotherapy, spinal mobilization, manipulative therapy, spinal manipulative therapy, osteopathic treatment or chiropractic. We identified studies by a comprehensive computerized search. Relevant reviews were screened for additional relevant RCTs. The selection of articles was performed by the authors. All RCTs written in English using either of the manual therapies for CM, CTTH and/or chronic cluster headache were evaluated. Studies including combined headache types without specific results for CM, CTTH and/or chronic cluster headache were excluded. The review included manual therapy RCTs presenting at least one of the following efficacy parameters; headache frequency, duration and pain intensity for CM, CTTH and/or chronic cluster headache as recommended by the International Headache Society’s clinical trial guidelines [13,14]. Headache frequency is a primary end-point, while duration and pain intensity are secondary end-points. Headache diagnoses were preferentially classified according to the criteria of ICHD-III β or previous editions [2,15-17]. The methodological quality of the included RCTs was evaluated using the PEDro scale, Table 1[18]. A RCT was considered to be of high quality if the PEDro score was ≥6 of a maximum score of 10. The methodological quality of the RCTs was assessed by AC. The PRISMA 2009 checklist was applied for this systematic review. Effect size was calculated when possible. Effect size of 0.2 was regarded as small, 0.5 as medium and 0.8 as large [19].

 

Table-1-PEDro-Score-Yes-or-No-Items.png

Table 1: PEDro score yes or no items.

 

This systematic review was executed directly based on the ascertained RCTs available and has not been registered as a review protocol.

 

Results

 

The literature search identified six RCTs that met our inclusion criteria. One study applied massage therapy (MT) and five studies applied physiotherapy (PT) [20-25]. All studies assessed CTTH, while no studies assessed CM or chronic cluster headache.

 

Methodological quality Table 2 shows that the methodological PEDro score of the included RCTs ranged from 1 to 8 points. Four RCTs were considered of good methodological quality, while two RCTs had lower scores.

 

Table 2 The Methodological PEDro Score of the Included RCTs

Table 2: The methodological PEDro score of the included randomized controlled trials (RCTs).

 

Randomized controlled trials (RCT) Table 3 shows the study population, intervention and efficacy of the six RCTs.

 

Table 3 Results of Manual Therapy RCTs of CTTH

Table 3: Results of manual therapy randomized controlled trials (RCTs) of chronic tension-type headache (CTTH).

 

Massage therapy A Spanish physiotherapist conducted a 2-armed prospective crossover RCT with pairwise comparisons and blinded outcome measures [20]. The study included participants with CTTH diagnosed by a neurologist. The ICHD-II criteria for CTTH were slightly modified, i.e. pain intensity was defined as ≤5 on a 0-10 numeric pain rating scale, and the accompanying symptoms photophobia, phonophobia or mild nausea was not allowed [16]. Primary and secondary end-points were not specified. Results are shown in Table 3.

 

Physiotherapy An American 3-armed retrospectively RCT had unblinded outcome measures [21]. The diagnostic criteria were ≥25 headache days/month for >6 months without associated symptoms nausea, vomiting, photo- and phonophobia, but with tender muscles, i.e. CTTH with pericranial tenderness. Participants with cervicogenic headache or neurological findings were excluded. Primary and secondary end-points were not pre-specified, but headache index, defined here as headache frequency × severity, was the evaluated end-point.

 

A Turkish study conducted a 2-armed prospective RCT with unblinded outcome measures [22]. The participants were diagnosed with CTTH according to ICHD-I [15]. Participants with mixed headache, neurological and systemic aliment, or participants whom had received physiotherapy within 6 months prior to the study were excluded. Primary end-points was headache index defined as frequency × severity.

 

A Danish study conducted a 2-armed prospective RCT with blinded outcome measures [23]. Participants were diagnosed CTTH by a neurologist according to the criteria of ICHD-I [15]. Participants with other primary headaches, neuralgia, neurological, systemic or psychiatric disorders or medication overuse defined as >100 analgesic tablets or >2 doses of triptans and ergotamine per month were excluded. The primary end-point was headache frequency, and the secondary end-points were headache duration and intensity. The results shown in Table 3 were not influenced by pericranial muscles tenderness.

 

A Dutch study conducted a 2-armed prospective, multicentre RCT with blinded outcome measures [24]. Participants were diagnosed with CTTH by a physician according to ICHD-I [15]. Participants with multiple headache types or those whom had received physiotherapy within the last 6 months were excluded. Primary end-points were headache frequency while duration and intensity were secondary end-points.

 

The 2nd Dutch study conducted a 2-armed prospective pragmatic, multicentre RCT with self-reported primary and secondary end-points, i.e. headache frequency, duration and intensity [25]. Participants were diagnosed by a physician according to the criteria of ICHD-II [16]. Participants with rheumatoid arthritis, suspected malignancy, pregnancy, non-Dutch speaking, those whom had received physiotherapy within the last 2 months, triptan, ergotamine or opiods users were excluded.

 

Discussion

 

The current systematic review evaluating the efficacy of manual therapy in RCTs for primary chronic headaches only identified RCTs treating CTTH. Thus, the efficacy of CM and chronic cluster headache could not be evaluated in this review.

 

Methodological considerations The methodological quality of studies assessing manual therapies for headache disorders are frequently being criticised for being too low. Occasionally rightly so, but often do the methodological design prevent manual therapy studies from reaching what is considered gold standard in pharmacological RCTs. For instance, a placebo treatment is difficult to establish while the investigator cannot be blinded for its applied intervention. The average score of the included studies was 5.8 (SD 2.6) points and four studies were considered of good quality. All RCTs failed to include sample size ≥50 in the smallest group. Sufficient sample size with power calculation prior is important to confine type 2 errors. Three studies did not state primary and secondary end-points, which confound effect-size calculation, and risk of type 2 errors inferred from multiple measures [20-22]. Conducting a manual therapy RCT is both time and cost consuming, while blinding often is difficult as there is no single validated standardized sham-treatment which can be used as a control group to this date. Thus, all of the included studies were pragmatic or used no treatment as a control group.

 

Apart from the participants in the retrospective study [21], all participants were diagnosed by a physician or neurologist. A diagnostic interview is the gold standard, while questionnaire and lay interviews are less precise diagnostic tools regarding headache disorders [26].

 

Co-intervention was only avoided in two studies [22,20]. Two studies performed intention-to-treat analysis which is recommended to protect against odd outcome values and preserve baseline comparability [24,25,27].

 

Results The massage therapy study included only 11 participants, but the massage group had significantly more reduction in their headache intensity than detuned ultrasound group [20].

 

54%, 82% and 85% of the participants in three of the physiotherapy RCTs had a ≥50% reduction in headache frequency post-treatment [23-25], and the effect was maintained in the two studies that had a 6 months follow-up [24,25]. This is comparable with the 40-70% of participants whom have a similar effect using tricyclic antidepressants [28,29]. The effect of tricyclic also seems to improve over time, i.e. after more than 6 months treatment [29]. However, tricyclic antidepressants have a series of side effects in contrast to physiotherapy, while manual therapy requires more consultations. Two studies assessed headache index defined as headache frequency × intensity [21,22]. Both studies showed a significant improvement post-treatment and at 1 month and 6 months follow-up respectively.

 

Four of the studies reported 10.1 mean years with headache, thus, the effect observed is likely to be due to the therapeutic effect rather than spontaneous improvement or regression to the mean [21-23,25].

 

Acute headache medication is frequently used for primary headaches, and if the headache frequency increases, there is an increased risk for medication overuse headache. Increased use of prophylactic medication has thus been suggested in the management for primary chronic headaches [3]. Since manual therapies seems to have a beneficial effect that equals the effect of prophylactic medication [28,29], without the pharmacological side effects, manual therapies should be considered on an equal level as pharmacological management strategies.

 

Effect size could be calculated in three of the six RCTs. Effect size on headache frequency was up to 0.62, while it was less regarding duration and intensity, while headache index (frequency × intensity) was up to 0.37 (Table 3). Thus, a small to moderate effect size might however, be substantial to the individual, especially considering that nearly daily headache i.e. mean 12/14 days reduced to mean 3/14 days [25], which equals ≥75% reduction in headache frequency. Usually a ≥50% reduction is traditionally used in pain trails, but considering the fact that CTTH is difficult to treat, some investigators operate with ≥30% improvement of primary efficacy parameter compared with placebo [30].

 

Limitations The present study might have possible biases. One of them being publication bias as the authors made no attempt to identify unpublished RCTs. Although we did perform a comprehensive search, we acknowledge it is possible to miss a single or few RCT, especially non-English RCT.

 

Conclusion

 

Manual therapy has an efficacy in the management of CTTH that equals prophylactic medication with tricyclic antidepressant. At present no manual therapy studies exist for chronic migraine or chronic cluster headache. Future manual therapy RCTs on primary chronic headache should adhere to the recommendation of the International Headache Society, i.e. primary end point is headache frequency and secondary end-points are duration and intensity. Future manual therapy studies on CM with and without medication overuse is also warranted, since such studies do not exist today.

 

Competing Interests

 

The authors declare that they have no competing interests.

 

Authors’ Contributions

 

AC prepared the initial draft and performed the methodological assessment of the included studies. MBR had the original idea of the study, planned the overall design and revised the drafted manuscript. Both authors have read and approved the final manuscript.

 

Authors’ Information

 

Aleksander Chaibi is a BPT, MChiro, PhD student and Michael Bjørn Russell is a professor, MD, PhD, DrMedSci.

 

Acknowledgements

 

Akershus University Hospital, Norway, kindly provided research facilities.

 

Funding: The study received funding from Extrastiftelsen, the Norwegian Chiropractic Association in Norway and University of Oslo.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Cervical disc herniation is a common condition which occurs when an intervertebral disc in the neck, or cervical spine, ruptures and its soft, gel-like center leaks out into the spinal canal, adding pressure to the nerve roots. Cervical herniated discs can cause symptoms of pain, numbness and weakness in the neck, shoulders, chest, arms and hands as well as radiating symptoms along the lower extremities. Migraine can also be a symptoms associated with herniated discs in the neck. As we age, the intervertebral discs naturally begin to degenerate, making them more susceptible to damage or injury. Common causes of cervical disc herniation include wear and tear, repetitive movements, improper lifting, injury, obesity and genetics.

 

Long Term Follow-Up of Cervical Intervertebral Disc Herniation in Patients Treated with Integrated Complementary and Alternative Medicine: a Prospective Case Series Observational Study

 

Abstract

 

Background

 

Symptomatic cervical intervertebral disc herniation (IDH) presenting as neck pain accompanied by arm pain is a common affliction whose prevalence continues to rise, and is a frequent reason for integrative inpatient care using complementary and alternative medicine (CAM) in Korea. However, studies on its long term effects are scarce.

 

Methods

 

A total 165 patients with cervical IDH admitted between January 2011 and September 2014 to a hospital that provides conventional and Korean medicine integrative treatment with CAM as the main modality were observed in a prospective observational study. Patients underwent CAM treatment administered by Korean medicine doctors (KMDs) in accordance with a predetermined protocol for the length of hospital stay, and additional conventional treatment by medical doctors (MDs) as referred by KMDs. Short term outcomes were assessed at discharge and long term follow-ups were conducted through phone interviews after discharge. Numeric rating scale (NRS) of neck and radiating arm pain, neck disability index (NDI), 5-point patient global impression of change (PGIC), and factors influencing long term satisfaction rates in PGIC were assessed.

 

Results

 

Of 165 patients who received inpatient treatment 20.8 ± 11.2 days, 117 completed the long term follow-up up at 625.36 ± 196.7 days post-admission. Difference in NRS between admission and discharge in the long term follow-up group (n = 117) was 2.71 (95 % CI, 2.33, 3.09) for neck pain, 2.33 (95 % CI, 1.9, 2.77) for arm pain, and that of NDI 14.6 (95 % CI, 11.89, 17.32), and corresponding scores in the non-long term follow-up group (n = 48) were 2.83 (95 % CI, 2.22, 3.45) for neck pain, 2.48 (95 % CI, 1.84, 3.12) for arm pain, and that of NDI was 14.86 (95 % CI, 10.41, 19.3). Difference in long term NRS of neck pain and arm pain from baseline was 3.15 (95 % CI, 2.67, 3.64), and 2.64 (95 % CI, 1.99, 3.29), respectively. PGIC was reported to be “satisfactory” or higher in 79.5 % of patients at long term follow-up.

 

Conclusions

 

Though the observational nature of this study limits us from drawing a more decisive conclusion, these results suggest that integrative treatment focused on CAM in cervical IDH inpatients may achieve favorable results in pain and functional improvement.

 

Trial Registration

 

ClinicalTrials.gov Identifier: NCT02257723. Registered October 2, 2014.

 

Keywords: Cervical intervertebral disc herniation, Complementary and alternative medicine, Integrative treatment, Inpatient treatment

 

Background

 

Neck pain is a common compliant whose point prevalence is estimated at 10–18 %, with lifetime prevalence reaching 30–50 %. Prevalence of neck pain in populations aged 40 or older is approximately 20 % [1, 2]. Neck pain is also related with restricted neck movement [3], and frequently accompanied by headache, dizziness, visual impairment, tinnitus, and autonomic nervous system dysfunction [4, 5]. Frequent concurrent symptoms include upper extremity pain and neurological disorders [6], and neck pain symptoms also persist in many cases leading to work loss due to discomfort [7]. Neck-related disability is generally more serious in patients with radiating pain than pain limited to the neck area [8, 9], and the main characteristic of cervical intervertebral disc herniation (IDH) is arm pain in the region innervated at the herniated disc level and/or compressed nerve root [10, 11].

 

The range of available treatments for cervical IDH is vast, spanning conservative treatments to various surgical modalities. Conservative treatments include NSAIDs, oral steroids, steroid injections, patient education, rest, Thomas collars, and physical therapy [12–14]. Surgical treatment may be considered when conservative treatment fails. Neuropathy from spinal cord compression is an absolute indication for surgery. Other indications include nerve root compression signs and related motor and sensory loss. Relative indications may involve decreased quality of life due to prolonged chronic pain [15]. While surgical treatment may benefit some patients suffering severe neurological symptoms, most studies on neuropathic pain of the spine state that the long term effects are not significant [16–20]. Although studies on the effect of conservative treatment in cervical IDH patients have occasionally been reported, whether it is effective is yet a matter of controversy, and there is a paucity of studies on the effect of complementary and alternative medicine (CAM) treatment.

 

According to Benefits by Frequency of Disease data from the 2013 Korean National Health Insurance Statistical Yearbook [21], 5585 patients received treatment for cervical disc disorders for 99,582 days in outpatient care, of which 100,205 days were covered by the National Health Insurance, and medical treatment expenses eligible for reimbursement surmounted to 5,370,217 Korean Won, with 4,004,731 Korean Won reimbursed. Cervical disc disorders was the 12th most frequent reason for admission to Korean medicine hospitals, showing that it is not uncommon to receive inpatient care for cervical IDH.

 

Such CAM treatments as acupuncture, pharmacopuncture, herbal medicine, and manual therapy are well-sought in Korea to the aim of securing a less invasive, non-surgical method of treatment. Jaseng Hospital of Korean medicine, a Korean medicine hospital accredited by the Korean Ministry of Health and Welfare to specialize in spine disorders, treats over 900,000 spinal disease outpatient cases per year. This hospital manages patients with an integrative system utilizing conventional and Korean medicine, where conventional doctors and Korean medicine doctors (KMDs) cooperate for optimal treatment results. Conventional doctors participate in diagnosis using imaging technology such as X-rays and MRIs, and in treatment by caring for a small percentage of patients potentially in need of more intensive care. KMDs supervise and manage the main treatment of all patients, and decide whether the patient requires additional diagnosis and treatment from a conventional doctor. Cervical IDH patients suffering neck pain or radiating pain unable to receive outpatient treatment are thus provided with concentrated non-surgical integrative treatment during admission.

 

Despite the widespread use of inpatient treatment for cervical IDH encompassing a number of treatment modalities, studies on its treatment effect in patients admitted for cervical IDH are scarce. An integrative inpatient treatment approach with focus on CAM may not be widely available to patients, and the objective of this study is to introduce and assess the feasibility and long term effect of this integrative treatment model in inpatients with cervical IDH using a practical study design.

 

Methods

 

Study Design

 

This study is a prospective observational study. We observed patients with a main complaint of neck pain or radiating arm pain diagnosed as cervical IDH and admitted from January 2011 to September 2014 at Jaseng Hospital of Korean medicine in Korea which provides integrated conventional and Korean medicine services with CAM as the main modality. The authors conducted a long term follow-up by phone interview during March 2015. Outcome measures covered 5 parts: numeric rating scale (NRS), neck disability index (NDI), patient global impression of change (PGIC), ever-surgery after discharge, and current treatment.

 

This study is a report on part of a registry collecting prospective data on integrated treatment for musculoskeletal disorder patients (ClinicalTrials.gov Identifier: NCT02257723). The study protocol was approved by the Institutional Review Boards of Jaseng Hospital of Korean medicine. All participants gave written informed consent prior to participation.

 

Participants

 

Patients meeting the following criteria were included.

 

  1. Admission for treatment of neck pain or radiating arm pain
  2. Cervical IDH confirmed on MRI
  3. Diagnosis by KMD that main cause of chief complaint (neck pain or radiating pain) is cervical IDH

 

Patients meeting the following criteria were excluded.

 

  1. Main complaint other than neck pain or radiating pain
  2. Concomitant musculoskeletal complaint (e.g. low back pain, knee pain)
  3. Cause of neck pain unrelated to cervical IDH (e.g. spinal tumor, pregnancy, rheumatoid arthritis)
  4. Refusal to participate in the study or nonagreement to collection and disclosure of personal information for study purposes

 

KMDs assessed the cause of current neck pain or arm pain symptoms with reference to neurological test results (sensory loss, motor weakness, and tendon reflex) and MRI readings by radiology specialists. Patients who met the proposed inclusion criteria were visited at the inpatient ward on the first day of admission for assessment by a KMD, and followed up using a similar interview and survey process upon discharge. If a patient was admitted multiple times during the study period, only the first admission record was appraised and included.

 

Interventions

 

Though the treatment protocol was comprised with most frequented treatments for cervical IDH patients, any and all treatment methods not included in the treatment protocol were allowed and available to all physicians and patients and use of these treatments (type and frequency) were recorded in electronic medical records pragmatically. Conventional treatments such as pain medications and epidural injections (using local anesthetics such as lidocaine, steroids, and anti-adhesion adjuvants) were administered by a conventional rehabilitation specialist through KMD referral. Only non-surgical treatments were allowed during admission.

 

Complementary and Alternative Medicine Treatment Protocol

 

Herbal medicine was taken 3 times/day in pill (2 g) and water-based decoction form (120 ml) (Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Saposhnikovia divaricata, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis, Glycine max, and Atractylodes japonica). These herbs were carefully selected from herbs frequently prescribed for IDH treatment in Traditional Chinese Medicine and Korean Medicine [22] and the prescription was further developed through clinical practice [23]. The main ingredients of the herbal medicine used in this study (Acanthopanax sessiliflorus Seem, Achyranthes japonica Nakai, Saposhnikovia divaricata Schischk, Cibotium barometz J. Smith, Glycine max Merrill, and Eucommia ulmoides Oliver) have been studied in vivo and in vitro as GCSB-5 for their anti-inflammatory [24], and nerve [25] and joint protective effects [26], and clinically for non-inferiority in safety and efficacy compared to Celecoxib in treatment of osteoarthritis [27].

 

Acupuncture was administered 1–2 sessions/day at cervical Ah-shi points and acupuncture points pertaining to neck pain. Ah-shi point acupuncture refers to acupuncture needling of painful or pathological sites. Ah-shi points do not exactly match tender points or Buding, Tianying points, but generally correspond to points that induce relaxation or pain upon palpation [28].

 

The pharmacopuncture solution was prepared with ingredients similar to the orally administered herbal medicine (Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Saposhnikovia divaricata, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis, Glycine max, and Atractylodes japonica) by decocting and freeze drying, then mixing the prepared powder with normal saline and adjusting for acidity and pH. Pharmacopuncture was administered 1 session/day at cervical Hyeopcheok (Huatuo Jiaji, EX B2) and Ah-shi points up to 1 cc using disposable injection needles (CPL, 1 cc, 26G x 1.5 syringe, Shinchang medical co. Korea).

 

Bee-venom pharmacopuncture was applied if the skin reaction test to bee-venom was negative. Diluted bee-venom solution (mixed with normal saline at a ratio of 1000:1) was injected at 4–5 cervical Hyeopcheok (Huatuo Jiaji, EX B2) and Ah-shi points at the physician’s discretion. Each point was injected with about 0.2 cc up to a total 0.5–1 cc using disposable injection needles (CPL, 1 cc, 26G x 1.5 syringe, Shinchang medical co. Korea)

 

Chuna spinal manipulation [29, 30], which is a Korean manipulation method that combines conventional manipulation techniques with high-velocity, low amplitude thrusts to joints slightly beyond the passive range of motion, and manual force within the passive range, was conducted 3–5 sessions/week.

 

Outcome Measures

 

All outcomes were assessed by KMDs who had received prior training and education. Demographic and health behavior characteristics (sex, age, occupation, smoking, alcohol consumption, and underlying disease) were collected on the first day of admission using short surveys on current pain levels and neurological exams. Follow-ups were conducted at 2 weeks post-admission or upon discharge and after discharge.

 

NRS [31] uses an 11-point scale to evaluate current neck pain and radiating pain where no pain is indicated by ‘0’, and the worst pain imaginable by ‘10’. NRS was assessed at admission, discharge, and long term follow-up. Due to lack of references on minimum clinically important difference (MCID) of neck pain or radiating pain for NRS, MCID for visual analogue scale (VAS) was used for further evaluation of NRS.

 

The NDI [32] is a 10-item survey that assesses the degree of disability from 0 to 5 in fulfilling daily activities. The total is divided by 50, then multiplied by 100. NDI was assessed at admission and discharge.

 

PGIC [33] was used to assess patient satisfaction rate of current state after admission. Satisfaction was rated with a 5-point scale ranging from very satisfactory, satisfactory, slightly satisfactory, dissatisfactory, and very dissatisfactory at discharge and long term follow-up.

 

Participants underwent physical and neurological examination at admission and discharge for objective motor and sensory evaluation of the cervical region. Range of motion (ROM) for neck flexion and extension, distraction, compression, Valsalva, Spurling, Adson’s, and swallowing tests, and upper extremity motor strength and sensory tests and deep tendon reflex tests were performed.

 

Safety Assessments

 

All potential adverse events regarding treatment, ranging from skin and local reactions to systemic reactions, and including change or aggravation in pain patterns were carefully observed, recorded and reported during admission. Adverse events associated with bee-venom therapy are known to range from skin reactions to severe immunological responses, and therefore adverse reactions including systemic immunological reactions requiring additional treatment (e.g. antihistaminic agents) were closely monitored. . Blood cell count, liver and renal function tests, and inflammatory activity tests were conducted in all patients at admission, and if there was an abnormal finding requiring follow-up as assessed by KMDs and conventional doctors, relevant markers were rechecked. A total 46 patients were judged to require follow-up at admission by KMDs and conventional doctors and were followed up accordingly during hospital stay, of which 9 patients showed abnormal findings in liver function at admission. Liver function was tracked in these nine patients. Presence of liver injury was also measured to assess possibility of drug-induced liver injury from herbal or conventional medicine intake using a definition of (a) ALT or DB increase of 2× or over the upper limit of normal (ULN) or (b) combined AST, ALP, and TB increase, provided one of them is above 2 × ULN.

 

Statistical Methods

 

All analyses were conducted using statistical package SAS version 9.3 (SAS Institute, Cary, NC, USA), and p < 0.05 was regarded to be statistically significant. Continuous data is presented as mean and standard deviation, and categorical data as frequency and percent (%). The mean difference in NRS of neck pain, NRS of radiating pain, and NDI between admission (baseline), discharge and long term follow-up was analyzed for significance with 95 % confidence intervals (CIs). Satisfaction rate assessed with a 5-point Likert scale at long term follow-up was recategorized into binary values of satisfactory (very satisfactory, or satisfactory) and dissatisfactory (slightly satisfactory, dissatisfactory, and very dissatisfactory). Multivariable logistic regression analysis was conducted to calculate odds ratios (ORs) and 95 % CIs, and estimate the influence of predictive factors on satisfaction rate. Baseline factors that met p < 0.10 in univariate analysis were included in the final model with age and sex, and factors were selected using stepwise method (p < 0.05).

 

Results

 

During the study period 784 patients with neck disorders were admitted, and of these, 234 patients were diagnosed with cervical IDH with no other major musculoskeletal complaints. Of the 234 cervical IDH patients, 175 patients had no missing values in NRS and NDI at admission and at 2 weeks post-admission or at discharge (short term follow-up). Ten patients were re-admissions and after inclusion of initial admission data if initial admission was during the study period, 165 patients remained. Long term follow-up assessments were conducted in 117 patients. In the non-long term follow-up group (n = 48), 23 patients did not answer the phone, 10 refused to participate in the long term follow-up, and 15 had since changed number or had incoming calls barred (Fig. 1). Baseline characteristics by long term follow-up group and non-long term follow-up group are listed in Table 1. Though there were no other marked differences between the 2 groups, 29 patients in the long term follow-up group had been recommended surgery (24.8 %), while only 1 patient in the non-long term follow-up group (0.02 %) had been recommended.

 

Figure 1 Flow Diagram of the Study

Figure 1: Flow Diagram of the Study

 

Table 1 Baseline Demographic Characteristics

Table 1: Baseline demographic characteristics.

 

Average length of hospital stay was 20.8 ± 11.2 days. The majority of participants received inpatient treatment focused on Korean medicine and CAM. Herbal medicine was taken in accordance with the treatment protocol in decoction form by 81.8 % of patients and in pill form in 86.1 %, and the other patients were prescribed other herbal medicines at the KMD’s discretion. In use of conventional treatments not specified in the CAM treatment protocol, 18.2 % patients took analgesic medications or intramuscular injections an average 2.7 ± 2.3 times, and 4.8 % patients were administered 1.6 ± 0.5 epidural injections during hospital stay (Table 2). We did not implement restrictions in pharmacological treatment for study purposes, and allowed conventional medicine physicians full freedom to assess and prescribe conventional medicine as the physician deemed necessary for the patient. NSAIDs, antidepressants, and muscle relaxants were the main medicines used, and opioids were administered in the short-term in only 2 patients.

 

Table 2 Length of Hospital Stay and Interventions Administered During Stay

Table 2: Length of hospital stay and interventions administered during stay.

 

NRS of neck pain, NRS of radiating pain, and NDI all decreased significantly at discharge and at long term follow-up compared to baseline (admission) (Table 3). The major site of pain of neck and radiating arm pain showed a decrease larger than MCID (NRS decrease of 2.5 or larger in neck pain or radiating pain), and NDI scores also improved over the MCID score of 7.5 [34, 35]. Difference in NRS at discharge in the long term follow-up group (n = 117) was 2.71 (95 % CI, 2.33, 3.09) for neck pain, 2.33 (95 % CI, 1.9, 2.77) for arm pain, and that of NDI, 14.6 (95 % CI, 11.89, 17.32). Difference in NRS at long term follow-up for neck pain and arm pain from baseline was 3.15 (95 % CI, 2.67, 3.64) and 2.64 (95 % CI, 1.99, 3.29), respectively. Difference in NRS at discharge in the non-long term follow-up group (n = 48) was 2.83 (95 % CI, 2.22, 3.45) for neck pain, 2.48 for arm pain (95 % CI, 1.84, 3.12), and that of NDI was 14.86 (95 % CI, 10.41, 19.3). The between-group difference in effect between admission and discharge in the long term follow-up and non-long term follow-up patients was not significant (NRS of neck pain : p-value = 0.741; NRS of radiating arm pain: p-value = 0.646; Neck disability index: p-value = 0.775).

 

Table 3 Comparison of Numeric Rating Scale, Radiating Arm Pain and Neck Disability Index Score

Table 3: Comparison of numeric rating scale for neck and radiating arm pain and neck disability index score in long term follow-up group and non-long term follow-up group.

 

The average period from admission to long term follow-up was 625.36 ± 196.7 days. All 165 patients answered the PGIC at discharge, and of these patients 84.2 % replied that their state was “satisfactory” or higher. A total 117 patients replied to PGIC at long term follow-up, and 79.5 % rated their current state to be “satisfactory” or higher. PGIC was reported to be very satisfactory in 48 patients (41.0 %), satisfactory in 45 (38.5 %), slightly satisfactory in 18 (15.4 %), and dissatisfactory in 6 (5.1 %). Nine patients had undergone surgery (7.6 %), while 21 patients replied that they were currently receiving treatment. Of patients currently under treatment, 10 patients (8.5 %) continued to receive CAM, 12 patients (10.3 %) had selected conventional treatment, and 1 patient was receiving both (Table 4).

 

Table 4 Period from Admission Date to Long Term Follow Up and Patient Global Impression of Change

Table 4: Period from admission date to long term follow-up, and patient global impression of change, ever-surgery and current treatment status in long term follow-up group.

 

Sex, age, and unilateral radiating pain satisfied p < 0.10 in univariate analysis of baseline characteristics. Satisfaction rate increased with older age in multivariate analysis. Patients with unilateral radiating arm pain tended to be more satisfied with treatment that those without radiating pain. Also, patients receiving CAM treatment showed higher satisfaction rates than patients receiving no treatment (Table 5).

 

Table 5 Assessment of Predictive Baseline Factors

Table 5: Assessment of predictive baseline factors associated with satisfaction rate.

 

Liver function was measured in all patients at admission, and nine patients with liver enzyme abnormalities at admission received follow-up blood tests at discharge. Liver enzyme levels returned to normal in 6 patients at discharge, while 2 retained liver enzyme abnormalities, and 1 patient sustained liver injury and on further assessment was diagnosed with active hepatitis showing Hbs antigen positive and Hbs antibody negative. There were no cases of systemic immunological reactions to bee venom pharmacopuncture requiring additional treatment and no other adverse events were reported.

 

Discussion

 

These results show that inpatient treatment primarily focused on CAM maintains long term effects of pain relief and functional improvement in cervical IDH patients with neck pain or radiating arm pain. NRS and NDI scores at discharge and at long term follow-up all displayed significant decrease. Also, as statistical significance and clinical significance may differ, we checked for MCID and confirmed that both NRS and NDI scores improved over MCID. MCID has been reported at 2.5 in VAS for neck pain and radiating arm pain, and 7.5 in NDI scores [34, 35]. Average improvement in pain and functionality scales all exceeded MCID, and these results are likely to be reflected in patient satisfaction rate. Out of 165 patients, 128 patients (84.2 %) rated their current state as “satisfactory” or higher at discharge. At long term follow-up, 9 (7.6 %) out of 117 patients were confirmed to have received neck surgery, and most patients showed continued decrease in NRS and NDI. In addition, 96 patients (82.1 %) currently did not receive treatment for neck pain symptoms, and 93 patients (79.5 %) replied their state was “satisfactory” or higher. As comparison of between-group difference in the long term follow-up and non-long term follow-up patients was not designed a priori, this data may be regarded to be a post hoc data analysis. The between-group difference in effect between admission and discharge in the long term follow-up and non-long term follow-up patients was not significant, and in MCID, which could be considered a more clinical measure, the 2 groups produced comparable results.

 

Despite the fact that all patients underwent intensive Korean medicine treatment for the duration of hospital stay, no adverse events related to treatment were reported, demonstrating the safety of integrative medicine with focus on CAM. The authors had previously conducted a retrospective study to assess safety of herbal medicine and combined intake of herbal and conventional medicine in liver function test results of 6894 inpatients hospitalized at Korean medicine hospitals, and test results of the cervical disc herniation patients included in the present study were also described [36].

 

A major strength of this study is that it depicts clinical practice and the results reflect treatment as it is actually practiced in Korea in conventional and Korean medicine integrative treatment settings focused on CAM. Protocol treatment was standardized and comprised of interventions whose efficacy has been confirmed in pilot studies and frequently used in clinical practice, but the protocol also allowed for individual tailoring according to patient characteristics and symptoms as seen necessary by KMDs, and the percentage and frequency of these deviations were recorded. The satisfaction rate assessed at discharge not only reflects patient attitude toward treatment effect, but also increased medical costs entailed by inclusion of various treatments. Taking into account that the participants of this study were not patients recruited through advertisements, but patients visiting a Korean medicine hospital from personal choice receiving no economic compensation for study participation, the fact that most patients’ satisfaction rate was high is particularly noteworthy. The results of this study contribute to an evidence base for superior efficacy of compositive treatment over individual treatment in patients diagnosed with cervical IDH, and verify feasibility of clinical implementation with consideration for increased compositive treatment costs.

 

The largest limitation of our study is probably the inherent quality of a prospective observational study lacking a control. We are unable to draw conclusions on whether the suggested CAM integrative treatment is superior to an active control (e.g. surgery, conventional non-surgical intervention) or the natural course of disease. Another limitation is the heterogeneity of the patient groups and treatment composition. Participants were cervical IDH patients of varying symptoms, severity and chronicity whose progress are generally known to differ, and interventions included conventional treatments such as epidural injections or pain medications in some cases. Therefore it would be more accurate to construe these results to be the effect of a conventional and Korean medicine integrative treatment system than that solely of CAM integrative treatment. The compliance rate of 74 % (n = 175) at 2 weeks post-admission or discharge out of 234 admitted patients is low, especially considering the short follow-up period. This low compliance may be related to patient attitude toward study participation. As participants did not receive direct compensation for trial participation, they may have lacked incentive to continue participation, and the possibility that patients who refused follow-up assessment were dissatisfied with admission treatment should be considered. Long term assessment was conducted by phone interview in 117 patients (70 %) out of 165 baseline participants partly due to lapse in time, which limited the amount and quality of long term information that could be gathered and led to further patient loss from loss of contact.

 

Another limitation is that we failed to conduct more comprehensive medical evaluations. For example, although participants were diagnosed as disc herniation to be the main pathology based on MRI readings and neurological symptoms by KMDs, additional imaging information such as pathological disc level and severity of herniation were not collected. Also, data on subsequent recurrences, duration of all episodes and whether some were absolutely cured were not included in long term follow-up assessments, limiting multidimensional evaluation. In addition, while these cervical IDH patients required admission for severe neck and arm pain and consequent functional disability, the fact that this was the first attack of neck pain for many may have been cause for more favorable outcome.

 

However, the influence of long term follow-up compliance may not be confined to availability but potentially be associated with long term treatment effectiveness. As difference in characteristics of long term follow-up and non-long term follow-up patients may be reflected in short-term outcomes assessed at discharge and types and amount of additional conventional treatment, the fact that this study did not consider for these potential effects through additional analyses is a further limitation of this study.

 

Controversy still surrounds the efficacy of treatments for cervical IDH. While epidural steroid injections are the commonest modality of conservative treatment used in the United States [37] various systematic reviews show that effects are highly variable and not conclusive [38–44]. Two approaches are widely used in epidural injections: interlaminar and transforaminal approaches. The transforaminal approach has been criticized for safety risks [45–50], and though safer than the transforaminal approach, the interlaminar approach also holds potential risks [51–56]. Reports on the efficacy of conventional medicine for neuropathic pain show conflicting results [57–61], and study results on physical therapy are also inconsistent [62–64].

 

Gebremariam et al. [65] evaluated the efficacy of various cervical IDH treatments in a recent review, and concluded that though the single published study on conservative treatment versus surgery showed that surgery led to better results than conservative treatment, lacking intergroup analysis, there is no evidence supporting that one treatment is more superior. Despite recommendations for initial conservative treatment and management, some patients may select surgery for cervical IDH to the main aim of alleviating radiating pain in neuropathy and preventing progression of neurological damage in myelopathy [66]. Although the evidence base of conventional conservative and surgical treatments for cervical IDH weighing the benefits and harms is somewhat insufficient, the area has been extensively studied, while there is a distinct paucity of correlative studies on CAM.

 

Manchikanti et al. [67] stated in a 2 year follow-up study comparing epidural injection treatment with lidocaine and a mix of lidocaine and steroids for cervical IDH that NRS in the lidocaine group was 7.9 ± 1.0 at baseline, and 3.8 ± 1.6 at the 2 year follow-up, while NRS in the lidocaine and steroid group was 7.9 ± 0.9 at baseline, and 3.8 ± 1.7 at the 2 year follow-up. NDI in the lidocaine group was 29.6 ± 5.3 at baseline, and 13.7 ± 5.7 at the 2 year follow-up, and NDI in the lidocaine and steroid group was 29.2 ± 6.1 at baseline, and 14.3 ± 6.9 at the 2 year follow-up. When compared to our study, though improvement in NRS is slightly bigger in the study by Manchikanti et al., that of NDI is similar. The baseline NRS was higher at 7.9 in this previous study, and they did not differentiate between neck pain and radiating pain in NRS assessment.

 

The 1 year follow-up results comparing conservative treatment and plasma disc decompression (PDD) for contained cervical IDH show that VAS scores decreased 65.73, while NDI decreased 16.7 in the PDD group (n = 61), and that VAS scores decreased 36.45, and NDI decreased 12.40 in the conservative treatment group (n = 57) [68]. However, the study subject was limited to contained cervical IDH, the outcome measure for pain was VAS preventing direct comparison, and the follow-up period was shorter than our study.

 

The model of integrative treatment used at a Korean medicine hospital may be highly disparate from CAM treatment models used in Western countries. Although CAM treatment is gaining widespread popularity in the West, CAM is usually limited to “complementary” rather than “alternative” medicine, and is generally practiced by conventional practitioners as an adjunctive to conventional treatment after education on acupuncture/naturopathy/etc. or through referral to CAM specialists, of whom some do not hold individual practice rights. On the other hand, Korea adopts a dual medical system where KMDs hold practice rights equal to conventional practitioners, and she does not employ a primarily family practice-based medical system, allowing patients the freedom of primary treatment selection of conventional treatment or Korean medicine treatment. The participants of this study were patients visiting and admitted to a Korean medicine hospital for Korean medicine treatment of cervical IDH, and the integrative treatment model implemented at this Korean medicine hospital does not use CAM as a supplementary measure. Therefore, treatment comprised of CAM treatment such as acupuncture, herbal medicine, Chuna manipulation, and bee-venom pharmacopuncture in most patients, and conventional treatment was administered by conventional doctors through referral in a select few. A total 18.2 % of patients received analgesic medications prescriptions 2.7 times over an average admission period of 20.8 days, which is equivalent to 1–2 days worth’s prescription (calculated as 2 times/day), and epidural injections were administered to only 4.8 %, which is low considering that these patients required admission. It can be surmised that the main objective of admission in conservative treatment for most cervical IDH patients is alleviation of pain. The fact that many inpatients displayed significant pain and functional recovery in this study holds relevance for patients considering selecting a Korean medicine hospital for conservative treatment over surgery. Also, patients were confirmed to have maintained their improved state at long term follow-up, and only 9 received surgery out of the 117 patients assessed in the long term.

 

Patients were divided into 2 groups by satisfaction rate as evaluated at long term follow-up with PGIC, and multivariable logistic regression analysis was conducted on baseline characteristics to assess predictive factors for satisfaction and dissatisfaction. Older age was associated with higher satisfaction rate, and unilateral radiating pain was shown to be related with higher satisfaction rates than no radiating pain. In addition, patients receiving CAM treatment were associated with higher satisfaction rates compared to those not receiving treatment. This could be partly explained by the fact that more older patients may have higher levels of pain and be in more advanced stages of degeneration, resulting in more favorable and satisfactory treatment outcomes. Similarly, patients with unilateral radiating pain suffer neurological symptoms likely to be more severe than those with no radiating pain. In addition, patients continuing to receive CAM treatment may be more favorably predisposed toward CAM, resulting in higher satisfaction rates.

 

While numerous prospective long term studies have been conducted on injection treatment or surgical procedures, those on CAM treatment and inpatient treatment are few. The results of this study are comparable to the prospective long term results of injection treatment. Few studies have been conducted on admission treatment for patients with a main complaint of cervical IDH, which may be related with the difference in general healthcare systems.

 

Conclusions

 

In conclusion, although the observational nature of this study limits us from drawing more decisive conclusions lacking a control, 3 weeks’ integrative inpatient treatment mainly comprised of CAM applied to actual clinical settings may result in satisfactory results and pain and functional improvement maintained in the long term in neck pain or radiating arm pain patients diagnosed with cervical IDH.

 

Acknowledgements

 

This work was supported by Jaseng Medical Foundation.

 

Abbreviations

 

  • IDH Intervertebral disc herniation
  • CAM Complementary and alternative medicine
  • KMD Korean medicine doctor
  • NRS Numeric rating scale
  • NDI Neck disability index
  • PGIC Patient global impression of change
  • MCID Minimum clinically important difference
  • VAS Visual analogue scale
  • ROM Range of motion
  • ULN Upper limit of normal
  • CI Confidence interval
  • OR Odds ratio
  • PDD Plasma disc decompression

 

Footnotes

 

Competing interests: The authors declare that they have no competing interests.

 

Authors’ contributions: SHB, JWO, JSS, JHL and IHH conceived of the study and drafted the manuscript, and SHB, MRK and IHH wrote the final manuscript. SHB, JWO, YJA and ARC participated in data acquisition, and KBP performed the statistical analysis. YJL, MRK, YJA and IHH contributed to analysis and interpretation of data. SHB, JWO, JSS, JHL, YJL, MRK, YJA, ARC, KBP, BCS, MSL and IHH contributed to the study design and made critical revisions. All of the authors have read and approved the final manuscript.

 

Contributor information: Ncbi.nlm.nih.gov/pmc/articles/PMC4744400/

 

In conclusion, migraine and cervical disc herniation treatment such as manual therapy as well as integrated complementary and alternative medicine may be effective towards the improvement and management of their symptoms. Information referenced from the National Center for Biotechnology Information (NCBI). The above research studies utilized a variety of methods to conclude the final results. Although the findings were shown to be effective migraine and cervical disc herniation treatment, further research studies are required to determine their true efficacy. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

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References

1. Grande RB, Aaseth K, Gulbrandsen P, Lundqvist C, Russell MB. Prevalence of primary chronic headache in a population-based sample of 30- to 44-year-old persons: the Akershus study of chronic headache. Neuroepidemiology. 2008;30(2):76–83. doi: 10.1159/000116244. [PubMed] [Cross Ref]
2. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version) Cephalalgia. 2013;33:629–808. [PubMed]
3. Kristoffersen ES, Grande RB, Aaseth K, Lundqvist C, Russell MB. Management of primary chronic headache in the general population: the Akershus study of chronic headache. J Headache Pain. 2012;13(2):113–120. doi: 10.1007/s10194-011-0391-8. [PMC free article] [PubMed] [Cross Ref]
4. Aaseth K, Grande RB, Kvaerner KJ, Gulbrandsen P, Lundqvist C, Russell MB. Prevalence of secondary chronic headaches in a population-based sample of 30-44-year-old persons: the Akershus study of chronic headache. Cephalalgia. 2008;28(7):705–713. doi: 10.1111/j.1468-2982.2008.01577.x. [PubMed] [Cross Ref]
5. Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, Bouter LM. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev. 2004;3:1–69. [PubMed]
6. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain. 2011;12(2):127–133. doi: 10.1007/s10194-011-0296-6. [PMC free article] [PubMed] [Cross Ref]
7. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Man Ther. 2010;15(4):355–363. doi: 10.1016/j.math.2009.12.006. [PubMed] [Cross Ref]
8. Lenssinck ML, Damen L, Verhagen AP, Berger MY, Passchier J, Koes BW. The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Pain. 2004;112(3):381–388. doi: 10.1016/j.pain.2004.09.026. doi:10.1016/j.pain.2004.09.026. [PubMed] [Cross Ref]
9. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA. Are manual therapies effective in reducing pain from tension-type headache: a systematic review. Clin J Pain. 2006;22(3):278–285. doi: 10.1097/01.ajp.0000173017.64741.86. doi:10.1097/01.ajp.0000173017.64741.86. [PubMed] [Cross Ref]
10. Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. 2012;13(5):351–359. doi: 10.1007/s10194-012-0436-7. [PMC free article] [PubMed] [Cross Ref]
11. Posadzki P, Ernst E. Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials. Complement Ther Med. 2012;20(4):232–239. doi: 10.1016/j.ctim.2011.12.001. doi:10.1016/j.ctim.2011.12.001. [PubMed] [Cross Ref]
12. French HP, Brennan A, White B, Cusack T. Manual therapy for osteoarthritis of the hip or knee – a systematic review. Man Ther. 2011;16(2):109–117. doi: 10.1016/j.math.2010.10.011. doi:10.1016/j.math.2010.10.011. [PubMed] [Cross Ref]
13. Tfelt-Hansen P, Block G, Dahlof C, Diener HC, Ferrari MD, Goadsby PJ, Guidetti V, Jones B, Lipton RB, Massiou H, Meinert C, Sandrini G, Steiner T, Winter PB. International Headache Society Clinical Trial Subcommittee. Guidelines for controlled trials of drugs in migraine: second edition. Cephalalgia. 2000;20(9):765–786. [PubMed]
14. Silberstein S, Tfelt-Hansen P, Dodick DW, Limmroth V, Lipton RB, Pascual J, Wang SJ. Task Force of the International Headache Society Clinical Trial Subcommittee. Guidelines for controlled trials of prophylactic treatment of chronic migraine in adults. Cephalalgia. 2008;28(5):484–495. doi: 10.1111/j.1468-2982.2008.01555.x. [PubMed] [Cross Ref]
15. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain: Headache Classification Committee of the International Headache Society. Cephalalgia. 1988;8(suppl 7):1–96. [PubMed]
16. Headache Classification Subcommittee of the International Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9–160. [PubMed]
17. Olesen J, Bousser MG, Diener HC, Dodick D, First M, Goadsby PJ, Gobel H, Lainez MJ, Lance JW, Lipton RB, Nappi G, Sakai F, Schoenen J, Silberstein SD, Steiner TJ. International Headache Society New appendix criteria open for a broader concept of chronic migraine. Cephalalgia. 2006;26(6):742–746. [PubMed]
18. Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro) Aust J Physiother. 2002;48(1):43–49. doi: 10.1016/S0004-9514(14)60281-6. [PubMed] [Cross Ref]
19. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2. Routledge, USA; 1988.
20. Toro-Velasco C, Arroyo-Morales M, Fernandez-de-las-Penas C, Cleland JA, Barrero-Hernandez FJ. Short-term effects of manual therapy on heart rate variability, mood state, and pressure pain sensitivity in patients with chronic tension-type headache: a pilot study. J Manipulative Physiol Ther. 2009;32(7):527–535. doi: 10.1016/j.jmpt.2009.08.011. [PubMed] [Cross Ref]
21. Jay GW, Brunson J, Branson SJ. The effectiveness of physical therapy in the treatment of chronic daily headaches. Headache. 1989;29(3):156–162. doi: 10.1111/j.1526-4610.1989.hed2903156.x. [PubMed] [Cross Ref]
22. Demirturk F, Akarcali I, Akbayrak T, Citak I, Inan L. Results of two different manual therapy techniques in chronic tension-type headache. Pain Clin. 2002;14(2):121–128. doi: 10.1163/156856902760196333. [Cross Ref]
23. Torelli P, Jensen R, Olesen J. Physiotherapy for tension-type headache: a controlled study. Cephalalgia. 2004;24(1):29–36. doi: 10.1111/j.1468-2982.2004.00633.x. [PubMed] [Cross Ref]
24. Ettekoven VH, Lucas C. Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial. Cephalalgia. 2006;26(8):983–991. doi: 10.1111/j.1468-2982.2006.01163.x. [PubMed] [Cross Ref]
25. Castien RF, Van der Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2011;31(2):133–143. doi: 10.1177/0333102410377362. [PubMed] [Cross Ref]
26. Rasmussen BK, Jensen R, Olesen J. Questionnaire versus clinical interview in the diagnosis of headache. Headache. 1991;31(5):290–295. doi: 10.1111/j.1526-4610.1991.hed3105290.x. [PubMed] [Cross Ref]
27. Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c869. doi: 10.1136/bmj.c869. [PMC free article] [PubMed] [Cross Ref]
28. Bendtsen L, Jensen R, Olesen J. A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is effective in the prophylactic treatment of chronic tension-type headache. J Neurol Neurosurg Psychiatry. 1996;61(3):285–290. doi: 10.1136/jnnp.61.3.285. [PMC free article] [PubMed] [Cross Ref]
29. Jackson JL, Shimeall W, Sessums L, Dezee KJ, Becher D, Diemer M, Berbano E, O’Malley PG. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ. 2010;341:c5222. doi: 10.1136/bmj.c5222. [PMC free article] [PubMed] [Cross Ref]
30. Bendtsen L, Bigal ME, Cerbo R, Diener HC, Holroyd K, Lampl C, Mitsikostas DD, Steiner TJ, Tfelt-Hansen P. Guidelines for controlled trials of drugs in tension-type headache: second edition. Cephalalgia. 2010;30(1):1–16. [PubMed]

Close Accordion
Blank
References

1. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine (Phila Pa 1976) 1994;19(12):1307–1309. doi: 10.1097/00007632-199406000-00001. [PubMed] [Cross Ref]
2. Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain. 1989;37(2):215–222. doi: 10.1016/0304-3959(89)90133-4. [PubMed] [Cross Ref]
3. Hagen KB, Harms-Ringdahl K, Enger NO, Hedenstad R, Morten H. Relationship between subjective neck disorders and cervical spine mobility and motion-related pain in male machine operators. Spine (Phila Pa 1976) 1997;22(13):1501–1507. doi: 10.1097/00007632-199707010-00015. [PubMed] [Cross Ref]
4. Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol. 1985;60(6):615–623. doi: 10.1016/0030-4220(85)90364-0. [PubMed] [Cross Ref]
5. Stovner LJ. The nosologic status of the whiplash syndrome: a critical review based on a methodological approach. Spine (Phila Pa 1976) 1996;21(23):2735–2746. doi: 10.1097/00007632-199612010-00006. [PubMed] [Cross Ref]
6. Frank AO, De Souza LH, Frank CA. Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic. Int J Clin Pract. 2005;59(2):173–182. doi: 10.1111/j.1742-1241.2004.00237.x. [PubMed] [Cross Ref]
7. Andersson G. The epidemiology of spinal disorders. In: Frymoyer J, editor. The adult spine: principles and practice. Philadelphia: Lippincott Raven; 1997. pp. 130–141.
8. Rasmussen C, Leboeuf-Yde C, Hestbaek L, Manniche C. Poor outcome in patients with spine-related leg or arm pain who are involved in compensation claims: a prospective study of patients in the secondary care sector. Scand J Rheumatol. 2008;37(6):462–468. doi: 10.1080/03009740802241709. [PubMed] [Cross Ref]
9. Daffner SD, Hilibrand AS, Hanscom BS, Brislin BT, Vaccaro AR, Albert TJ. Impact of neck and arm pain on overall health status. Spine (Phila Pa 1976) 2003;28(17):2030–2035. doi: 10.1097/01.BRS.0000083325.27357.39. [PubMed] [Cross Ref]
10. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery. 2007;60(1 Supp1 1):S28–34. [PubMed]
11. Lauerman W, Scherping S, Wiesel S. The spine. In: Wiesel S, Delahay J, editors. Essentials of Orthopedic Surgery. 3. New York: Springer; 2007. pp. 276–332.
12. Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med. 2005;353(4):392–399. doi: 10.1056/NEJMcp043887. [PubMed] [Cross Ref]
13. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976) 2008;33(4 Suppl):S123–52. doi: 10.1097/BRS.0b013e3181644b1d. [PubMed] [Cross Ref]
14. Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine (Phila Pa 1976) 1996;21(16):1877–1883. doi: 10.1097/00007632-199608150-00008. [PubMed] [Cross Ref]
15. Clark C. The Cervical Spine. 4. Philadelphia: Lippincott Williams & Wilkins; 2005.
16. Engquist M, Lofgren H, Oberg B, Holtz A, Peolsson A, Soderlund A, et al. Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. Spine (Phila Pa 1976) 2013;38(20):1715–1722. [PubMed]
17. Nikolaidis I, Fouyas IP, Sandercock PA, Statham PF: Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev 2010, (1):CD001466. doi(1):CD001466. [PubMed]
18. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441–2450. doi: 10.1001/jama.296.20.2441. [PMC free article] [PubMed] [Cross Ref]
19. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356(22):2245–2256. doi: 10.1056/NEJMoa064039. [PubMed] [Cross Ref]
20. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 1983;8(2):131–140. doi: 10.1097/00007632-198303000-00003. [PubMed] [Cross Ref]
21. Kim JD, Son MS. 2013 National Health Insurance Statistical Yearbook. Seoul: Health Insurance Review and Assessment Service and National Health Insurance Service; 2014.
22. Lin XJ, Chen CY. Advances on study of treatment of lumbar disk herniation by Chinese medicinal herbs. Zhongguo Zhong Yao Za Zhi. 2007;32(3):186–191. [PubMed]
23. Stevens L, Duarte H, Park J. Promising implications for integrative medicine for back pain: a profile of a Korean hospital. J Altern Complement Med. 2007;13(5):481–484. doi: 10.1089/acm.2007.6263. [PubMed] [Cross Ref]
24. Chung HJ, Lee HS, Shin JS, Lee SH, Park BM, Youn YS, et al. Modulation of acute and chronic inflammatory processes by a traditional medicine preparation GCSB-5 both in vitro and in vivo animal models. J Ethnopharmacol. 2010;130(3):450–459. doi: 10.1016/j.jep.2010.05.020. [PubMed] [Cross Ref]
25. Kim TH, Yoon SJ, Lee WC, Kim JK, Shin J, Lee S, et al. Protective effect of GCSB-5, an herbal preparation, against peripheral nerve injury in rats. J Ethnopharmacol. 2011;136(2):297–304. doi: 10.1016/j.jep.2011.04.037. [PubMed] [Cross Ref]
26. Kim JK, Park SW, Kang JW, Kim YJ, Lee SY, Shin J, et al. Effect of GCSB-5, a Herbal Formulation, on Monosodium Iodoacetate-Induced Osteoarthritis in Rats. Evid Based Complement Alternat Med. 2012;2012:730907. [PMC free article] [PubMed]
27. Park YG, Ha CW, Han CD, Bin SI, Kim HC, Jung YB, et al. A prospective, randomized, double-blind, multicenter comparative study on the safety and efficacy of Celecoxib and GCSB-5, dried extracts of six herbs, for the treatment of osteoarthritis of knee joint. J Ethnopharmacol. 2013;149(3):816–824. doi: 10.1016/j.jep.2013.08.008. [PubMed] [Cross Ref]
28. Xu RD, Li H. Conception of Ashi points. Zhongguo Zhen Jiu. 2005;25(4):281–283. [PubMed]
29. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138(11):871–881. doi: 10.7326/0003-4819-138-11-200306030-00008. [PubMed] [Cross Ref]
30. Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008;8(1):213–225. doi: 10.1016/j.spinee.2007.10.023. [PubMed] [Cross Ref]
31. Turk DC, Rudy TE, Sorkin BA. Neglected topics in chronic pain treatment outcome studies: determination of success. Pain. 1993;53(1):3–16. doi: 10.1016/0304-3959(93)90049-U. [PubMed] [Cross Ref]
32. Ponce de Leon S, Lara-Munoz C, Feinstein AR, Wells CK. A comparison of three rating scales for measuring subjective phenomena in clinical research. II. Use of experimentally controlled visual stimuli. Arch Med Res. 2004;35(2):157–162. doi: 10.1016/j.arcmed.2003.07.009. [PubMed] [Cross Ref]
33. Farrar JT, Young JP, Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149–158. doi: 10.1016/S0304-3959(01)00349-9. [PubMed] [Cross Ref]
34. Carreon LY, Glassman SD, Campbell MJ, Anderson PA. Neck Disability Index, short form-36 physical component summary, and pain scales for neck and arm pain: the minimum clinically important difference and substantial clinical benefit after cervical spine fusion. Spine J. 2010;10(6):469–474. doi: 10.1016/j.spinee.2010.02.007. [PubMed] [Cross Ref]
35. Parker SL, Godil SS, Shau DN, Mendenhall SK, McGirt MJ. Assessment of the minimum clinically important difference in pain, disability, and quality of life after anterior cervical discectomy and fusion: clinical article. J Neurosurg Spine. 2013;18(2):154–160. doi: 10.3171/2012.10.SPINE12312. [PubMed] [Cross Ref]
36. Lee J, Shin JS, Kim MR, Byun JH, Lee SY, Shin YS, et al. Liver enzyme abnormalities in taking traditional herbal medicine in Korea: A retrospective large sample cohort study of musculoskeletal disorder patients. J Ethnopharmacol. 2015;169:407–412. doi: 10.1016/j.jep.2015.04.048. [PubMed] [Cross Ref]
37. Manchikanti L, Falco FJ, Singh V, Pampati V, Parr AT, Benyamin RM, et al. Utilization of interventional techniques in managing chronic pain in the Medicare population: analysis of growth patterns from 2000 to 2011. Pain Physician. 2012;15(6):E969–82. [PubMed]
38. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009;34(10):1078–1093. doi: 10.1097/BRS.0b013e3181a103b1. [PubMed] [Cross Ref]
39. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15(Suppl 2):S192–300. doi: 10.1007/s00586-006-1072-1. [PMC free article] [PubMed] [Cross Ref]
40. Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila Pa 1976) 2009;34(1):49–59. doi: 10.1097/BRS.0b013e3181909558. [PubMed] [Cross Ref]
41. Armon C, Argoff CE, Samuels J, Backonja MM, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68(10):723–729. doi: 10.1212/01.wnl.0000256734.34238.e7. [PubMed] [Cross Ref]
42. Parr AT, Diwan S, Abdi S. Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician. 2009;12(1):163–188. [PubMed]
43. DePalma MJ, Slipman CW. Evidence-informed management of chronic low back pain with epidural steroid injections. Spine J. 2008;8(1):45–55. doi: 10.1016/j.spinee.2007.09.009. [PubMed] [Cross Ref]
44. Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013;38(3):175–200. doi: 10.1097/AAP.0b013e31828ea086. [PubMed] [Cross Ref]
45. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine (Phila Pa 1976) 2007;32(11):1249–1256. doi: 10.1097/BRS.0b013e318053ec50. [PubMed] [Cross Ref]
46. Rathmell JP, Benzon HT. Transforaminal injection of steroids: should we continue? Reg Anesth Pain Med. 2004;29(5):397–399. [PubMed]
47. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004;4(4):468–474. doi: 10.1016/j.spinee.2003.10.007. [PubMed] [Cross Ref]
48. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001;91(3):397–399. doi: 10.1016/S0304-3959(00)00437-1. [PubMed] [Cross Ref]
49. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P. Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. AJR Am J Roentgenol. 2007;188(5):1218–1221. doi: 10.2214/AJR.04.1541. [PubMed] [Cross Ref]
50. Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology. 2004;100(6):1595–1600. doi: 10.1097/00000542-200406000-00035. [PubMed] [Cross Ref]
51. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. 2012;15(2):131–140. [PubMed]
52. Abbasi A, Malhotra G, Malanga G, Elovic EP, Kahn S. Complications of interlaminar cervical epidural steroid injections: a review of the literature. Spine (Phila Pa 1976) 2007;32(19):2144–2151. doi: 10.1097/BRS.0b013e318145a360. [PubMed] [Cross Ref]
53. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine (Phila Pa 1976) 1998;23(19):2137–42. doi: 10.1097/00007632-199810010-00020. [PubMed] [Cross Ref]
54. Kaplan MS, Cunniff J, Cooke J, Collins JG. Intravascular uptake during fluoroscopically guided cervical interlaminar steroid injection at C6-7: a case report. Arch Phys Med Rehabil. 2008;89(3):553–558. doi: 10.1016/j.apmr.2007.08.165. [PubMed] [Cross Ref]
55. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12(5):726–731. doi: 10.1111/j.1526-4637.2011.01077.x. [PubMed] [Cross Ref]
56. Shanthanna H, Park J. Acute epidural haematoma following epidural steroid injection in a patient with spinal stenosis. Anaesthesia. 2011;66(9):837–839. doi: 10.1111/j.1365-2044.2011.06770.x. [PubMed] [Cross Ref]
57. McCleane G. Does gabapentin have an analgesic effect on background, movement and referred pain? A randomized, double-blind, placebo controlled study. Pain Clinic. 2001;13:103–107. doi: 10.1163/156856901753420945. [Cross Ref]
58. Yildirim K, Sisecioglu M, Karatay S, Erdal A, Levent A, Ugur M, et al. The effectiveness of gabapentin in patients with chronic radiculopathy. Pain Clinic. 2003;15:213–218. doi: 10.1163/156856903767650718. [Cross Ref]
59. Khoromi S, Cui L, Nackers L, Max MB. Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain. Pain. 2007;130(1-2):66–75. doi: 10.1016/j.pain.2006.10.029. [PMC free article] [PubMed] [Cross Ref]
60. Khoromi S, Patsalides A, Parada S, Salehi V, Meegan JM, Max MB. Topiramate in chronic lumbar radicular pain. J Pain. 2005;6(12):829–836. doi: 10.1016/j.jpain.2005.08.002. [PubMed] [Cross Ref]
61. Baron R, Freynhagen R, Tolle TR, Cloutier C, Leon T, Murphy TK, et al. The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy. Pain. 2010;150(3):420–427. doi: 10.1016/j.pain.2010.04.013. [PubMed] [Cross Ref]
62. Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Spine (Phila Pa 1976) 2010;35(11):E488–504. [PubMed]
63. Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain. Man Ther. 2011;16(1):53–65. doi: 10.1016/j.math.2010.09.005. [PubMed] [Cross Ref]
64. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009;339:b3883. doi: 10.1136/bmj.b3883. [PMC free article] [PubMed] [Cross Ref]
65. Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976) 2012;37(2):E109–18. doi: 10.1097/BRS.0b013e318221b5af. [PubMed] [Cross Ref]
66. Boselie TF, Willems PC, van Mameren H, de Bie RA, Benzel EC, van Santbrink H. Arthroplasty versus fusion in single-level cervical degenerative disc disease: a Cochrane review. Spine (Phila Pa 1976) 2013;38(17):E1096–107. doi: 10.1097/BRS.0b013e3182994a32. [PubMed] [Cross Ref]
67. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. Cervical epidural injections in chronic discogenic neck pain without disc herniation or radiculitis: preliminary results of a randomized, double-blind, controlled trial. Pain Physician. 2010;13(4):E265–78. [PubMed]
68. Cesaroni A, Nardi PV. Plasma disc decompression for contained cervical disc herniation: a randomized, controlled trial. Eur Spine J. 2010;19(3):477–486. doi: 10.1007/s00586-009-1189-0. [PMC free article] [PubMed] [Cross Ref]

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