Successful evidence-based chiropractors continually leverage new studies to improve their clinical decision-making. ChiroUp helps me by scouring fresh literature to mine out useful best practice data. This month, we’ve summarized more than a dozen studies for your review.
1. A new (very large) European Spine Journal Study examined the risk of acute lumbar disc herniation requiring early surgery in patients who visited a chiropractor vs. those who visited a PCP:
“The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits. Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH.”
P.S. Abundant research has revealed a similar conclusion for the relationship between cervical manipulation and stroke. Click here to download a helpful patient education handout regarding the safety of neck manipulation.
Hincapié, C.A., Tomlinson, G.A., Côté, P. et al. Eur Spine J (2018) 27: 1526.
2.A systematic review of carpal tunnel syndrome research comparing surgical vs. non-surgical outcomes found: “No significant differences at 3 or 12 months” in terms of functional status, symptom severity, and nerve conduction outcomes. Interestingly, the surgical patients experienced greater improvement at 6 months, but not before or after.
Qiyun S. et al. Comparison of the Short-term and Long-term Effects of Surgery and Nonsurgical Intervention in Treating Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis. Hand. 2018 Jul 1:1558944718787892. [Epub ahead of print]
3.A study of more than 500 pregnant women found: “If both P4 and ASLR tests were positive mid-pregnancy, a persistent bothersome pelvic girdle pain of more than 5 days per week throughout the remainder of pregnancy could be predicted.”
Malmqvist S, Kjaermann I, Andersen K, et al Can a bothersome course of pelvic pain from mid-pregnancy to birth be predicted? A Norwegian prospective longitudinal SMS-Track study BMJ Open 2018;8:e021378.
4. A systematic review found no correlation between LBP intensity and the degree of MODIC degenerative change in the lumbar spine.
Herlin C et al. Modic changes—Their associations with low back pain and activity limitation: A systematic literature review and meta-analysis. PLoS1 2018 Aug 1;13(8):e0200677. doi: 10.1371/journal.pone.0200677. eCollection 2018.
5. According to a systematic review with meta-analysis in the journal Physiotherapy: “There is very low evidence to support the use of trigger point dry needling (TDN) in the shoulder region for treating patients with upper extremity pain or dysfunction.”
Hall, Michelle Louise et al. Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis. Physiotherapy , Volume 104 , Issue 2 , 167 – 177
6. A JMPT study of 82 cervicogenic headache patients found, “upper cervical spinal mobilization increased cervical range of motion and induced immediate headache relief.”
Malo-Urriés, Miguel et al. Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial. Journal of Manipulative & Physiological Therapeutics, Volume 40 , Issue 9 , 649 – 658
7. A study of more than 6000 chiropractic patients revealed that few (5.4%) of the chiropractic patients used narcotics for their chronic pain, which is substantially lower than the 45% to 60% use typically found in chronic LBP populations. Additionally, if chiropractic care was no longer a covered insurance benefit, 30% of patients would continue as is, 61% would go less often, and only 7% would discontinue care.
Herman, Patricia M. et al.Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain. JMPT 2018 Aug 15. [Epub ahead of print]
8. “Opioids are no more effective than non-opioid medications in the treatment of acute and chronic low back pain.”
Wertli, M.M. & Steurer, J. Pain medications for acute and chronic low back pain. Internist (2018). 2018 Aug 16. doi: 10.1007/s00108-018-0475-5. [Epub ahead of print]
9. A new article in the Journal of Family Practice endorsed a select group of therapies that show “good-quality patient-oriented evidence” for managing chronic low back pain. The journal advised physicians to:
10. A recent spine Journal study was “the first to measure facet gapping during cervical manipulation on live humans. The results demonstrate that:
Anderst WJ et al. Intervertebral Kinematics of the Cervical Spine Before, During and After High Velocity Low Amplitude Manipulation. The Spine Journal Available online 22 August 2018
11. A study of 100 fibromyalgia (FM) patients found recurrent “electrodiagnostic features of polyneuropathy, muscle denervation, and chronic inflammatory demyelinating polyneuropathy (CIDP)”.
Caro XJ, Galbraith RG, Winter EF. Evidence of peripheral large nerve involvement in fibromyalgia: a retrospective review of EMG and nerve conduction findings in 55 FM subjects. Eur J Rheumatol 2018; 5: 104-10.
12. A study of 40 collegiate athletes found that application of elastic therapeutic tape over the gluteus medius “improved strength immediately after taping (and) it was maintained even on the third day.” Hip taping also generated short-term correction of dynamic knee valgus.
Rajasekar, Sannasi et al. Does Kinesio taping correct exaggerated dynamic knee valgus? A randomized double blinded sham-controlled trial. Journal of Bodywork and Movement Therapies , Volume 22 , Issue 3 , 727 – 732
Review the latest news: Manipulation for headaches and lateral elbow pain
KinesioTape for carpal tunnel syndrome
Epidural steroid injections increase the risk of fracture
How common are rotator cuff tears?
1. A Spine Journal study found that in patients suffering from cervicogenic headache, spinal manipulation cuts the number of symptomatic days in half:
“256 adults with chronic cervicogenic headache (CGH) were randomized to four dose levels of chiropractic SMT: 0, 6, 12, or 18 sessions. Participants were treated three times per week for 6 weeks and received a focused light-massage control at sessions when SMT was not assigned. A linear dose-response was observed for all follow-ups, a reduction of approximately 1 CGH day/month for each additional 6 SMT visits. Cervicogenic headache days/month were reduced from about 16 to 8 for the highest and most effective dose of 18 SMT visits. Cervicogenic headache intensity showed no important improvement nor differed by dose.”
Incidentally, SMT proved to be more effective than massage for CGH.
Haas M. et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine J. 2018 Feb 23. [Epub ahead of print]
2. Archive of Physical Medicine & Rehabilitation: “For patients with neurogenic claudication due to lumbar spine stenosis, a comprehensive conservative program demonstrated superior, large and sustained improvements in walking ability and can be a safe non-surgical treatment option.”
Ammendolia C, et al. Comprehensive non-surgical treatment versus self-directed care to improve walking ability in lumbar spinal stenosis: A randomized trial. Arch Phys Med Rehabil. 2018.
3. As many as 96% of persons over age 50 years may have shoulder abnormalities involving the rotator cuff. Many of these individuals remain asymptomatic. Now a new study has found the incidence and prevalence of subclinical supraspinatus pathology in young subjects may be significantly greater than expected:
“Forty-six subjects, having no shoulder pain or known functional impairment were assessed using physical screening and musculoskeletal sonography. Results showed that 24% of these asymptomatic shoulders demonstrated degenerative changes.”
Guffey JS, et al. Degenerative Changes in Asymptomatic Subjects: A Descriptive Study Examining the Using Musculoskeletal Sonography in a Young Population. J Allied Health. 2018.
4. A study in Spine Journal found that sheep that underwent L3/4 spinal fusion experienced significant degenerative changes:
“(In fused specimens) The MRI and histologic analysis demonstrated significant disc degeneration. The mechanical environment set up by immobilization alone is capable of inducing lumbar disc degeneration.”
Wang T et. al. A novel in vivo large animal model of lumbar spinal joint degeneration. Spine J. 2018 May 22. [Epub ahead of print]
5. A study in the Journal of Bone & Joint Surgery found that lumbar epidural steroid injections increase the risk of osteoporotic vertebral compression fracture by 21%, per injection:
“Each successive injection increased the risk of fracture by a factor of 1.21. The findings suggest that Lumbar epidural steroid injections, like other forms of exogenous steroid administration, may lead to increased bone fragility.”
Mandel S. et al. A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections. The Journal of Bone & Joint Surgery. 95(11):961–964, JUN 2013
6. A study of over 32,000 people found that overweight people have a 21% increased risk of LBP, while obesity increases one’s risk by 55%.
Peng, Trent et al. The Association Among Overweight, Obesity, and Low Back Pain in U.S. Adults: A Cross-Sectional Study of the 2015 National Health Interview Survey. Journal of Manipulative & Physiological Therapeutics , Volume 41 , Issue 4 , 294 – 303
7. Individuals who received mobilization and expressed a positive perception of effect exhibited significantly greater changes in neurodynamic mobility than those without a positive perception.
Hartstein, Aaron J. et al. Immediate Effects of Thoracic Spine Thrust Manipulation on Neurodynamic Mobility. Journal of Manipulative & Physiological Therapeutics , Volume 41 , Issue 4 , 332 – 341
8. A systematic review in the Journal of Hand Therapy has shown “compelling evidence” that joint mobilization and manipulation improve pain, grip strength, and functional outcomes in patients with tennis elbow.
Lucado AM. et. al. Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. J. Hand Therapy 2018 Apr 25. [Epub ahead of print]
9. A randomized clinical trial compared the effectiveness of a splint vs. KinesioTape (KT) for the management of carpal tunnel syndrome:
“A significant improvement was observed in the KT group compared to the splint group in terms of electrophysiological changes, provocative test responses, symptom severity, and functional status scores. KT may help prevent the disease from progressing further in mild and moderate idiopathic CTS when applied in time using the appropriate technique and be a good alternative to neutral splinting in terms of patient compliance.”
Akturk S. et. al. Comparison of splinting and Kinesio taping in the treatment of carpal tunnel syndrome: a prospective randomized study.Clin Rheumatol. 2018 Jun 15. [Epub ahead of print]
10. NEJM: “A staggering 36,000 randomized controlled trials (RCTs) are published each year, on average, and it typically takes about 17 years for findings to reach clinical practice.”
Kanter MH et. al. A Model for Implementing Evidence-Based Practices More Quickly. NEJM Catalyst. February 5, 2017
Evidence-based chiropractors explain the disconnect between symptoms and imaging findings.
Recently, Daimon K et al. (2018) published a landmark study for EVERY evidence-based chiropractor. It highlights the notion that degenerative changes are merely age-related and do not necessarily correlate with symptoms. This study assimilates two decades of sequential imaging to prove that there little association between degeneration and clinical symptoms:
“results of our statistical analysis and the different rates of disc degeneration versus clinical symptoms reported here and elsewhere, the degenerative findings on cervical MRI do not appear to be generally associated with the development of clinical symptoms.” (1)
Structural findings take months or years to progress. Acute symptoms usually occur within moments to days after a trauma, or change in activity, movement, hobby, or habit. Structural abnormalities can complicate tissue failure, but are not directly correlated with symptoms. It is essential that we focus on what is correctable and what is not. There is no treatment to eliminate the degenerative changes in the spine; however evidence-based chiropractic care can effectively and efficiently resolve symptoms.
Arthritic and degenerative changes are a fact of life. It is important not to focus on what shows up on imaging but rather focus on what we can do with the cards that were dealt.
“the rate of degenerative progression at one intervertebral disc level on MRI over the 20-year period was 95.3%, whereas the rate of the development of clinical symptoms was 66.9%. Statistical analysis of the relationship between the progression of the 5 degenerative findings in the cervical spine and the occurrence of clinical symptoms only detected a significant association between foraminal stenosis and upper limb pain.”
When a patient presents with a one-week onset of neck pain; is it from their stenosis? NO! The cervical narrowing has been there for years. Is it a complicating factor? YES. We treat the patient’s symptoms by focusing on the functional reasons the pain started. Once the pain is gone, the stenosis will still be there. Our office educates the patient to not blame their arthritis for every malady affecting their life. We focus on their habits, hobbies, and postures to eliminate the stressors on their body that are exacerbating their spinal condition. This same paradigm works for disc pathology, or chronic meniscus injuries, or SLAP lesions, or…(name your chronic structural lesion)
“A study of clinical symptoms and cervical MRI findings by Siivola et al. showed that neck and shoulder pain in young adults was not associated with disc degeneration, an annular tear, or disc protrusion on MRI.”(2)
Lower back pain is an undesired consequence of the activities that our patients partake in on a daily basis. Without appropriate intervention and adequate rest, these repetitive stressors can lead to injury.
Desk jockeys are filling chiropractic offices with complaints triggered by cumulative stressors, compounded by inactivity. Prolonged seated postures and general deconditioning lead to overloaded spinal ligaments, muscles, and discs.
Altering seat and keyboard height, as well as monitor elevation & distance are all critical variables for those who spend their day sitting. But more recently, increasing numbers of workstation users are transitioning to standing desks; and standing in one spot for an extended period is not without its own set of risks.
What advice should an evidence-based chiropractor give to patients concerning their standing workstation?
Do you know why taverns have foot rails around their bars? The foot rails originated during a time when stools were not common, and patrons would stand, i.e. ‘belly up to’ the bar. The rail was intended to give patrons the ability to alternate legs, giving one a rest while providing a little flexion for those stenotic cowboy spines.
A new study examined the impact of standing workstations on LBP. (1) The authors concluded that one variable, footrest height, had a significant contribution to muscle fatigue and lower back pain. Their recommendation:
“The results suggest that a footrest height of 10% of the body height can be recommended as a normalized height for prolonged standing work in subjects with a history of non-specific lower back pain during prolonged standing.”
The take away from this is to incorporate a foot rest with your standing workstation. You can't argue with the evidence!
1. Son JI, et al. Effects of footrest heights on muscle fatigue, kinematics, and kinetics during prolonged standing work. J Back Musculoskelet Rehabil. 2017.
Reprinted with permission from ChiroUp
1.A systematic review of 11 pertinent articles determined that cervical HVLA manipulation increased pain-free handgrip strength in patients with lateral epicondylagia. Galindez-Ibarbengoetxea Xabier, Setuain Igor, Andersen Lars L., Ramírez-Velez Robinson, González-Izal Miriam, Jauregi Andoni, and Izquierdo Mikel. The Journal of Alternative and Complementary Medicine. September 2017, 23(9): 667-675.
2.A cross sectional study confirmed that in patients with adolescent idiopathic scoliosis, the Cobb angle has a direct correlation to pain and disability. Bracing was associated with lower disability and pain. Théroux J et al. Back Pain Prevalence Is Associated With Curve-type and Severity in Adolescents With Idiopathic Scoliosis: A Cross-sectional Study. SPINE. 42(15):E914–E919, AUG 2017
3.The Journal of Rheumatology published an articulate narrative on the genesis of arthritis: “Following skeletal maturation, chondrocyte numbers decline while increasing senescence occurs. Lower cartilage turnover causes diminished maintenance capacity, which produces accumulation of fibrillar crosslinks, resulting in increased stiffness and thereby destruction susceptibility. Mechanical loading changes proteoglycan content. Moderate mechanical loading causes hypertrophy and reduced mechanical loading causes atrophy. Overloading produces collagen network damage and proteoglycan loss, leading to irreversible cartilage destruction because of lack of regenerative capacity. Thus, age seems to be a predisposing factor for OA, with mechanical overload being the likely triggering cause.” Jorgensen AE et al. The Effect of Aging and Mechanical Loading on the Metabolism of Articular Cartilage The Journal of Rheumatology April 2017, 44 (4) 410-417
4.“The knee is the most common site of OA. Numerous studies have shown an inconsistency between patients’ reports of pain and their radiographic findings. This inconsistency may be partially explained by the fact that a portion of the pain originates from the myofascial trigger points (MTrPs) located in the surrounding muscles. Treatment focusing on MTrPs seems to be effective in reducing pain and improving function in OA patients.” Dor, Adi et al. A myofascial component of pain in knee osteoarthritis. Journal of Bodywork and Movement Therapies , Volume 21 , Issue 3 , 642 – 647
5.In patients undergoing MRI for degenerative spinal disease, expanding the regional study to include a T2 whole spine screen identified incidental findings in 15.8% of patients, 4.3% of which required further medical or surgical intervention. The authors concluded: “Considering the potential advantages in identifying significant incidental findings and the minimal extra time spent to perform whole spine screening, its application can be considered to be incorporated in routine imaging of spinal degenerative diseases.” Kanna, R.M., Kamal, Y., Mahesh, A. et al. The impact of routine whole spine MRI screening in the evaluation of spinal degenerative diseases. Eur Spine J (2017) 26: 1993.
6.A small randomized clinical trial demonstrated that periodic chiropractic maintenance care can prevent and/or minimize episodes of LBP. Patients who underwent an average of 7 visits per year suffered on average 19.3 fewer days with LBP. Eklund A, et al. Prevention of low back pain: effect, cost-effectiveness, and cost-utility of maintenance care – study protocol for a randomized clinical trial. Trials. 2014;15:102 Eklund A et al., Prevention of Low Back Pain: Effect of Chiropractic Maintenance Care as Compared to Symptomatic Treatment – A Pragmatic Randomized Clinical Trial. First prize 2017 European Chiropractors Convention, Cyprus.
7.In athletes who sustained an acute musculoskeletal sports injury, three minutes of acupressure was effective in decreasing VAS pain intensity. Macznik AK. Does Acupressure Hit the Mark? A Three-Arm Randomized Placebo-Controlled Trial of Acupressure for Pain and Anxiety Relief in Athletes With Acute Musculoskeletal Sports Injuries. Clin J Sport Med. 2017 Jul;27(4):338-343.
8.A new study in Spine confirms that adults who participate in muscle strengthening exercise suffer lower incidence of LBP. Alnojeidi AH et al. Associations Between Low Back Pain and Muscle-strengthening Activity in U.S. Adults. Spine (Phila Pa 1976). 2017 Aug 15;42(16):1220-1225.
9.For patients with Failed Back Surgery Syndrome, evidence supports exercise or spinal cord stimulation as opposed to medication and re-operation. Amirdelfan K et al. Treatment Options for Failed Back Surgery Syndrome Patients With Refractory Chronic Pain: An Evidence Based Approach. Spine (Phila Pa 1976). 2017 Jul 15;42 Suppl 14:S41-S52.
10.A systematic review and meta-analysis found that workplace exercise programs and workstation modifications reduce the prevalence and intensity of shoulder pain. Lowry V et al. Efficacy of workplace interventions for shoulder pain: A systematic review and meta-analysis. J Rehabil Med 2017 Jul 7;49(7):529-542.
Reprinted via Permission from ChiroUp
Medline contains more than 24 million articles, with almost one million new citations added each year. Evidence-based chiropractors know that they must employ and continually refine “best practices” to obtain great outcomes. The following up-to-date chiropractic research review offers 11 new studies that impact our patients and practices.
1.A new paper provides additional confirmation that patellofemoral pain syndrome (PFPS) and dynamic knee valgus do not arise from within the knee, rather from hip abductor/ external rotator weakness and/or foot hyperpronation: “The most effective intervention programs included exercises targeting the hip external rotator and abductor muscles and knee extensor muscles.” and “PFPS patients with foot abnormalities, such as those with increased rearfoot eversion or pes pronatus, may benefit the most from foot orthotics.”Petersen W, Rembitzki I, Liebau C. Patellofemoral pain in athletes. Open Access Journal of Sports Medicine. 2017;8:143-154.
2.A systematic review and meta-analysis of more than 1700 cases determined that patients with a decreased lumbar lordosis have significantly higher levels of lumbar disc herniation and LBP. Chun, Se-Woong et al. The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis. The Spine Journal , Volume 17 , Issue 8 , 1180 – 1191
3.A study of more than 300 adult patients found that both hypo- and hyper-lordosis correlate with DJD in the lumbar spine. Murray KJ, Le Grande MR, Ortega de Mues A, Azari MF. Characterisation of the correlation between standing lordosis and degenerative joint disease in the lower lumbar spine in women and men: a radiographic study. BMC Musculoskeletal Disorders. 2017;18:330.
4.Weakness of the deep neck flexors is a known contributor to chronic neck pain, particularly cervicogenic headaches and cervicogenic vertigo. A systematic review confirmed that low-load craniocervical flexion exercise is highly effective for improving deep cervical flexor muscle impairments in these patients. Amiri AS, et al. The Effect of Different Exercise Programs on Size and Function of Deep Cervical Flexor Muscles in Patients With Chronic Nonspecific Neck Pain: A Systematic Review of Randomized Controlled Trials. Am J Phys Med Rehabil. 2017 Aug;96(8):582-588.
5.In a small study of patients with cervicogenic headache, chiropractic spinal manipulation resulted in decreased headache frequency and intensity with only mild and transient adverse events. Chaibi A, Knackstedt H, Tuchin PJ, Russell MB. Chiropractic spinal manipulative therapy for cervicogenic headache: a single-blinded, placebo, randomized controlled trial. BMC Research Notes. 2017;10:310. doi:10.1186/s13104-017-2651-4.
6.In patients exhibiting a loss of the cervical lordosis, a 12-week home exercise program consisting of isometric cervical extension improves cervical lordosis and reduces pain levels. Alpayci M et. al. Isometric Exercise for the Cervical Extensors Can Help Restore Physiological Lordosis and Reduce Neck Pain: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2017 Sep;96(9):621-626.
7.Regarding cervical spine pain, the definition “acute” should be reserved for the period of 0-4 weeks. Nyirö L, Peterson CK, Humphreys BK. Exploring the definition of «acute» neck pain: a prospective cohort observational study comparing the outcomes of chiropractic patients with 0–2 weeks, 2–4 weeks and 4–12 weeks of symptoms. Chiropractic & Manual Therapies. 2017;25:24. doi:10.1186/s12998-017-0154-y.
8.In patients with neck pain, intermittent cervical traction provides significant immediate relief but little functional improvement or long-term benefit. Yang JD et al. Intermittent Cervical Traction for Treating Neck Pain: A Meta-analysis of Randomized Controlled Trials. Spine (Phila Pa 1976). 2017 Jul 1;42(13):959-965.
9.A randomized clinical trial of patients with shoulder impingement syndrome determined that thoracic manipulation decreased pain and improved scapular upward rotation i.e. lessened the impingement effect of scapular dyskinesis. Haik, Melina N. et al. Short-Term Effects of Thoracic Spine Manipulation on Shoulder Impingement Syndrome. Archives of Physical Medicine and Rehabilitation , Volume 98 , Issue 8 , 1594 – 1605
10.Belief about the relative risk of acute lumbar disc herniation (LDH) resulting from chiropractic spinal manipulation varies by profession. Chiropractors generally fell into a group with the most optimistic views, believing that chiropractic SMT reduces the incidence of acute LDH by about 60%. Family physicians expressed a neutral belief, while orthopedic surgeons comprised the majority of a group with the most pessimistic views believing that chiropractic SMT increases the incidence of acute LDH by about 30%. Hincapié, C.A., Cassidy, J.D., Côté, P. et al. Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study Eur Spine J (2017).
11.An electromyographic study confirms that athletes with rotator cuff tendinopathy demonstrate an aberrant patter of scapular movement, i.e. delayed activation of the serratus anterior and lower trapezius. This muscular dysfunction impairs upward rotation of the scapula resulting in further rotator cuff impingement. Leong HT. et al. Rotator cuff tendinopathy alters the muscle activity onset and kinematics of scapula. J Electromyogr Kinesiol 2017 Aug;35:40-46.
Reprinted with permission from Chiro Up
Cliff Atwell, B.S., D.C.