Migraine is a genetic neurological disease, characterized by episodes called Migraine attacks. They are quite different from regular headaches which are non-migrainous. About 100 million people suffer from headaches in the U.S. And 37 million of these people suffer migraines. The World Health Organization estimates that 18 percent of women and 7 percent of men in the U.S. suffer from these headaches. Migraines are called primary headaches because the pain is not caused by a disorder or disease i.e. a brain tumor or head injury. Some cause pain only on the right side or left side of the head. While others result in pain everywhere. Migraine sufferers can have moderate or severe pain but usually can’t participate in regular activities because of the pain. When a migraine strikes, a quiet dark room may help with the symptoms. They can last for four hours or can last for days. The range of time someone is affected by an attack is actually longer than the headache itself. This is because there is a pre-monitory, or build-up, and then a post-drome that can last for one to two days.
Cyrex Laboratories is an advanced clinical laboratory that specializes in the functional approach in environmentally induced autoimmunity. Cyrex works with the leading experts in medical research and provides arrays that address the cross-connections throughout the body systems. In addition to this, Cyrex strives to deliver the best quality for the patients by always improving and using the most accurate and advanced technology.
Cyrex has multiple arrays they use to test patients depending on their symptoms. These arrays range from Alzheimer’s to Joint auto-immune reactivity screenings. Often times, patients who have issues with their joints or headaches and pain, can be traced back to an underlying issue. When a patient comes to a doctor, the practitioner will evaluate and assess the patient based on the symptoms they bring. From here, the practitioner can go to Cyrex and order the arrays that best suit their patient’s needs. The Cyrex system revolves around immune function and measures the identifiers that can affect multiple tissues in the body, including the brain, heart, pancreas, nervous system, liver, gastrointestinal system, bones, and joints. The turn around time for these labs is fairly quick and helps highlight the underlying route of the patient’s symptoms.
Cyrex arrays use serum (a blood draw) as their main form of testing. No matter the array the doctor orders, the patient will receive the same kit. The requisition form that is inside the kit is what matters to the phlebotomist and lab as this is where the array ordered will be marked.
The kit is a small box labeled Cyrex Laboratories, Serum Collection Kit. On top of the kit held in place by a rubber band will be a shipping label and bag for the sample to go in once collected. Inside the kit is a smaller styrofoam box that includes a serum separator tube, a serum transport tube, tube labels, a biohazard bag, and collection instructions.
As one can see from the above photo, the different arrays test for different reactions/conditions. A doctor may order one or multiple arrays depending on the patient.
Array 2 is one of the most popular, as leaky gut is a condition that affects most Americans. This test screens for IgG, IgA, and IgM of Lipopolysaccharides and Occludin/Zonulin.
Often times, practitioners will use multiple lab companies on one patient. This is not because one is superior to the other, but rather because they specialize in different areas. Even though the doctor may order labs from different companies, it is in the patient’s best interest because it allows the practitioner to view multiple areas to truly understand the underlying issue.
Patients who come in with symptoms like aching joints, headaches, trouble falling asleep, difficulty staying asleep, leaky gut, and brain fog will certainly benefit from using multiple lab companies.
Using Cyrex array 2 and DUTCH + CAR the patient will get extremely accurate information in regards to what is occurring in their body. The Cyrex array test will show the practitioner if the patient has a leaky gut and how severe. While the DUTCH + CAR allows the doctor to determine the cortisol patterns in the individual’s body. Sometimes, these levels are not rising and falling at the right times, causing the patient to be tired or having trouble staying asleep.
The patient’s health should always come first, and when doctors are knowledgable enough to use more than one lab, the patient benefits are outstanding. By using the companies together, the doctor is able to check multiple areas, leaving no guesswork when it comes to a treatment protocol. However, it is important to remember that labs vary on patient needs. Some patients are able to use the same company for all labs and obtain the accurate results they need.
Cyrex tests for many conditions and has multiple arrays. Although many
Cyrex labs are a great tool for practitioners and health coaches to use! By using these arrays, it helps the practitioner not only treat the symptoms, but it allows them the insight they need to treat the problem at the route source. The tools that Cyrex provides go a long way in evaluating the complex disorders the human body may have. By using Cyrex and coupling it with other tests from DUTCH or labrix, the patient is able to get proper treatment and get back to the hobbies they used to love and enjoy. These companies are all fantastic and provide specialities in different areas. By using more than one company, the pateint truly gets the best results and the doctors are able to construct a solid treatment protocol with all of the information obtained. – Kenna Vaughn, Senior Health Coach
*All information was obtained from Cyrex.com
The scope of our information is limited to chiropractic, musculoskeletal and nervous health issues as well as functional medicine articles, topics, and discussions. We use functional health protocols to treat injuries or chronic disorders of the musculoskeletal system. To further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.
Damaris Foreman suffered from migraines before she received chiropractic care with the chiropractor, Dr. Alex Jimenez. After various treatment approaches were unable to provide Damaris Foreman with the migraine pain relief she needed, she was skeptical at first about chiropractic care. However, following the migraine pain relief she found with Dr. Alex Jimenez, Damaris Foreman highly recommends chiropractic care. She emphasizes how much Dr. Jimenez has helped her and how much she has learned about her health issue. Damaris Foreman states that Dr. Alex Jimenez has provided her with the best treatment approach she has ever received for her migraines. Dr. Jimenez is the non-surgical choice for a variety of injuries and conditions, including headaches and migraines.
We are blessed to present to you El Paso’s Premier Wellness & Injury Care Clinic.
As El Paso’s Chiropractic Rehabilitation Clinic & Integrated Medicine Center, we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
We want you to live a life that is fulfilled with more energy, positive attitude, better sleep, less pain, proper body weight and educated on how to maintain this way of life. I have made a life of taking care of every one of my patients.
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Headaches are a real pain (insert eye-roll here). Many individuals suffer from them, and there are a variety of causes, symptoms, and treatment options. For some, they are a rare occurrence, while others deal with them on a weekly, or even daily, basis. They can range from minor inconveniences to full-fledged life-changing afflictions.
The first step in treating headaches is to understand the type of headache you are experiencing. Some people think they have a migraine, when in fact, they are suffering from a tension headache. While tension headaches are more common, it’s estimated by the Migraine Research Foundation that 1 in 4 U.S. Households include someone with a migraine.
Determining which headache being dealt with takes a bit of research. Individuals suffering from headaches need to ask themselves these questions to determine if they are having a migraine, or experiencing a tension headache.
When in life did the headaches begin? According to the Mayo Clinic, migraines start in adolescence or early adulthood. In contrast, tension headaches can start at any time in a person’s life. If an adult just began suffering from headaches, they are most likely tension headaches.
Where does it hurt? Migraines typically occur on one side of the head. Tension headaches affect both sides of the head and can produce a feeling of pressure at the forehead area. The location of the pain is a vital indicator of the type of headache.
What kind of pain is it? If it is a dull pain, a feeling of pressure, or tenderness around the scalp, it’s most likely a tension headache. If, on the other hand, the pain is throbbing or pulsing pain, it could be a migraine. Both headaches can offer up severe pain, just different types.
Are there any other symptoms?Migraines typically come with symptoms beyond head pain. Nausea, light and sound sensitivity, seeing bright flashing or sparkling lights, pins and needle sensations down one or both arms, or dizziness are common. Individuals who don’t experience any of these symptoms are most likely dealing with a tension headache.
Can you function? While painful and frustrating, many people with a tension headache can still perform their jobs, drive, read, and deal with daily life. A migraine is a different story. Lying in a dark, quiet room with a sleep mask on until the headache passes is how most people handle migraines. If the headache is life-disrupting, it could very well be a migraine.
Do regular painkillers work? Tension headaches can often be relieved by over-the-counter pain medications. Migraines don’t budge with these treatments. Once a migraine is in full force, the sufferer generally must ride it out. If a headache reacts well to a couple of non-prescription painkillers, it’s most likely a tension headache.
The majority of individuals will, unfortunately, deal with a headache at one point in their lives. It’s important to note that tension headaches are much more common than migraines, but that doesn’t rule out the possibility of a headache being a migraine. The answers to the above questions combined give insight as to the type of a headache occurring, and how best to proactively handle the treatment. No matter the type of headache, if the pain is severe, or begins after a head injury, seek medical treatment immediately.
Damaris Foreman experienced migraine headaches for approximately 23 years. After visiting many healthcare professionals due to her migraine pain without seeing a great deal of progress, she was finally advised to find migraine pain treatment with Dr. Alex Jimenez, a chiropractor located in the city of El Paso, TX. Damaris significantly benefitted from chiropractic care and she experienced a massive sense of relief after her first spinal adjustment and manual manipulation. Damaris Foreman was able to confront a great deal of her questions and concerns and she was efficiently taught how to deal with her migraine pain. Damaris clarifies how Dr. Alex Jimenez’s migraine treatment is one of the best treatments she’s received and she highly recommends chiropractic care as the best non-surgical choice for enhancing and healing her migraine headaches.
Chiropractic Migraine Treatment & Relief
A migraine is commonly referred to as a primary headache disorder characterized by recurrent headaches as well as identified by moderate to severe in intensity. Ordinarily, the migraine headaches affect one half of the brain, are pulsating in personality, and might last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, noise, or odor. The pain could be aggravated by bodily activity. One third of people who suffer with migraines experience migraine with aura: normally a brief number of visual disturbance suggests that the headache will soon happen. It can also occur with minimal if any aggravation pain following it.
We are blessed to present to you El Paso’s Premier Wellness & Injury Care Clinic.
As El Paso’s Chiropractic Rehabilitation Clinic & Integrated Medicine Center, we passionately are focused treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
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My treatment with Dr. Alex Jimenez has been helping me by simply making me less tired. I’m not experiencing as many headaches. The headaches are going down dramatically and my back feels much better. I would highly recommend Dr. Alex Jimenez. He’s very friendly, his staff is very friendly and everybody goes well beyond what they can do to help you. – Shane Scott
A majority of the populations has suffered from this well-known nagging health issue, however, did you know that headaches can sometimes be caused by neck pain? While these headaches are commonly referred to as as cervicogenic headaches, other types of headaches, such as cluster headaches and even migraines, have also been determined to be caused by neck pain. Neck pain can develop due to a variety of reasons and it can vary tremendously from mild to severe.
Therefore, it’s fundamental to seek a proper diagnosis if you’ve experienced headaches or neck pain to determine the root cause of your symptoms as well as to properly determine what treatment option will be best for your specific health issue. Healthcare professionals will assess your upper back, or the cervical spine, including your neck, base of the skull and cranium, and also all the surrounding muscles and nerves to find the source of your symptoms. Before seeking help from a doctor, however, it’s important to understand how neck pain can cause headaches. Below, we will discuss the anatomy of the cervical spine, or neck, as well as demonstrate how neck pain is connected to headaches.
How Neck Pain Causes Headaches
The muscles located between the shoulder blades, upper portion of the shoulders and those surrounding the neck, or cervical spine, may all cause neck pain if they become too tight or stiff. This can generally occur due to trauma or damage from an injury, as well as in consequence to bad posture or poor sitting, lifting or work habits. The tight muscles will result in your neck joints feeling stiff or compressed and it can even radiate pain towards your shoulders. Over time, the balance of the neck muscles changes and those specific muscles which are meant to support the neck become weak and can ultimately begin to make the head start to feel heavy, increasing the risk of experiencing neck pain as well as headaches..
Furthermore, the roots of the upper 3 cervical spinal nerves, which are found at C1, C2, and C3, share a pain nucleus, which routes pain signals to the brain, along with the trigeminal nerve. The trigeminal nerve is the main sensory nerve that is in charge of carrying messages from the face to your brain. Because of the shared nerve tracts, pain is misunderstood and thus “felt” by the brain as being located in the head. Fortunately, many healthcare professionals are experienced in the assessment and correction of muscular imbalances which may lead to neck pain and headaches. Moreover, they can help to relieve muscle tension, enhance muscle length and joint mobility, and retrain correct posture.
What Causes Neck Pain and Headaches?
Cervicogenic headaches, otherwise known as “neck headaches”, are caused by painful neck joints, tendons or other structures surrounding the neck, or cervical spine, which may refer pain to the bottom of the skull, to your face or head. Researchers believe that neck headaches, or cervicogenic headaches, account for approximately 20 percent of all headaches diagnosed clinically. Cervicogenic headaches and neck pain are closely associated with each other, although other types of headaches can also cause neck pain.
This type of head pain generally starts because of an injury, stiffness or lack of proper functioning of the joints found at the top of your neck, as well as tight neck muscles or swollen nerves, which could trigger pain signals that the brain then interprets as neck pain. The usual cause of neck headaches is dysfunction in the upper three neck joints, or 0/C1, C1/C2, C2/C3, including added tension in the sub-occipital muscles. Other causes for cervicogenic headaches and neck pain can include:
Cranial tension or trauma
TMJ (JAW) tension or altered bite
The Link Between Migraines and Neck Pain
Neck pain and migraines also have an intricate connection with each other. While in some cases, severe trauma, damage or injury to the neck can lead to severe headaches like migraine, in other situations neck pain might be the result of a migraine headache. However, it’s never a good idea to assume that one is the end result of the other. Seeking treatment for neck pain when the reason for your concern is in fact a migraine, often will not lead to effective pain management or pain relief. The best thing that you can do if you’re experiencing neck pain and headaches is to seek immediate medical attention from a specialized healthcare professional in order to determine the cause of your pain, as well as to determine the root cause of the symptoms.
Unfortunately, neck pain, as well as a variety of headaches, are commonly misdiagnosed or even sometimes go undiagnosed for an extended period of time. As a matter of fact, one of the top reasons as to why neck pain may be so difficult to treat is primarily because it takes a long time for people to take this health issue seriously and seek a proper diagnosis. Waiting an extended amount of time to take care of your neck pain, especially after an injury, may lead to acute pain and it may even make the symptoms more difficult to control, turning them into chronic pain. By the time a patient seeks diagnosis for their neck pain, it may have already been a persistent problem. Also, the most frequent reasons people seek treatment for neck pain and headaches include:
Chronic migraines and headaches
Restricted neck function, including difficulties moving the head
Soreness in the neck, upper back and shoulders
Stabbing pain and other symptoms, particularly in the neck
Pain radiating from the neck and shoulders to the fingertips
Aside from the symptoms mentioned above, individuals with neck pain and headaches can also experience additional symptoms, including nausea, diminished eyesight, difficulty concentrating, severe fatigue, and even difficulty sleeping.While there are circumstances in which the cause of your headaches or neck pain may be apparent, such as being in a recent automobile accident or suffering from sport-related trauma, damage or injuries, in several instances, the cause may not be quite as obvious.
Because neck pain and headaches can also develop as a result of bad posture or even due to nutritional problems, it’s fundamental to find the origin of the pain to increase the success of treatment, in addition to enabling you to prevent the health issue from happening again in the future. It’s common for a healthcare professional to devote their time working with you to ascertain what could have caused the pain in the first place.
A Health Issue You Can’t Ignore
Neck pain is typically not a problem which should be ignored. You may think that you’re only experiencing minor neck discomfort and that it’s irrelevant to any other health issues you may be having, but more frequently than not, you can’t know for sure till you receive a proper diagnosis for your symptoms. Patients who seek immediate medical attention and treatment for their neck-centered problems are surprised to learn that some of the other health issues they may be experiencing may actually be correlated, such as in the case of neck pain and headaches. Thus, even in the event that you think you can “live with” not being able to turn your neck completely, other health issues can develop, and these problems might be more challenging to deal with.
There are circumstances in which a pinched nerve in the neck is the main reason for chronic tension headaches, where a previous sports injury that was not properly addressed before is now the cause of the individual’s limited neck mobility and in which a bruised vertebrae at the base of the neck induces throbbing sensations throughout the spine, which radiates through the shoulders into the arms, hands and fingers. You might also blame your chronic migraines on a hectic schedule and stressful conditions, however, it might truly be a consequence of poor posture and the obligated hours that you spend hunched over a computer screen. Untreated neck pain might even lead to problems you might never expect, such as balance problems or trouble gripping objects. This is because all the neural roots located on the upper ligaments of the cervical spine, or neck, are connected to other parts of the human body, from your biceps to each one of your small fingers.
Working with a healthcare professional to relieve the root cause of your neck pain and headaches may significantly enhance your quality of life and may be able to eliminate other symptoms from turning into a significant problem. While the most common causes of chronic migraines are generally caused by another health issue or nutritional deficiency, you might also be amazed to learn how often the outcome is something which may be resolved with concentrated exercises and stretches recommended by a healthcare professional, such as a chiropractor. Additionally, you may understand that the health issues you’ve been having often develop from compressed, pinched, irritated or inflamed nerves in your upper cervical nerves.
Dr. Alex Jimenez’s Insight
Although it may be difficult to distinguish the various types of headaches, neck pain is generally considered to be a common symptom associated with head pain. Cervicogenic headaches are very similar to migraines, however, the primary difference between these two types of head pain is that a migraine occurs in the brain while a cervicogenic headache occurs in the base of the skull or in the cervical spine, or neck. Furthermore, some headaches may be caused by stress, tiredness, eyestrain and/or trauma or injury along the complex structures of the cervical spine, or neck. If you are experiencing neck pain and headaches, it’s important to seek help from a healthcare professional in order to determine the true cause of your symptoms.
Treatment for Neck Pain and Headaches
Foremost, a healthcare professional must determine the cause of an individual’s symptoms through the use of appropriate diagnostic tools as well as to make sure they have the utmost success in relieving the headache and neck pain without prolonging the duration of the symptoms and extra cost of incorrect therapy. Once an individual’s source of neck pain and headaches has been diagnosed, the kind of treatment a patient receives ought to be dependent on the type of headache. As a rule of thumb, treatment starts once the diagnosis has been made. A healthcare professional will work with you to create a treatment plan that’s appropriate for your specific health issues. In your sessions, you’ll be taken through procedures that help build flexibility and strength.
Chiropractic care is a well-known, alternative treatment option which focuses on the diagnosis, treatment and prevention of a variety of musculoskeletal and nervous system injuries and/or conditions. A doctor of chiropractic, or chiropractor, can help treat neck pain and headache symptoms by carefully correcting any spinal misalignments, or subluxations, in the cervical spine or neck, through the use of spinal adjustments and manual manipulations, among other therapeutic techniques. Chiropractors, as well as physical therapists, may also utilize a combination of gentle Muscle Energy Techniques, muscle building, joint slides, cranio-sacral therapy, and specific posture and muscle re-education to lower the strain being placed on the structures surrounding the cervical spine. The staff will also help you understand how to better position yourself during your daily life to prevent relapses, like ergonomic and posture tips. Contact a healthcare professional in order for them to be able to assist you immediately.
In cases where alternative treatment options have been utilized without any results, or sometimes simply being used together with other complementary treatment approaches, pain drugs and/or medications may be contemplated, such as non-steroidal anti-inflammatory drugs (NSAIDs), anti-seizure agents such as gabapentin, tricyclic anti-depressants, or migraine prescriptions. If pain medications prove ineffective, then injections may be contemplated, including peripheral nerve blocks, atlantoaxial joint block administered at C1-C2, or aspect joint blocks administered in C2-C3. Surgical interventions may also be other treatment options, however, healthcare professionals suggest attempting all other treatment options before considering surgery. 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
Additional Topics: Back Pain
Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of 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.
The therapeutic effects of Cannabidiol or CBD, is often the cannabinoid’s pain soothing effect that gets talked about. Headaches are the most common source of pain for the general population. Therefore, it makes sense that CBD use for migraines and headaches is an obvious.
Migraines and headaches can be a medical mystery, but usually their causes are brought on by problems with brain stem centers. The only treatments thus far, has been painkillers i.e. paracetamol or ibuprofen. Triptan medications, which constricts the blood vessels in order to block pain pathways in the brain are used as well. But is there a better more natural way to treat headaches and migraines?
Cannabis Has Been Treating Headaches For Quite Awhile
CBD oil for headaches is not a new therapy. Cannabis is mentioned as treatment for headaches in ancient texts that go back thousands of years. However, its use didn’t become familiar in the west until the 19th century when it would be prescribed by doctors as a tincture.
Today conclusive clinical evidence is incomplete, as far as, medical cannabis and hemp oil use for headaches. But scientists do know when it comes to CBD oil use for headaches and migraines, that the endocannabinoid system is working in conjunction with the compounds.
The Endocannabinoid System & Migraines
A theory brought about a possible contributing cause of migraines is dysfunction in the endocannabinoid system or (ECS). This is the body’s network of receptors and cannabis-like chemicals that respond and regulate:
Researchers have noted ECS mechanisms that could have a connection to migraine attacks.
Anandamide (AEA) is one of the prime endocannabinoids in the body. It is both a painkiller and has been found to power the serotonin 5-HT1A receptors.
The clearest record of endocannabinoid dysfunction that contributes to migraines is from a study in 2007 at the University of Perugia and published in the Journal of Neuropsychopharmacology. Researchers measured endocannabinoid levels in the cerebrospinal fluid of patients with chronic migraines and found significantly lower amounts of Anandamide. These findings, could “reflect an impairment of the endocannabinoid system in these patients, which may contribute to chronic head pain.”
Clinical Endocannabinoid Deficiency? Migraines Could Be A Sign
The link between lower levels of endocannabinoids in migraine patients has contributed to the formulation of what has been termed Clinical Endocannabinoid Deficiency. This theory was developed by Neurologist and Cannabinoid Researcher Dr. Ethan Russo.
The theory comes from how many brain disorders are inadequate or missing neurotransmitters like acetylcholine. Russo has suggested “a comparable deﬁciency in endocannabinoid levels might manifest similarly in certain disorders that display predictable clinical features as sequelae of this deﬁciency.”
In an interview he describes how, “If you don’t have enough endocannabinoids you have pain where there shouldn’t be pain. You would be sick, meaning nauseated. You would have a lowered seizure threshold. And just a whole litany of other problems.”
Russo relates these deficiencies can be addressed through introduction to plant cannabinoids, which act almost like those found in the body, by stimulating the endocannabinoid receptors. There is CB1 agonists such as Marinol and Nabilone have been tested for migraines, Russo suggests that the ECS needs a “gentle nudge” rather than a “forceful shove” given by these synthetic alternatives. He suggests small doses of whole plant cannabis, which contain “additional synergistic and buffering components, such as CBD and cannabis terpenoids.”
Cannabidiol CBD Oil: Migraines
Russo in particular singles out CBD (Cannabidiol) in that it brings balance to the endocannabinoid system. In his interview with Martin Lee from Project CBD he says, “cannabidiol is an endocannabinoid modulator, in other words, when given chronically it actually increases the gain of the system…. So, if there’s too much activity in a system, homeostasis requires that it be brought back down. If there’s too little, it’s got to come up. And that’s what cannabidiol can do as a promoter of endocannabinoid tone.”
Scientists still are not exactly sure of how CBD interacts with the endocannabinoid system. Unlike psychoactive THC, CBD does not bind with any of the endocannabinoid receptors. Instead it activates a host of other non-endocannabinoid receptors, which work in the development and treatment of migraines, i.e. the 5-HT1A serotonin and TRPV-1 receptors.
Another possible explanation is CBD’s role as a fatty acid amide hydrolase (FAAH) inhibitor, which breaks down anandamide in the body. By inhibiting its production the theory is that it might lead to higher levels of pain relieving endocannabinoid. This is something that would benefit migraine sufferers.
Lack Of Clinical Evidence
Currently there are no gold standard, double blind, placebo clinical studies published to back up any accounts that suggest CBD or cannabis is an effective treatment for headaches and migraines.
One placebo controlled study has been conducted, documenting the safety and efficacy of synthetic THC medication Dronabinol for migraines. However, the results are still pending.
The largest study to take place was done from a retrospective basis. It was published in 2016 and found that out of 121 participants that suffer from migraines and were prescribed medical cannabis by a doctor; 103 participants found their migraine frequency reduced by half.
Can Cannabidiol Cause A Headache?
There are those who tried CBD and noted persistent headaches and even migraines. Does CBD cause headaches, even though the research suggests the contrary.
Those who reported getting headaches after taking CBD oil noted that the oil they bought was low quality, and the ingredients used included ethanol, various alcohols, preservatives and harsh chemicals.
When purchasing CBD oil for migraines or other conditions, get the best quality, not the cheapest!
How To Use CBD For Head Pain
There are different ways to apply CBD oil for headaches. If taking CBD for tension headaches, migraines or general headaches, there are many way to administer. Probably the simplest and most effective ways of using CBD is the sublingual method.
With this method one places a few drops of oil underneath the tongue. There it permeates through the membrane and makes its way to where it needs to go.
This isn’t the only method and many others can be just as effective. Make sure to do research when looking for CBD products online and the methods of administering these products.
Just like the nature of migraines, CBD for headaches and migraines is still not completely and scientifically understood. But with continued research of CBD and Cannabinoid based medicine, the future of sufferers of headaches and migraines will get better.
Injury Medical Clinic: Migraine Treatment & Recovery
Origin: The most common cause of migraines/headaches can relate to neck complications. From spending excessive time looking down at a laptop, desktop, iPad, and even from constant texting, an incorrect posture for extended periods of time can begin to place pressure on the neck and upper back leading to problems that can cause headaches. The majority of these type of headaches occurs as a result of tightness between the shoulder blades, which in turn causes the muscles on the top of the shoulders to also tighten and radiate pain into the head.
Headaches are very common health issues, and lots of people treat themselves by using basic painkillers, drinking additional water, with rest, or by simply waiting for the headache to go away on its own. As a matter of fact, a headache is among the most common reasons for doctor office visits.
Just about everyone will experience a headache sometime during their life. Most headaches are not caused by serious or sinister conditions. However, people understandably worry if headaches feel different, whether they’re especially severe, particularly frequent or unusual in any other manner. But, the most common concern is whether the headache may be a symptom of an underlying health issue, such as a brain tumor.
The following article discusses headaches generally. It explains the various types of headaches you may experience and describes those very rare situations where a headache may be a symptom of a serious disease.
Types of Headaches
Headaches can be categorized as primary, or they can be classified as secondary, meaning they are a side-effect of another injury or condition.
A healthcare professional can usually determine the possible cause of your headaches from speaking to you and examining you. When they have found the cause then you’ll have the ability to decide the best treatment approach for your head pain symptoms. This may involve taking drugs only when you get the headaches, taking daily medication to stop them altogether, and/or even stopping medication you’re already taking. Very occasionally, headaches may need further diagnosis to rule out more serious underlying causes. Chiropractic care and physical therapy are also commonly utilized to help treat headaches. Below, we will discuss the different types of headaches.
The most common types of headaches, by far, are tension headaches and migraines.
Tension headaches are generally felt as a band around the forehead. They may last for many days. They may be tiring and uncomfortable, but they don’t normally disturb sleep. Most people can carry on working with a tension headache. These often have a tendency to worsen as the day progresses, however, they aren’t usually made worse with physical activities, though it’s not strange to be somewhat sensitive to bright light or noise.
Migraines are also very common types of headaches. A typical migraine is described as a throbbing sensation. Headaches which are one-sided, headaches which throb and headaches that make you feel sick are more inclined to be migraines compared to anything else. Migraines are often severe enough to be disabling. Some individuals will need to go to bed to sleep off their aggravation.
Cluster headaches are extremely severe headaches, sometimes called “suicide headaches”. They occur in clusters, often every day for a number of days or maybe weeks. Then they vanish for weeks on end. These types of headaches are rare and often occur particularly in adult male smokers. They’re intense, one-sided headaches, which are very disabling, meaning they stop routine activity. People often describe them as the worst pain they have ever felt. Cluster headaches are typically one-sided. Patients frequently have a red watery eye on the other hand, a stuffy runny nose and a droopy eyelid.
Chronic Tension Headaches
Chronic tension headaches (or chronic daily headache) is generally caused by muscle tension in the back of the neck and affects women more frequently than men. Chronic means that the problem is persistent and ongoing. These headaches can develop due to neck injuries or tiredness and may worsen with drug/medication overuse. A headache that occurs virtually every day for 3 weeks or more is known as a chronic daily headache or a chronic tension headaches.
Medication-overuse headaches or medication-induced aggravation, is an unpleasant and long-term headache. It’s brought on by taking painkillers usually meant for headaches. Unfortunately, when painkillers are taken regularly for headaches, the body reacts by creating additional pain sensors in the brain. Finally, the pain sensors are so many that the head becomes super-sensitive and the headache won’t go away. Individuals who have these headaches often take an increasing number of painkillers to attempt and feel much better. But, the painkillers may have regularly long ceased to work. Medication-overuse headaches are the most common cause of secondary headache.
Exertional Headaches/Sexual Headaches
Exertional headaches are headaches associated with physical activity. They may get severe very quickly following a strenuous activity like coughing, running, with intercourse, and straining with bowel movements. They’re more commonly experienced by patients that also have migraines, or who have relatives with migraine.
Headaches associated with sex particularly worry patients. They can occur as sex starts, at orgasm, or following sex. Headaches at orgasm would be the most common type. They are generally acute, at the back of the head, behind the eyes or all around. They last about twenty minutes and aren’t usually an indication of any other underlying health issues or problems.
Exertional and sexual intercourse-related headaches aren’t typically an indication of serious underlying problems. Very occasionally, they can be a sign that there is a leaky blood vessel on the surface of the brain. As a result, if they are marked and repeated, it’s sensible to talk about them with your healthcare professional.
Primary Stabbing Headaches
Primary traumatic headaches are sometimes called “ice-pick headaches” or “idiopathic stabbing headache”. The term “idiopathic” is used by doctors for something that comes without a clear cause. These are brief, stabbing headaches that are extremely sudden and severe. They generally last between 5 and 30 seconds and they occur at any time of the day or night. They feel as though a sharp object, like an ice pick, is being stuck into your head. They frequently occur in or just behind the ear and they are sometimes quite frightening. Even though they aren’t migraines they’re more prevalent in those who suffer from migraines, nearly half of individuals who experience migraines have principal stabbing headaches.
They are often felt at the place on the head where the migraines have a tendency to happen. Primary stabbing headaches are too brief to take care of, even though migraine prevention medications may reduce their number.
Hemicrania continua is a major chronic daily headache. It typically induces a continuous but shifting pain on one side of the brain. The pain is generally continuous with episodes of severe pain, which can last between 20 minutes and several days. During those episodes of severe pain there may be other symptoms, such as watering or redness of the eye, runny or blocked nose, and drooping of the eyelid, around precisely the same side as the aggravation. Similar to a migraine, there may also be sensitivity to light, feeling sick, such as nausea, and being sick, such as vomiting. The headaches do not go away but there may be periods when you don’t have any headaches. Hemicrania continua headaches respond to medicine called indometacin.
Trigeminal neuralgia causes facial pain. The pain consists of very short bursts of electric shock-like sensations in the face, particularly at the area of the eyes, nose, scalp, brow, lips or limbs. It’s usually one-sided and is more common in people over age 50. It may be triggered by touch or a light breeze on the surface area.
Occasionally, headaches have underlying causes, and treatment of the headache involves treating the cause. Individuals often fear that headaches are caused by serious illness, or by high blood pressure. Both of these are extremely uncommon causes of headache, really increased blood pressure usually causes no symptoms in any way.
Chemicals, Drugs and Substance Withdrawal
Headaches can be because of a substance, or its withdrawal, for example:
Carbon monoxide, that is made by gas heaters which aren’t properly ventilated
Drinking alcohol, with headache often experienced the morning afterwards
Deficiency of body fluid or dehydration
Headaches Due to Referred Pain
Some headaches may be caused by pain in some other portion of the head, such as ear or tooth pain, pain in the jaw joint and pain in the neck.
Sinusitis is also a frequent cause of headaches. The sinuses are “holes” in the skull which are there to stop it from becoming too heavy for the neck to transport around. They are lined with mucous membranes, such as the lining of the nose, and this creates mucus in response to colds or allergy. The liner membranes also swell and can block the drainage of the mucus out of the space. It subsequently becomes cracked and infected, resulting in headache. The headache of sinusitis is often felt at the front of the head and also in the face or teeth.
Frequently the face feels tender to tension, particularly just below the eyes beside the nose. You might have a stuffy nose and the pain is often worse when you bend forwards. Acute sinusitis is the kind that comes on fast in conjunction with a cold or abrupt allergy. You may have a temperature and be generating a lot of mucus. Chronic sinusitis may be caused by allergy, by overusing decongestants or with the acute sinusitis that doesn’t settle. The sinuses become chronically infected and the nasal linings chronically swollen. The contents of this uterus may be thick but frequently not infected.
Acute glaucoma can cause severe headaches. In this condition, the pressure inside the eyes goes up suddenly and this causes a surprisingly, very severe headache behind the eye. Even the eyeball can feel really hard to touch, the eye is red, the front part of the eye, or cornea, can seem cloudy and the eyesight is generally blurred.
What Types of Headaches are Dangerous or Serious?
All headaches are unpleasant and some, such as headache from medication abuse, are serious in the sense that if not treated correctly they might never go away. But a few headaches are indications of serious underlying issues. These are uncommon, in many cases very rare. Dangerous headaches often occur suddenly, and also eventually become increasingly worse over time. They are more common in elderly people. They comprise of the following:
Bleeding Around the Brain (Subarachnoid Haemorrhage)
Subarachnoid haemorrhage is a really serious condition which occurs when a tiny blood vessel pops on the surface of the brain. Patients develop a serious headache and stiff neck and may become unconscious. This is a rare cause of acute headache.
Meningitis and Brain Infections
Meningitis is infection of the tissues around and on the surface of the brain and encephalitis is infection of the brain itself. Brain infections can be caused by germs called bacteria, viruses or parasites and they are thankfully rare. They cause a severe, disabling headache. Normally, patients may feel sick or vomit and can’t bear bright lights, something known as photophobia. Often they have a rigid neck, too stiff for your physician to have the ability to bend the head down so that the chin touches the chest, even in the event that you attempt to relax. Patients are generally also unwell, experiencing hot, sweaty and overall sick sensations.
Giant Cell Arteritis (Temporal Arteritis)
Giant cell arteritis (temporal arteritis) is, generally, just seen in people over the age of 50. It is due to swelling, or inflammation, of the arteries at the temples and behind the eye. It causes a headache behind the forehead, also referred to as a sinus headache. Typically the blood vessels at the forehead are tender and individuals detect pain from the scalp when they comb their own hair. Frequently the pain gets worse with chewing. Temporal arteritis is severe because if it’s not treated it can cause sudden loss of eyesight. Treatment is with a course of steroids. The need to keep these steroids is generally monitored by the GP through blood tests, and they are typically needed for several months.
Brain tumors are a very uncommon cause of headache, although most patients with long-term, severe or persistent headaches start to worry that this might be the reason. Brain tumors can lead to headaches. Usually the aggravation of brain tumors exists on waking in the morning, is worse on sitting up, and becoming steadily worse in the day to day, never easing and never disappearing. It can sometimes be worse on coughing and sneezing, as may sinus headaches and migraines.
When Should I Worry About a Headache?
Most headaches do not have a serious underlying cause. However, healthcare professionals are trained to ask you about the signs and symptoms that might suggest your headache needs further diagnosis, just to make certain it’s nothing serious.
The things which would suggest to your physician and nurse that your headache may need additional evaluation include the following. They don’t mean that your headache is severe or sinister, but they imply that the healthcare professional may wish to do some additional evaluations to make sure if:
You have had a substantial head injury in the previous three months.
Your headaches are worsening and accompanied with high temperature or fever.
Your headaches begin extremely unexpectedly.
You’ve developed problems with speech and balance as well as headache.
You’ve developed problems with your memory or changes in your behavior or personality in addition to headache.
You’re confused or muddled along with your headache.
Your headache started when you coughed, sneezed or strained.
Your headache is much worse when you sit or stand.
Your headache is associated with red or painful eyes.
Your headaches are not like anything you’ve ever experienced before.
You have unexplained nausea together with the aggravation.
You have low immunity, for instance, when you have HIV, or are about oral steroid medicine or immune suppressing drugs.
You have or have had a type of cancer that can spread throughout the body.
Dr. Alex Jimenez’s Insight
Headaches are extremely common health issues which affect a wide range of the population around the world. Although frequent, a headache which is described to be like no other ever experienced before, may often become a concern. There are several types of headaches which can be caused by a variety of injuries and/or underlying conditions. As a healthcare professional, it’s essential to be able to determine between sinister or dangerous types of headaches and benign types of headaches, in order to decide the best treatment approach. By properly diagnosing the source of a patient’s headaches, both benign and sinister types of headaches can be treated accordingly.
Many headaches, whilst unpleasant, are harmless and react to a variety of treatments, including chiropractic care. Migraine, tension headaches and medication-overuse headaches are very common. The majority of the populace will experience one or more of these. Working out exactly the underlying cause of any headaches through discussion with your doctor is often the best method to resolve them. It is possible to develop a persistent or chronic and constant headache through taking drugs and/or medications that you took to get rid of your headache. Your physician can support you through the practice of quitting painkillers when that is the case.
Headaches are, quite infrequently, an indication of a serious or sinister underlying illness, and many headaches go away on their own.
If you have a headache which is uncommon for you then you need to discuss it with your doctor. You should also speak to your doctor about headaches which are particularly severe or that affect your regular activities, those that are associated with other symptoms, such as tingling or weakness, and those which make your own scalp tender, especially if you’re over 50 years old. Finally, always speak to a healthcare professional when you have an unremitting morning headache which is present for at least three days or is becoming gradually worse.
Remember that headaches are not as likely to occur in people who:
Handle their anxiety levels well.
Eat a balanced, regular diet.
Take balanced routine exercise.
Focus on posture and core muscles.
Sleep on two pillows or fewer.
Drink loads of water.
Have plenty of sleep.
Anything that you can do to enhance one or more of these aspects of your life will improve your health and well-being and cut back the number of headaches you experience. Make sure to seek the appropriate medical attention from a qualified and experienced healthcare professional in the event of a severe headache unlike anything you’ve ever experienced before. 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
Additional Topics: Back Pain
Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of 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.
Chiropractic Benefits: If you have ever had a migraine before then you know that it is much more than a simple headache. The symptoms of a migraine can be debilitating, lasting hours and even days. According to the Migraine Research Foundation, it is the eighth most disabling disease in the world. It is estimated that 38 million people in the United States alone suffer from migraine headaches. That’s around one in every ten people.
According to the Migraine Research Foundation, migraine headaches are extremely difficult to treat and even more difficult to control. This is mainly due to the fact that doctors still don’t know exactly what causes it. This leaves it undiagnosed in many patients and often terribly under treated in those with a diagnosis.
The best many doctors seem to be able to do is prescribe pain medication that has undesirable side effects in an effort to manage the symptoms. However, chiropractic has been shown in several studies to not only effectively manage the pain of migraines, it also helps stop and prevent them.
Anatomy Of A Migraine Headache
There are two types of migraines, those with an aura and those without an aura. An aura can appear up to an hour before the onset of a migraine. It is a warning sign that usually presents as a disturbance that is either visual or olfactory. The person may see flashes of light or smell particular odors before the headache begins. About one in six migraines are preceded by an aura.
Once the migraine itself begins, the pain is typically on one side of the head, although this is not always the case. Other symptoms may include nausea, vomiting, sensitivity to noise, sensitivity to light, and sensitivity to smell. Some patients experience an inability to concentrate, hot or cold flashes, stiffness in neck or shoulders, slurred speech, loss of coordination, and in rare cases, loss of consciousness.
The migraine can last several minutes, hours, or even days. Afterwards the patient may feel fatigued or washed out. They may be unable to concentrate and either lethargic or extremely energetic.
Studies Show: Chiropractic As A Migraine Treatment
There have been several clinical studies on chiropractic as a treatment for migraine headaches. The results of one study reported that 22 percent of patients who received chiropractic treatment for their migraines reported that their attacks were reduced by more than 90 percent. Additionally, 49 percent reported that the intensity of their migraines was significantly reduced.
Another study randomly assigned people with migraine headaches several different treatments. One group was given Elavil, a daily medication, another group was given chiropractic treatment and a third group received a combination of the two treatments. The results showed that chiropractic was as effective in reducing migraines as the medication and it had fewer side effects. Other studies have also found that chiropractic is as effective as medication for the treatment and prevention of migraine or tension headaches.
Chiropractic Benefits For Migraines Headaches
Spinal adjustments are very effective as a treatment for migraines. The whole body approach of chiropractic also utilizes dietary recommendations, including foods to avoid, as well as lifestyle changes.
The patient may be counseled on managing stress, advised to engage in exercise, and given supplements. The treatments may be used to reduce the pain and severity of a migraine once it begins or it can be used to prevent migraines and reduce their frequency.
Chiropractic benefits everyone and is a safer treatment with fewer side effects than prescription medications. Chiropractic is quickly becoming the treatment of choice for many migraine sufferers. As the studies show, it works! So if you or a loved one suffer from migraines, give us a call. Our Doctor of Chiropractic is here to help!
Suffer Migraines: If you’ve ever had a migraine you know that it’s more than just a headache. The debilitating pain can be accompanied by nausea and other symptoms – and it’s more common than you may think. Research shows that in every four American households, one person is a migraine sufferer. In fact, 12 percent of the U.S. population suffers from migraines, including children. This means migraines affect more people that asthma and diabetes combined.
It is estimated that 18 percent of women suffer from migraines while 6 percent of men are migraine sufferers. It most commonly affects people who are between the ages of 25 and 55, but even young children have been diagnosed. Migraines can stop you in your tracks, but there are treatments that can help. Chiropractic care has been shown to help ease the pain, intensity, and frequency of migraines.
Suffer From Migraines
What Is A Migraine?
Migraines are vicious headaches that can last several minutes to several hours or even days. It is characterized by intense pulsing or a throbbing sensation that is typically confined to one area of the head. It is often accompanied by vomiting, nausea, and extreme sensitivity to sound and light. The pain can be so severe that you can barely function. Many people find themselves confined to bed in a darkened room, waiting for it to pass.
Many times migraine sufferers report experiencing an aura, or sensory warning symptoms, such as strange smells, blind spots, flashes of light, or tingling in your leg or arm. They also tend to run in families. If one parent is a migraine sufferer the child has a 40 percent chance of having migraines as well. If both parents get migraines that chance jumps to 90 percent. It is the 8th most debilitating illness on a global scale.
For the most part, doctors do not know much about what causes migraines. However, there are some things that have been identified as migraine triggers:
Hormonal changes – at certain times during the month, women experience fluctuations in estrogen which can trigger migraines
Oral contraceptives – medications that change or replace hormones can make headaches worse
Certain foods – processed foods, MSG, salty foods, aged cheeses
Fasting or skipping meals
Intense physical exertion
Too much or too little sleep
How Chiropractic Care Can Help Migraine Sufferers
Many doctors believe that headaches and migraines may be caused by a spine that is out of alignment. When your spine is misaligned your entire body suffers. It can irritate the nerves that run from the brain to the spine causing a headache. Chiropractic adjustments can help relieve the pain of migraines. In fact, many people report a distinct difference after just one session.
A Doctor of Chiropractic will align your spine and work with you to create a wellness plan that includes lifestyle changes and diet. Making changes to your sleep patterns and eliminating certain foods from your diet can help prevent migraines. By creating a whole body wellness program, you and your chiropractor can not only help prevent your migraines, but other health conditions as well.
Your chiropractor may also recommend that you keep a journal to help you pinpoint your own unique migraine triggers. You will record the foods you eat, environmental factors that may affect you, stressors, and sleep patterns, as well as when you have migraines, how long they last, and their severity. By tracking these things, you can determine what may be causing your migraines and make adjustments to your lifestyle, thus preventing them. Incorporating chiropractic care as part of your whole body maintenance, as well as migraine prevention, can help you stave off these headaches so you can get on with your life.
If you or a loved one suffers from migraine headaches, make sure you give us a call. Our Doctor of Chiropractic is here to help!
Damaris Foreman started chiropractic care with Dr. Alex Jimenez for her migraine headache pain. When every traditional treatment she received proved ineffective, she turned to spinal adjustments and manual manipulations for relief. Damaris Foreman experienced the benefits of chiropractic care almost immediately after her first visit with Dr. Alex Jimenez and she experienced reduced migraine headache pain symptoms. Furthermore, Damaris Foreman highly recommends chiropractic care with Dr. Alex Jimenez as a non-surgical choice for the effective treatment of migraines.
Globally, approximately 15 percent of people are affected by migraines. It often begins at puberty and is worst through middle age. In many women they become common during menopause. As of 2016, it is among the most common cause of disability. Migraines present with recurrent severe headache associated symptoms. Approximately 15 to 30 percent of people with migraines experience an aura. Those who have migraines with aura also frequently have migraines without aura. The seriousness of the pain, length of the headache, and frequency of the migraine may differ.
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Damaris Foreman suffered from migraines for about 23 years. After receiving traditional treatment for her migraine pain without much improvement, she was finally recommended to seek migraine pain treatment with Dr. Alex Jimenez, a chiropractor in El Paso, TX. Damaris greatly benefitted from chiropractic care and she experienced a tremendous sense of relief following her first spinal adjustment and manual manipulation. Damaris Foreman was able to confront many of her misconceptions and she learned very much about her migraine pain. Damaris describes Dr. Alex Jimenez’s migraine pain treatment as one of the best treatment she’s received and she highly recommends chiropractic care as the best non-surgical choice for improving and managing her migraines.
A migraine can be identified as a primary headache disorder characterized by recurrent headaches characterized from moderate to severe in intensity. Typically, the headaches affect one half of the head, are pulsating in nature, and can last from two to 72 hours. Associated symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. The pain may be aggravated by physical activity. Up to one-third of people who suffer from migraines experience migraine with aura: typically a brief period of visual disturbance that signals that the headache will soon happen. An aura can occur with little or no headache pain following it.
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Everyone experiences pain from time to time. Pain is a physical feeling of discomfort caused by injury or illness. When you pull a muscle or cut your finger, for instance, a signal is sent through the nerve roots to the brain, signaling you that something is wrong in the body. Pain may be different for everyone and there are several ways of feeling and describing pain. After an injury or illness heals, the pain will subside, however, what happens if the pain continues even after you’ve healed?
Chronic pain is often defined as any pain which lasts more than 12 weeks. Chronic pain can range from mild to severe and it can be the result of previous injury or surgery, migraine and headache, arthritis, nerve damage, infection and fibromyalgia. Chronic pain can affect an individual’s emotional and mental disposition, making it more difficult to relieve the symptoms. Research studies have demonstrated that psychological interventions can assist the chronic pain recovery process. Several healthcare professionals, like a doctor of chiropractic, can provide chiropractic care together with psychological interventions to help restore the overall health and wellness of their patients. The purpose of the following article is to demonstrate the role of psychological interventions in the management of patients with chronic pain, including headache and back pain.
The Role of Psychological Interventions in the Management of Patients with Chronic Pain
Chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient’s physiological state, thoughts, emotions, behaviors, and sociocultural influences. A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain. Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress – improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, psychologists can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives.
Chronic pain has previously been determined to affect the psychological health of those with persistent symptoms, ultimately altering their overall mental and emotional disposition. In addition, patients with overlapping conditions, including stress, anxiety and depression, can make treatment a challenge. The role of chiropractic care is to restore as well as maintain and improve the original alignment of the spine through the use of spinal adjustments and manual manipulations. Chiropractic care allows the body to naturally heal itself without the need for drugs/medications and surgical interventions, although these can be referred to by a chiropractor if needed. However, chiropractic care focuses on the body as a whole, rather than on a single injury and/or condition and its symptoms. Spinal adjustments and manual manipulations, among other treatment methods and techniques commonly used by a chiropractor, require awareness of the patient’s mental and emotional disposition in order to effectively provide them with overall health and wellness. Patients who visit my clinic with emotional distress from their chronic pain are often more susceptible to experience psychological issues as a result. Therefore, chiropractic care can be a fundamental psychological intervention for chronic pain management, along with those demonstrated below.
Pain is a ubiquitous human experience. It is estimated that approximately 20%–35% of adults experience chronic pain.[1,2] The National Institute of Nursing Research reports that pain affects more Americans than diabetes, heart disease, and cancer combined. Pain has been cited as the primary reason to seek medical care in the United States. Furthermore, pain relievers are the second most commonly prescribed medications in physicians’ offices and emergency rooms. Further solidifying the importance of adequate assessment of pain, the Joint Commission on the Accreditation of Healthcare Organizations issued a mandate requiring that pain be evaluated as the fifth vital sign during medical visits.
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The IASP’s definition highlights the multidimensional and subjective nature of pain, a complex experience that is unique to each individual. Chronic pain is typically differentiated from acute pain based on its chronicity or persistence, its physiological maintenance mechanisms, and/or its detrimental impact on an individual’s life. Generally, it is accepted that pain that persists beyond the expected period of time for tissue healing following an injury or surgery is considered chronic pain. However, the specific timeframe constituting an expected healing period is variable and often difficult to ascertain. For ease of classification, certain guidelines suggest that pain persisting beyond a 3–6 month time window is considered chronic pain. Nevertheless, classification of pain based solely on duration is a strictly practical and, in some instances, arbitrary criterion. More commonly, additional factors such as etiology, pain intensity, and impact are considered alongside duration when classifying chronic pain. An alternative way to characterize chronic pain has been based on its physiological maintenance mechanism; that is, pain that is thought to emerge as a result of peripheral and central reorganization. Common chronic pain conditions include musculoskeletal disorders, neuropathic pain conditions, headache pain, cancer pain, and visceral pain. More broadly, pain conditions may be primarily nociceptive (producing mechanical or chemical pain), neuropathic (resulting from nerve damage), or central (resulting from dysfunction in the neurons of the central nervous system).
Unfortunately, the experience of pain is frequently characterized by undue physical, psychological, social, and financial suffering. Chronic pain has been recognized as the leading cause of long-term disability in the working- age American population. Because chronic pain affects the individual at multiple domains of his/her existence it also constitutes an enormous financial burden to our society. The combined direct and indirect costs of pain have been estimated to range from $125 billion to $215 billion, annually.[10,11] The widespread implications of chronic pain include increased reports of emotional distress (eg, depression, anxiety, and frustration), increased rates of pain-related disability, pain-related alterations in cognition, and reduced quality of life. Thus, chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient’s physiological state, thoughts, emotions, behaviors, and sociocultural influences.
Given the widespread prevalence of pain and its multi-dimensional nature, an ideal pain management regimen will be comprehensive, integrative, and interdisciplinary. Current approaches to the management of chronic pain have increasingly transcended the reductionist and strictly surgical, physical, or pharmacological approach to treatment. Current approaches recognize the value of a multidisciplinary treatment framework that targets not only nociceptive aspects of pain but also cognitive-evaluative, and motivational-affective aspects alongside equally unpleasant and impacting sequelae. The interdisciplinary management of chronic pain typically includes multimodal treatments such as combinations of analgesics, physical therapy, behavioral therapy, and psychological therapy. The multimodal approach more adequately and comprehensively addresses pain management at the molecular, behavioral, cognitive-affective, and functional levels. These approaches have been shown to lead to superior and long-lasting subjective and objective outcomes including pain reports, mood, restoration of daily functioning, work status, and medication or health care use; multimodal approaches have also been shown to be more cost-effective than unimodal approaches.[12,13] The focus of this review will be specifically on elucidating the benefits of psychology in the management of chronic pain.
Patients will typically initially present to a physician’s office in the pursuit of a cure or treatment for their ailment/acute pain. For many patients, depending on the etiology and pathology of their pain alongside biopsychosocial influences on the pain experience, acute pain will resolve with the passage of time, or following treatments aimed at targeting the presumed cause of pain or its transmission. Nonetheless, some patients will not achieve resolution of their pain despite numerous medical and complementary interventions and will transition from an acute pain state to a state of chronic, intractable pain. For instance, research has demonstrated that approximately 30% of patients presenting to their primary-care physician for complaints related to acute back pain will continue to experience pain and, for many others, severe activity limitations and suffering 12 months later. As pain and its consequences continue to develop and manifest in diverse aspects of life, chronic pain may become primarily a biopsychosocial problem, whereby numerous biopsychosocial aspects may serve to perpetuate and maintain pain, thus continuing to negatively impact the affected individual’s life. It is at this point that the original treatment regimen may diversify to include other therapeutic components, including psychological approaches to pain management.
Psychological approaches for the management of chronic pain initially gained popularity in the late 1960s with the emergence of Melzack and Wall’s “gate-control theory of pain” and the subsequent “neuromatrix theory of pain”. Briefly, these theories posit that psychosocial and physiological processes interact to affect perception, transmission, and evaluation of pain, and recognize the influence of these processes as maintenance factors involved in the states of chronic or prolonged pain. Namely, these theories served as integral catalysts for instituting change in the dominant and unimodal approach to the treatment of pain, one heavily dominated by strictly biological perspectives. Clinicians and patients alike gained an increasing recognition and appreciation for the complexity of pain processing and maintenance; consequently, the acceptance of and preference for multidimensional conceptualizations of pain were established. Currently, the biopsychosocial model of pain is, perhaps, the most widely accepted heuristic approach to understanding pain. A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain. As the utility of a broader and more comprehensive approach to the management of chronic pain has become evident, psychologically-based interventions have witnessed a remarkable rise in popularity and recognition as adjunct treatments. The types of psychological interventions employed as part of a multidisciplinary pain treatment program vary according to therapist orientation, pain etiology, and patient characteristics. Likewise, research on the effectiveness of psychologically based interventions for chronic pain has shown variable, albeit promising, results on key variables studied. This overview will briefly describe frequently employed psychologically based treatment options and their respective effectiveness on key outcomes.
Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. As such, they target the frequently overlooked behavioral, emotional, and cognitive components of chronic pain and factors contributing to its maintenance. Informed by the framework offered by Hoffman et al and Kerns et al, the following frequently employed psychologically-based treatment domains are reviewed: psychophysiological techniques, behavioral approaches to treatment, cognitive behavioral therapy, and acceptance-based interventions.
Biofeedback is a learning technique through which patients learn to interpret feedback (in the form of physiological data) regarding certain physiological functions. For instance, a patient may use biofeedback equipment to learn to recognize areas of tension in their body and subsequently learn to relax those areas to reduce muscular tension. Feedback is provided by a variety of measurement instruments that can yield information about brain electrical activity, blood pressure, blood flow, muscle tone, electrodermal activity, heart rate, and skin temperature, among other physiological functions in a rapid manner. The goal of biofeedback approaches is for the patient to learn how to initiate physiological self-regulatory processes by achieving voluntary control over certain physiological responses to ultimately increase physiological flexibility through greater awareness and specific training. Thus a patient will use specific self-regulatory skills in an attempt to reduce an undesired event (eg, pain) or maladaptive physiological reactions to an undesired event (eg, stress response). Many psychologists are trained in biofeedback techniques and provide these services as part of therapy. Biofeedback has been designated as an efficacious treatment for pain associated with headache and temporomandibular disorders (TMD). A meta-analysis of 55 studies revealed that biofeedback interventions (including various biofeedback modalities) yielded significant improvements with regard to frequency of migraine attacks and perceptions of headache management self-efficacy when compared to control conditions. Studies have provided empirical support for biofeedback for TMD, albeit more robust improvements with regard to pain and pain-related disability have been found for protocols that combine biofeedback with cognitive behavioral skills training, under the assumption that a combined treatment approach more comprehensively addresses the gamut of biopsychosocial problems that may be encountered as a result of TMD.
It is generally accepted that stress is a key factor involved in the exacerbation and maintenance of chronic pain.[16,23] Stress can be predominantly of an environmental, physical, or psychological/emotional basis, though typically these mechanisms are intricately intertwined. The focus of relaxation training is to reduce tension levels (physical and mental) through activation of the parasympathetic nervous system and through attainment of greater awareness of physiological and psychological states, thereby achieving reductions in pain and increasing control over pain. Patients can be taught several relaxation techniques and practice them individually or in conjunction with one another, as well as adjuvant components to other behavioral and cognitive pain management techniques. The following are brief descriptions of relaxation techniques commonly taught by psychologists specializing in the management of chronic pain.
Diaphragmatic breathing. Diaphragmatic breathing is a basic relaxation technique whereby patients are instructed to use the muscles of their diaphragm as opposed to the muscles of their chest to engage in deep breathing exercises. Breathing by contracting the diaphragm allows the lungs to expand down (marked by expansion of abdomen during inhalation) and thus increase oxygen intake.
Progressive muscle relaxation (PMR). PMR is characterized by engaging in a combination of muscle tension and relaxation exercises of specific muscles or muscle groups throughout the body. The patient is typically instructed to engage in the tension/relaxation exercises in a sequential manner until all areas of the body have been addressed.
Autogenic training (AT). AT is a self-regulatory relaxation technique in which a patient repeats a phrase in conjunction with visualization to induce a state of relaxation.[26,27] This method combines passive concentration, visualization, and deep breathing techniques.
Visualization/Guided imagery. This technique encourages patients to use all of their senses in imagining a vivid, serene, and safe environment to achieve a sense of relaxation and distraction from their pain and pain-related thoughts and sensations.
Collectively, relaxation techniques have generally been found to be beneficial in the management of a variety of types of acute and chronic pain conditions as well as in the management of important pain sequelae (eg, health-related quality of life).[28–31] Relaxation techniques are usually practiced in conjunction with other pain management modalities, and there is considerable overlap in the presumed mechanisms of relaxation and biofeedback, for instance.
Operant Behavior Therapy
Operant behavior therapy for chronic pain is guided by the original operant conditioning principles proposed by Skinner and refined by Fordyce to be applicable to pain management. The main tenets of the operant conditioning model as it relates to pain hold that pain behavior can eventually evolve into and be maintained as chronic pain manifestations as a result of positive or negative reinforcement of a given pain behavior as well as punishment of more adaptive, non-pain behavior. If reinforcement and the ensuing consequences occur with sufficient frequency, they can serve to condition the behavior, thus increasing the likelihood of repeating the behavior in the future. Therefore, conditioned behaviors occur as a product of learning of the consequences (actual or anticipated) of engaging in the given behavior. An example of a conditioned behavior is continued use of medication – a behavior that results from learning through repeated associations that taking medication is followed by removal of an aversive sensation (pain). Likewise, pain behaviors (eg, verbal expressions of pain, low activity levels) can be become conditioned behaviors that serve to perpetuate chronic pain and its sequelae. Treatments that are guided by operant behavior principles aim to extinguish maladaptive pain behaviors through the same learning principles that these may have been established by. In general, treatment components of operant behavior therapy include graded activation, time contingent medication schedules, and use of reinforcement principles to increase well behaviors and decrease maladaptive pain behaviors.
Graded activation. Psychologists can implement graded activity programs for chronic pain patients who have vastly reduced their activity levels (increasing likelihood of physical deconditioning) and subsequently experience high levels of pain upon engaging in activity. Patients are instructed to safely break the cycle of inactivity and deconditioning by engaging in activity in a controlled and time-limited fashion. In this manner, patients can gradually increase the length of time and intensity of activity to improve functioning. Psychologists can oversee progress and provide appropriate reinforcement for compliance, correction of misperceptions or misinterpretations of pain resulting from activity, where appropriate, and problem-solve barriers to adherence. This approach is frequently embedded within cognitive-behavioral pain management treatments.
Time-contingent medication schedules. A psychologist can be an important adjunct healthcare provider in overseeing the management of pain medications. In some cases, psychologists have the opportunity for more frequent and in-depth contact with patients than physicians and thus can serve as valuable collaborators of an integrated multidisciplinary treatment approach. Psychologists can institute time-contingent medication schedules to reduce the likelihood of dependence on pain medications for attaining adequate control over pain. Furthermore, psychologists are well equipped to engage patients in important conversations regarding the importance of proper adherence to medications and medical recommendations and problem-solve perceived barriers to safe adherence.
Fear-avoidance. The fear-avoidance model of chronic pain is a heuristic most frequently applied in the context of chronic low back pain (LBP). This model draws largely from the operant behavior principles described previously. In essence, the fear-avoidance model posits that when acute pain states are repeatedly misinterpreted as danger signals or signs of serious injury, patients may be at risk of engaging in fear-driven avoidance behaviors and cognitions that further reinforce the belief that pain is a danger signal and perpetuate physical deconditioning. As the cycle continues, avoidance may generalize to broader types of activity and result in hypervigilance of physical sensations characterized by misinformed catastrophic interpretations of physical sensations. Research has shown that a high degree of pain catastrophizing is associated with maintenance of the cycle. Treatments aimed at breaking the fear-avoidance cycle employ systematic graded exposure to feared activities to disconfirm the feared, often catastrophic, consequences of engaging in activities. Graded exposure is typically supplemented with psychoeducation about pain and cognitive restructuring elements that target maladaptive cognitions and expectations about activity and pain. Psychologists are in an excellent position to execute these types of interventions that closely mimic exposure treatments traditionally used in the treatment of some anxiety disorders.
Though specific graded exposure treatments have been shown to be effective in the treatment of complex regional pain syndrome type I (CRPS-1) and LBP in single-case designs, a larger-scale randomized controlled trial comparing systematic graded exposure treatment combined with multidisciplinary pain program treatment with multidisciplinary pain program treatment alone and with a wait-list control group found that the two active treatments resulted in significant improvements on outcome measures of pain intensity, fear of movement/injury, pain self-efficacy, depression, and activity level. Results from this trial suggest that both interventions were associated with significant treatment effectiveness such that the graded exposure treatment did not appear to result in additional treatment gains. A cautionary note in the interpretation of these results highlights that the randomized controlled trial (RCT) included a variety of chronic pain conditions that extended beyond LBP and CRPS-1 and did not exclusively include patients with high levels of pain-related fear; the interventions were also delivered in group formats rather than individual formats. Although in-vivo exposure treatments are superior at reducing pain catastrophizing and perceptions of harmfulness of activities, exposure treatments seem to be as effective as graded activity interventions in improving functional disability and chief complaints. Another clinical trial compared the effectiveness of treatment-based classification (TBC) physical therapy alone to TBC augmented with graded activity or graded exposure for patients with acute and sub-acute LBP. Outcomes revealed that there were no differences in 4-week and 6-month outcomes for reduction of disability, pain intensity, pain catastrophizing, and physical impairment among treatment groups, although graded exposure and TBC yielded larger reductions in fear-avoidance beliefs at 6 months. Findings from this clinical trial suggest that enhancing TBC with graded activity or graded exposure does not lead to improved outcomes with regard to measures associated with the development of chronic LBP beyond improvements achieved with TBC alone.
Cognitive-behavioral therapy (CBT) interventions for chronic pain utilize psychological principles to effect adaptive changes in the patient’s behaviors, cognitions or evaluations, and emotions. These interventions are generally comprised of basic psychoeducation about pain and the patient’s particular pain syndrome, several behavioral components, coping skills training, problem-solving approaches, and a cognitive restructuring component, though the exact treatment components vary according to the clinician. Behavioral components may include a variety of relaxation skills (as reviewed in the behavioral approaches section), activity pacing instructions/graded activation, behavioral activation strategies, and promotion of resumption of physical activity if there is a significant history of activity avoidance and subsequent deconditioning. The primary aim in coping skills training is to identify current maladaptive coping strategies (eg, catastrophizing, avoidance) that the patient is engaging in alongside their use of adaptive coping strategies (eg, use of positive self-statements, social support). As a cautionary note, the degree to which a strategy is adaptive or maladaptive and the perceived effectiveness of particular coping strategies varies from individual to individual. Throughout treatment, problem-solving techniques are honed to aid patients in their adherence efforts and to help them increase their self-efficacy. Cognitive restructuring entails recognition of current maladaptive cognitions the patient is engaging in, challenging of the identified negative cognitions, and reformulation of thoughts to generate balanced, adaptive alternative thoughts. Through cognitive restructuring exercises, patients become increasingly adept at recognizing how their emotions, cognitions, and interpretations modulate their pain in positive and negative directions. As a result, it is presumed that the patients will attain a greater perception of control over their pain, be better able to manage their behavior and thoughts as they relate to pain, and be able to more adaptively evaluate the meaning they ascribe to their pain. Additional components sometimes included in a CBT intervention include social skills training, communication training, and broader approaches to stress management. Via a pain-oriented CBT intervention, many patients profit from improvements with regard to their emotional and functional well-being, and ultimately their global perceived health-related quality of life.
CBT interventions are delivered within a supportive and empathetic environment that strives to understand the patient’s pain from a biopsychosocial perspective and in an integrated manner. Therapists see their role as “teachers” or “coaches” and the message communicated to patients is that of learning to better manage their pain and improve their daily function and quality of life as opposed to aiming to cure or eradicate the pain. The overarching goal is to increase the patients’ understanding of their pain and their efforts to manage pain and its sequelae in a safe and adaptive manner; therefore, teaching patients to self-monitor their behavior, thoughts, and emotions is an integral component of therapy and a useful strategy to enhance self-efficacy. Additionally, the therapist endeavors to foster an optimistic, realistic, and encouraging environment in which the patient can become increasingly skilled at recognizing and learning from their successes and learning from and improving upon unsuccessful attempts. In this manner, therapists and patients work together to identify patient successes, barriers to adherence, and to develop maintenance and relapse-prevention plans in a constructive, collaborative, and trustworthy atmosphere. An appealing feature of the cognitive behavioral approach is its endorsement of the patient as an active participant of his/her pain rehabilitation or management program.
Research has found CBT to be an effective treatment for chronic pain and its sequelae as marked by significant changes in various domains (ie, measures of pain experience, mood/affect, cognitive coping and appraisal, pain behavior and activity level, and social role function) when compared with wait-list control conditions. When compared with other active treatments or control conditions, CBT has resulted in notable improvements, albeit smaller effects (effect size ~ 0.50), with regard to pain experience, cognitive coping and appraisal, and social role function. A more recent meta-analysis of 52 published studies compared behavior therapy (BT) and CBT against treatment as usual control conditions and active control conditions at various time-points. This meta-analysis concluded that their data did not lend support for BT beyond improvements in pain immediately following treatment when compared with treatment as usual control conditions. With regard to CBT, they concluded that CBT has limited positive effects for pain disability, and mood; nonetheless, there are insufficient data available to investigate the specific influence of treatment content on selected outcomes. Overall, it appears that CBT and BT are effective treatment approaches to improve mood; outcomes that remain robust at follow-up data points. However, as highlighted by several reviews and meta-analyses, a critical factor to consider in evaluating the effectiveness of CBT for the management of chronic pain is centered on issues of effective delivery, lack of uniform treatment components, differences in delivery across clinicians and treatment populations, and variability in outcome variables of interest across research trials. Further complicating the interpretation of effectiveness findings are patient characteristics and additional variables that may independently affect treatment outcome.
Acceptance-based approaches are frequently identified as third-wave cognitive-behavioral therapies. Acceptance and commitment therapy (ACT) is the most common of the acceptance-based psychotherapies. ACT emphasizes the importance of facilitating the client’s progress toward attaining a more valued and fulfilling life by increasing psychological flexibility rather than strictly focusing on restructuring cognitions. In the context of chronic pain, ACT targets ineffective control strategies and experiential avoidance by fostering techniques that establish psychological flexibility. The six core processes of ACT include: acceptance, cognitive defusion, being present, self as context, values, and committed action. Briefly, acceptance encourages chronic pain patients to actively embrace pain and its sequelae rather than attempt to change it, in doing so encouraging the patient to cease a futile fight directed at the eradication of their pain. Cognitive defusion (deliteralization) techniques are employed to modify the function of thoughts rather than to reduce their frequency or restructure their content. In this manner, cognitive defusion may simply alter the undesirable meaning or function of negative thoughts and thus decrease the attachment and subsequent emotional and behavioral response to such thoughts. The core process of being present emphasizes a non-judgmental interaction between the self and private thoughts and events. Values are utilized as guides for electing behaviors and interpretations that are characterized by those values an individual strives to instantiate in everyday life. Finally, through committed action, patients can realize behavior changes aligned with individual values. Thus, ACT utilizes the six core principles in conjunction with one another to take a holistic approach toward increasing psychological flexibility and decreasing suffering. Patients are encouraged to view pain as inevitable and accept it in a nonjudgmental manner so that they can continue to derive meaning from life despite the presence of pain. The interrelated core processes exemplify mindfulness and acceptance processes and commitment and behavior change processes.
Results of research on the effectiveness of ACT-based approaches for the management of chronic pain are promising, albeit still warranting further evaluation. A RCT comparing ACT with a waitlist control condition reported significant improvements in pain catastrophizing, pain-related disability, life satisfaction, fear of movements, and psychological distress that were maintained at the 7 month follow-up. A larger trial reported significant improvements for pain, depression, pain-related anxiety, disability, medical visits, work status, and physical performance. A recent meta-analysis evaluating acceptance-based interventions (ACT and mindfulness-based stress reduction) in patients with chronic pain found that, in general, acceptance-based therapies lead to favorable outcomes for patients with chronic pain. Specifically, the meta-analysis revealed small to medium effect sizes for pain intensity, depression, anxiety, physical wellbeing, and quality of life, with smaller effects found when controlled clinical trials were excluded and only RCTs were included in the analyses. Other acceptance-based interventions include contextual cognitive-behavioral therapy and mindfulness-based cognitive therapy, though empirical research on the effectiveness of these therapies for the management of chronic pain is still in its infancy.
An important and vastly overlooked common underlying element of all treatment approaches is consideration of the patient’s expectation for treatment success. Despite the numerous advances in the formulation and delivery of effective multidisciplinary treatments for chronic pain, relatively little emphasis has been placed on recognizing the importance of expectations for success and on focusing efforts on enhancement of patients’ expectations. The recognition that placebo for pain is characterized by active properties leading to reliable, observable, and quantifiable changes with neurobiological underpinnings is currently at the vanguard of pain research. Numerous studies have confirmed that, when induced in a manner that optimizes expectations (via manipulation of explicit expectations and/or conditioning), analgesic placebos can result in observable and measurable changes in pain perception at a conscious self-reported level as well as a neurological pain-processing level.[49,50] Analgesic placebos have been broadly defined as simulated treatments or procedures that occur within a psychosocial context and exert effects on an individual’s experience and/or physiology. The current conceptualization of placebo emphasizes the importance of the psychosocial context within which placebos are embedded. Underlying the psychosocial context and ritual of treatment are patients’ expectations. Therefore, it is not surprising that the placebo effect is intricately embedded in virtually every treatment; as such, clinicians and patients alike will likely benefit from recognition that therein lies an additional avenue by which current treatment approaches to pain can be enhanced.
It has been proposed that outcome expectancies are core influences driving the positive changes attained through the various modes of relaxation training, hypnosis, exposure treatments, and many cognitive-oriented therapeutic approaches. Thus, a sensible approach to the management of chronic pain capitalizes on the power of patients’ expectations for success. Regrettably, too often, health care providers neglect to directly address and emphasize the importance of patients’ expectations as integral factors contributing to successful management of chronic pain. The zeitgeist in our society is that of mounting medicalization of ailments fueling the general expectation that pain (even chronic pain) ought to be eradicated through medical advancements. These all too commonly held expectations leave many patients disillusioned with current treatment outcomes and contribute to an incessant search for the “cure”. Finding the “cure” is the exception rather than the rule with respect to chronic pain conditions. In our current climate, where chronic pain afflicts millions of Americans annually, it is in our best interest to instill and continue to advocate a conceptual shift that instead focuses on effective management of chronic pain. A viable and promising route to achieving this is to make the most of patients’ positive (realistic) expectations and educate pain patients as well as the lay public (20% of whom will at some future point become pain patients) on what constitutes realistic expectations regarding the management of pain. Perhaps, this can occur initially through current, evidence-based education regarding placebo and nonspecific treatment effects such that patients can correct misinformed beliefs they may have previously held. Subsequently clinicians can aim to enhance patients’ expectations within treatment contexts (in a realistic fashion) and minimize pessimistic expectations that deter from treatment success, therefore, learning to enhance their current multidisciplinary treatments through efforts guided at capitalizing on the improvements placebo can yield, even within an “active treatment”. Psychologists can readily address these issues with their patients and help them become advocates of their own treatment success.
Emotional Concomitants of Pain
An often challenging aspect of the management of chronic pain is the unequivocally high prevalence of comorbid emotional distress. Research has demonstrated that depression and anxiety disorders are upward to three times more prevalent among chronic pain patients than among the general population.[52,53] Frequently, pain patients with psychiatric comorbidities are labeled “difficult patients” by healthcare providers, possibly diminishing the quality of care they will receive. Patients with depression have poorer outcomes for both depression and pain treatments, compared with patients with single diagnoses of pain or depression.[54,55] Psychologists are remarkably suited to address most of the psychiatric comorbidities typically encountered in chronic pain populations and thus improve pain treatment outcomes and decrease the emotional suffering of patients. Psychologists can address key symptoms (eg, anhedonia, low motivation, problem-solving barriers) of depression that readily interfere with treatment participation and emotional distress. Moreover, irrespective of a psychiatric comorbidity, psychologists can help chronic pain patients process important role transitions they may undergo (eg, loss of job, disability), interpersonal difficulties they may be encountering (eg, sense of isolation brought about by pain), and emotional suffering (eg, anxiety, anger, sadness, disappointment) implicated in their experience. Thus, psychologists can positively impact the treatment course by reducing the influence of emotional concomitants that are addressed as part of therapy.
Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain are abundant. These include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress-improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, a psychologist can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives. Additional benefits of an integrated and holistic approach to the management of chronic pain may include increased rates of return to work, reductions in health care costs, and increased health-related quality of life for millions of patients throughout the world.
Disclosure:No conflicts of interest were declared in relation to this paper.
In conclusion, psychological interventions can be effectively used to help relieve symptoms of chronic pain along with the use of other treatment modalities, such as chiropractic care. Furthermore, the research study above demonstrated how specific psychological interventions can improve the outcome measures of chronic pain management. 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
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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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
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.
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.
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.
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.
The co-occurrence of tension headache and migraine is very high . Respectively, they are the second and third most common disorders worldwide with migraine ranking as the seventh highest specific cause of disability globally  and the sixteenth most commonly diagnosed condition in the US . 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 . 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’ .
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.
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.
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.
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  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.
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.
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 ; as 2.7% within a headache-clinic patient population  and as 1.7% within an osteopathy patient population . For headache the prevalence was 9% within a headache/pain clinic population  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 , 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 . 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 .
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 .
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  or the implementation of more effective approaches to headache management  or prevents discussion in circumstances where MT may be contraindicated . 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.
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 . 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.
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.
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.
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).
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.
The authors declare that they have no competing interests.
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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)
Concurrent prospective randomized and observational cohort studies.
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.
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.
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).
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
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. 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. 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. 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.
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]
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.
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]
Primary endpoints were the Bodily Pain (BP) and Physical Function (PF) scales of the SF-36 Health Survey and the AAOS/Modems version of the Oswestry Disability Index (ODI) 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; 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.
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. 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. 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 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. 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.
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.
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 of trial participants.
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 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.
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 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 (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 (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. 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).
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 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 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.
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.
The long-term results of SPORT are similar to the Maine Lumbar Spine Study (MLSS). 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.
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. 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.
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.
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.
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
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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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
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.
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 . 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 .
About 80% consult their primary physician for primary chronic headache , 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 . Non-pharmacological management has furthermore the advantage of few and usually minor transient adverse events and no pharmacological interaction/adverse event .
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 .
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.
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. 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 .
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.
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 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 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 . 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 . 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 . 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 . The participants were diagnosed with CTTH according to ICHD-I . 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 . Participants were diagnosed CTTH by a neurologist according to the criteria of ICHD-I . 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 . Participants were diagnosed with CTTH by a physician according to ICHD-I . 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 . Participants were diagnosed by a physician according to the criteria of ICHD-II . 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.
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 , 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 .
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 .
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 . 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 . 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 , 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 .
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.
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.
The authors declare that they have no competing interests.
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.
Aleksander Chaibi is a BPT, MChiro, PhD student and Michael Bjørn Russell is a professor, MD, PhD, DrMedSci.
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. 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
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.
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.
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.
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.
ClinicalTrials.gov Identifier: NCT02257723. Registered October 2, 2014.
Keywords:Cervical intervertebral disc herniation, Complementary and alternative medicine, Integrative treatment, Inpatient treatment
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 , 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 , and neck pain symptoms also persist in many cases leading to work loss due to discomfort . 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 . 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 , 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.
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.
Patients meeting the following criteria were included.
Admission for treatment of neck pain or radiating arm pain
Cervical IDH confirmed on MRI
Diagnosis by KMD that main cause of chief complaint (neck pain or radiating pain) is cervical IDH
Patients meeting the following criteria were excluded.
Main complaint other than neck pain or radiating pain
Concomitant musculoskeletal complaint (e.g. low back pain, knee pain)
Cause of neck pain unrelated to cervical IDH (e.g. spinal tumor, pregnancy, rheumatoid arthritis)
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.
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  and the prescription was further developed through clinical practice . 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 , and nerve  and joint protective effects , and clinically for non-inferiority in safety and efficacy compared to Celecoxib in treatment of osteoarthritis .
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 .
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.
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  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  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  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.
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.
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).
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
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.
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 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, 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 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.
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 .
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  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.  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 . 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.  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) . 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.
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.
This work was supported by Jaseng Medical Foundation.
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
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.
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
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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