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THE TRUTH OF CHIROPRACTIC PRACTICE: ANSWERS TO MISINFORMATION ABOUT CHIROPRACTICNEWS ARTICLES AND RESEARCH FINDINGS ON CHIROPRACTIC PRACTICE AND CLINICAL BENEFITS

James M. Cox, DC, DACBR, FICC, FACO(H), HonDLittSeptember 12, 2018

COST FACTORS IN SPINE CAREJames M. Cox, DC, DACBR

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ELDER C1, DEBAR L2, RITENBAUGH C3, DICKERSON J4, VOLLMER WM4, DEYORA5, JOHNSON ES4, HAAS M6. COMPARATIVE EFFECTIVENESS OF USUAL CARE WITH OR

WITHOUT CHIROPRACTIC CARE IN PATIENTS WITH RECURRENT MUSCULOSKELETAL BACK AND NECK PAIN. J GEN INTERN MED. 2018 JUN 25. DOI:

10.1007/S11606-018-4539-Y. [EPUB AHEAD OF PRINT]

• TREATMENT OF RECURRENT BACK AND NECK PAIN PATIENTS WITH OR WITHOUT CHIROPRACTIC CARE SHOWED TOTAL COSTS DURING THE 6-MONTH POST-ENROLLMENT FOLLOW-UP WERE SIGNIFICANTLY HIGHER ON AVERAGE IN THE NON-REFERRED VERSUS REFERRED GROUP ($1996 VS $1086).

• AS CLINICAL OUTCOMES WERE SIMILAR, AND THE PROVISION OF CHIROPRACTIC CARE DID NOT INCREASE COSTS, MAKING CHIROPRACTIC SERVICES AVAILABLE PROVIDED AN ADDITIONAL VIABLE OPTION FOR PATIENTS WHO PREFER THIS TYPE OF CARE, AT NO ADDITIONAL EXPENSE.

• ED NOTE: ACTUALLY CHIROPRACTIC TREATMENT GREATLY LOWERED THE COST OF CARE. JMC

BUCHBINDER R, BLYTH FM, MARCH LM, BROOKS P, WOOLF AD, HOY DG. PLACING THE GLOBAL BURDEN OF LOW BACK PAIN IN CONTEXT. BEST PRACT

RES CLIN RHEUMATOL. 2013 OCT;27(5):575-89.

• GLOBAL BURDEN OF LOW BACK PAIN: LOW BACK PAIN IS NOW THE LEADING CAUSE OF DISABILITY GLOBALLY, AHEAD OF 290 OTHER CONDITIONS. IT WAS ESTIMATED TO BE RESPONSIBLE FOR 58.2 MILLION YEARS LIVED WITH DISABILITY IN 1990, INCREASING TO 83 MILLION IN 2010

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CAREY, TS, EVANS A, HADLER N: CARE SEEKING AMONG INDIVIDUALS WITH CHRONIC LOW BACK PAIN. SPINE 1995 20(3):312-17

• One of 4 Worker’s Compensation Cases in North Carolina cost 95% of the money spent on chronic low back pain

RICHARD L. LILIEDAHL, MICHAEL D. FINCH, DAVID V. AXENE, CHRISTINE GOERTZ. COST OF CARE FOR COMMON BACK PAIN CONDITIONS INITIATED

WITH CHIROPRACTIC DOCTOR VS MEDICAL DOCTOR/DOCTOR OF OSTEOPATHY AS FIRST PHYSICIAN: EXPERIENCE OF ONE TENNESSEE-BASED

GENERAL HEALTH INSURER. JMPT 2010; 33(9):640-643

• To determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types.

• Blue Cross Blue Shield of Tennessee analyzed claims from October 1, 2004 and September 30, 2006 of the insured study population had open access to MDs and DCs through self-referral without any limit to the number of visits or differences in co-pays to these 2 provider types. Our analysis was based on episodes of care for low back pain. An episode was defined as all reimbursed care delivered between the first and the last encounter with a health care provider for low back pain. A 60 day window without an encounter was treated as a new episode. We compared paid claims and risk adjusted costs between episodes of care initiated with an MD with those initiated with a DC.

• Results: Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD.

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IALYNYTCHEV, ANNA PHD*; SEAR, ALAN M. PHD*; WILLIAMS, ARTHUR R. PHD†; LANGLAND-ORBAN, BARBARA PHD*; ZHANG, NANHUA PHD‡,§ PREDICTORS OF THE

CHARGES FOR LUMBAR FUSION SURGERY IN FLORIDA HOSPITALS. SPINE: 01 NOVEMBER 2014 - VOLUME 39 - ISSUE 23 - P 1990–1995

• The number of spinal fusion surgical procedures in the United States has grown exponentially in recent years despite the procedure's high costs and questionable efficacy for many of the principal diagnoses associated with it.

• The total hospital charges for lumbar fusion surgery in Florida in 2010 were $2,095,413,584 –3 times the charges as those incurred by the controls.

SNOOK S: STATE OF ART REVIEW SPINE 2(1)

• 1996 the cost of low back pain was 200-300 billion dollars in U.S

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FRYMOYER, J. ORTH CLIN NO AMER 22(2)

•50-100 Billion spent annually on low back pain

•75% of cost is for 5% of low back pain sufferers

KATZ JN: LUMBAR DISC DISORDERS AND LOW BACK PAIN: SOCIOECONOMIC FACTORS AND CONSEQUENCES. JBJS AM 88A(SUPPL), MAY, 2006:10-14

• LUMBAR DISC DISORDERS COST > 100 BILLION DOLLARS A YEAR, WITH 5% OF PATIENTS ABSORBING 75% OF THE COST

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DAFFNER, SD; HYMANSON, HJ; WANG, JC. COST AND USE OF CONSERVATIVE MANAGEMENT OF LUMBAR DISC HERNIATION BEFORE SURGICAL

DISCECTOMY. SPINE JOURNAL 10 (6). JUN 2010. P.463-468

• COST OF CHIROPRACTIC CARE FOR THE TREATMENT OF LUMBAR INTERVERTEBRAL DISC HERNIATION PATIENTS IS 2% OF TOTAL SPENT

• A TRIAL OF CONSERVATIVE NONOPERATIVE CARE IS ADVISED BEFORE SURGERY PATIENTS WITH LUMBAR DISC HERNIATION.

DAFFNER CONTINUES

• 30,709 PATIENTS WITH LUMBAR DISC HERNIATION COST A TOTAL OF $105,799,925 DURING THE 90 DAYS PREOPERATIVELY SHOWED AN AVERAGE OF $3,445 PER PATIENT. AVERAGE CHARGE FOR DISCECTOMY PROCEDURE WAS $7,841.

• CHARGES FOR INJECTION PROCEDURES TOTALED $16,211,246 OR 32% OF TOTAL CHARGES, DIAGNOSTIC IMAGING $15,648,769 (31%), OUTPATIENT VISITS $6,552,135 (13%), PHYSICAL THERAPY VISITS $5,723,644 (11%), CHIROPRACTIC MANIPULATION $1,177,406 (2%), PREOPERATIVE STUDIES $426,976 (0.8%), MEDICATIONS $263,039 (0.5%), AND MISCELLANEOUS CHARGES $1,177,371 (2%)

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HASHEMI. J OF OCCUP ENVIRON MED 39(10)

•10% of Worker’s Compensation Claims are 86% of the cost

OPIOID AND PAIN MEDICATION EPIDEMIC

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WONGRAKPANICH S1, WONGRAKPANICH A2, MELHADO K1, RANGASWAMIJ3. A COMPREHENSIVE REVIEW OF NON-STEROIDAL ANTI-INFLAMMATORY

DRUG USE IN THE ELDERLY. AGING DIS. 2018 FEB 1;9(1):143-150. DOI: 10.14336/AD.2017.0306. ECOLLECTION 2018 FEB.

• 96% of people over 65 use them• Increase stroke risk, GI bleeding, High Blood Pressure,

geriatric psychiatric events, falls, renal, cardiac, hepatic toxicity

• Use lowest dose for shortest duration possible recommended

• www.journalgazette.net 6-8-18 - <1% of Americans died in 1968 in Vietnam War – 1.5% of Americans died in 2016 from opioids. 1 0f 5 deaths of Americans aged 25-34 are due to opioids. This is CDC data which underestimate overdoses by 20-35%.

DEYO RA. USE OF PRESCRIPTION OPIOIDS BEFORE AND AFTER AN OPERATION FOR CHRONIC PAIN (LUMBAR FUSION SURGERY). PAIN. 2018 JUN;159(6):1147-

1154.

• USE OF OPIOIDS IN 2,491 ADULTS UNDERGOING LUMBAR FUSION SURGERY FOR DEGENERATIVE CONDITIONS SHOWED 1,045 PATIENTS RECEIVED LONG-TERM OPIOIDS PREOPERATIVELY, AND 1,094 POSTOPERATIVELY.

• AMONG PREOPERATIVE USERS, 34.4% RECEIVED A LOWER DOSE POSTOPERATIVELY, BUT 44.8% RECEIVED A HIGHER LONG-TERM DOSE.

• THE STRONGEST PREDICTOR OF LONG-TERM POSTOPERATIVE USE WAS CUMULATIVE PREOPERATIVE OPIOID DOSE.

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RASMUSSEN-BARR E1, HELD U, GROOTEN WJ, ROELOFS PD, KOES BW, VAN TULDER MW, WERTLI MM. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS FOR SCIATICA: AN UPDATED

COCHRANE REVIEW. SPINE (PHILA PA 1976). 2017 APR 15;42(8):586-594. DOI: 10.1097/BRS.0000000000002092.

• VERY LOW-QUALITY EVIDENCE THAT THE EFFICACY OF NSAIDS FOR PAIN REDUCTION IS COMPARABLE WITH THAT OF PLACEBO

[ARTICLE IN GERMAN]WERTLI MM1,2, STEURER J3. [PAIN MEDICATIONS FOR ACUTE AND CHRONIC LOW BACK

PAIN]. INTERNIST (BERL). 2018 AUG 16. DOI: 10.1007/S00108-018-0475-5. [EPUB AHEAD OF PRINT]

• INCREASING EVIDENCE THAT OPIOIDS ARE NO MORE EFFECTIVE THAN NON-OPIOID MEDICATIONS IN THE TREATMENT OF ACUTE AND CHRONIC LOW BACK PAIN

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AZAD T1, VAIL D1, BENTLEY J2, HAN S1,2, SUAREZ P1, VARSHNEYA K1, MITTAL V1, VEERAVAGU A1, DESAI M2, BHATTACHARYA J3, RATLIFF J1. INITIAL PROVIDER SPECIALTY IS ASSOCIATED WITH LONG-TERM OPIATE USE IN PATIENTS WITH NEWLY

DIAGNOSED LOW BACK AND LOWER EXTREMITY PAIN. SPINE (PHILA PA 1976). 2018 AUG 7. DOI: 10.1097/BRS.0000000000002840. [EPUB AHEAD OF PRINT]

• FAMILY DOCTOR IS MOST COMMON SOURCE OF OPIOIDS.• 478,981 NEWLY DIAGNOSED OPIATE-NAÏVE PATIENTS FOUND

40.4% RECEIVED AN OPIATE PRESCRIPTION WITHIN ONE YEAR.• RISK OF RECEIVING AN EARLY OPIATE PRESCRIPTION WAS

HIGHER AMONG PATIENTS INITIALLY DIAGNOSED BY EMERGENCY MEDICINE

• RISK OF LONG-TERM OPIATE USE WAS HIGHEST FOR PATIENTS INITIALLY DIAGNOSED BY PAIN MANAGEMENT/ANESTHESIA (6.7%) OR PHYSICAL MEDICINE AND REHABILITATION (3.4%) PROVIDERS.

HAYES CJ1,2, PAYAKACHAT N1, LI C3.EVALUATION OF OPIOID USE AMONG PATIENTS WITH BACK DISORDERS AND

ARTHRITIS. QUAL LIFE RES. 2018 JUL 23. DOI: 10.1007/S11136-018-1941-1. [EPUB AHEAD OF PRINT]

• LONG-TERM OPIOID USE IS NOT ASSOCIATED WITH IMPROVEMENTS IN HRQOL. CLINICIANS SHOULD CAREFULLY EVALUATE THE NEED FOR OPIOID USE, ESPECIALLY LONG-TERM USE IN MANAGING CHRONIC BACK PAIN AND ARTHRITIS

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MATHIESON S(1), MAHER CG(1), MCLACHLAN AJ(1), LATIMER J(1), KOES BW(1), HANCOCK MJ(1), HARRIS I(1), DAY RO(1), BILLOT L(1), PIK J(1), JAN S(1), LIN CC(1). TRIAL OF PREGABALIN FOR ACUTE

AND CHRONIC SCIATICA. N ENGL J MED. 2017 MAR 23;376(12):1111-1120. DOI: 10.1056/NEJMOA1614292.

• TREATMENT WITH PREGABALIN DID NOT SIGNIFICANTLY REDUCE THE INTENSITY OF LEG PAIN ASSOCIATED WITH SCIATICA AND DID NOT SIGNIFICANTLY IMPROVE OTHER OUTCOMES, AS COMPARED WITH PLACEBO, OVER THE COURSE OF 8 WEEKS. THE INCIDENCE OF ADVERSE EVENTS WAS SIGNIFICANTLY HIGHER IN THE PREGABALIN GROUP THAN IN THE PLACEBO GROUP

MARKMAN J, FRAZER M, RAST S, MCDERMOTT M, GEWANDTER J, CHOWDHRY A, CZERNIECKA K, PILCHER W, SIMON L, DWORKIN R: DOUBLE-BLIND, RANDOMIZED,

CONTROLLED, CROSSOVER TRIAL OF PREGABALIN FOR NEUROGENIC CLAUDICATION. NEUROLOGY 2015;84:265–272

CORRESPONDENCE TODR. MARKMAN:JOHN_MARKMAN@URMC.ROCHESTER.EDU

• Pregabalin was not more effective than active placebo in reducing painful symptoms or functional limitations in patients with neurogenic claudication associated with lumbar spinal stenosis.

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FRIEDMAN BW, DYM AA, DAVITT M, HOLDEN L, SOLORZANO C, ESSES D, BIJUR PE, GALLAGHER EJ: NAPROXEN WITH CYCLOBENZAPRINE,

OXYCODONE/ACETAMINOPHEN, OR PLACEBO FOR TREATING ACUTE LOW BACK PAIN: A RANDOMIZED CLINICAL TRIAL. JAMA 2015;314(15):1572-80

• AMONG PATIENTS WITH ACUTE, NONTRAUMATIC, NONRADICULAR LBP PRESENTING TO THE EMERGENCY DEPARTMENT, ADDING CYCLOBENZAPRINE OR OXYCODONE/ACETAMINOPHEN TO NAPROXEN ALONE DID NOT IMPROVE FUNCTIONAL OUTCOMES OR PAIN AT 1-WEEK FOLLOW-UP. THESE FINDINGS DO NOT SUPPORT USE OF THESE ADDITIONAL MEDICATIONS IN THIS SETTING.

• Editor note by JMC: Naproxen is a nonsteroidal anti-inflammatory drug of the propionic acid class that relieves pain, fever, swelling, and stiffness. It is a nonselective COX inhibitor, usually sold as the sodium salt. Cyclobenzaprine, brand name Flexeril among others, is a muscle relaxer medication used to relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions. The combination oxycodone/paracetamol is a combined opioid/non-opioid pain reliever used to treat moderate to severe acute pain. Here is a method to decrease opioid use????

DENG XT1,2, HAN Y1,3, LIU WT3, SONG XJ1. B VITAMINS POTENTIATE ACUTE MORPHINE ANTINOCICEPTION AND ATTENUATE THE DEVELOPMENT OF

TOLERANCE TO CHRONIC MORPHINE IN MICE. PAIN MED. 2017 OCT 1;18(10):1961-1974. DOI: 10.1093/PM/PNW358.

• B VITAMINS POTENTIATE ACUTE MORPHINE ANTINOCICEPTION AND ATTENUATE THE DEVELOPMENT OF TOLERANCE TO CHRONIC MORPHINE IN MICE.

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DETERMINANTS OF RELIEF FROM SPINAL MANIPULATION

WONG A, PARENT E, DHILLON S, PRASAD N, KAWCHUK G: DO PARTICIPANTS WITH LOW BACK PAIN WHO RESPOND TO SPINAL MANIPULATIVE THERAPY DIFFER

BIOMECHANICALLY FROM NONRESPONDERS, UNTREATED CONTROLS OR ASYMPTOMATIC CONTROLS? SPINE: 01 SEPTEMBER 2015 - VOLUME 40 - ISSUE 17 - P

1329–1337 DOI: 10.1097/BRS.0000000000000981

• AFTER THE FIRST SMT, SMT RESPONDERS DISPLAYED STATISTICALLY SIGNIFICANT DECREASES IN SPINAL STIFFNESS AND INCREASES IN MULTIFIDUS THICKNESS RATIO SUSTAINED FOR MORE THAN 7 DAYS;

• THESE FINDINGS WERE NOT OBSERVED IN OTHER GROUPS. SIMILARLY, ONLY SMT RESPONDERS DISPLAYED SIGNIFICANT POST-SMT IMPROVEMENT IN APPARENT DIFFUSION COEFFICIENTS.

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BEATTIE PF, BUTTS R, DONLEY JW, LIUZZO DM. THE WITHIN-SESSION CHANGE IN LOW BACK PAIN INTENSITY FOLLOWING SPINAL MANIPULATIVE THERAPY IS RELATED TO DIFFERENCES IN DIFFUSION OF

WATER IN THE INTERVERTEBRAL DISCS OF THE UPPER LUMBAR SPINE AND L5-S1. ORTHOP SPORTS PHYS THER. 2013 NOV 21.

DOCTORAL PROGRAM IN PHYSICAL THERAPY, DEPARTMENT OF EXERCISE SCIENCE, ARNOLD SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF SOUTH CAROLINA, COLUMBIA, SC.

• STUDY TO DETERMINE DIFFERENCES IN THE CHANGES IN DIFFUSION OF WATER WITHIN THE LUMBAR INTERVERTEBRAL DISCS BETWEEN THOSE SUBJECTS WITH LOW BACK PAIN (LBP) WHO DID, AND DID NOT, REPORT A WITHIN-SESSION REDUCTION IN PAIN INTENSITY FOLLOWING A SINGLE TREATMENT OF SPINAL MANIPULATIVE THERAPY (SMT) WAS DONE.

• CHANGES IN THE DIFFUSION OF WATER WITHIN THE LUMBAR INTERVERTEBRAL DISCS AT THE L1-2, L2-3, AND L5-1 LEVELS APPEAR TO BE RELATED TO DIFFERENCES IN WITHIN-SESSION PAIN REPORTS FOLLOWING A SINGLE TREATMENT OF SPINAL MANIPULATIVE THERAPY. PARTICIPANTS UNDERWENT T2- AND DIFFUSION-WEIGHTED LUMBAR MAGNETIC RESONANCE IMAGING SCANS IMMEDIATELY BEFORE, AND AFTER, RECEIVING A SINGLE TREATMENT OF SMTJ

KUO, YA-WEN PHD; HSU, YU-CHUN MS; CHUANG, I-TING MS; CHAO, PEN-HSIU GRACE PHD; WANG, JAW-LIN PHD SPINAL TRACTION PROMOTES MOLECULAR

TRANSPORTATION IN A SIMULATED DEGENERATIVE INTERVERTEBRAL DISC MODEL. SPINE: APRIL 20TH, 2014 - VOLUME 39 - ISSUE 9 - P E550–E556

• Traction biomechanics studied in the porcine model biomechanical benefits include disc height recovery, foramen enlargement, and intradiscal pressure reduction.

• 48 thoracic discs were dissected from 8 porcine spines and then divided into 3 groups: intact, degraded without traction, and degraded with traction.

• From Day 4 to Day 6, half of the degraded discs received a 30 min traction treatment per day (traction force: 20 kg, loading: unloading = 30 sec: 10 sec).

• Traction treatment is effective in enhancing nutrition supply and promoting disc cell proliferation of the degraded discs.

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KROEBER M1, UNGLAUB F, GUEHRING T, NERLICH A, HADI T, LOTZ J, CARSTENSC. EFFECTS OF CONTROLLED DYNAMIC DISC DISTRACTION ON

DEGENERATED INTERVERTEBRAL DISCS: AN IN VIVO STUDY ON THE RABBITLUMBAR SPINE MODEL. SPINE (PHILA PA 1976). 2005 JAN 15;30(2):181-7.

• KROEBER ET AL: THE RESULTS OF THIS STUDY SUGGEST THAT DISC REGENERATION CAN BE INDUCED BY AXIAL DYNAMIC DISTRACTION IN THE RABBIT INTERVERTEBRAL DISC. THE DECOMPRESSED RABBIT INTERVERTEBRAL DISCS SHOWED SIGNS OF TISSUE RECOVERY ON A BIOLOGIC, CELLULAR, AND A BIOMECHANICAL LEVEL AFTER 28 DAYS OF DISTRACTION.

GUEHRING T1, OMLOR GW, LORENZ H, ENGELLEITER K, RICHTER W, CARSTENS C, KROEBER M. DISC DISTRACTION SHOWS EVIDENCE OF REGENERATIVE POTENTIAL IN

DEGENERATED INTERVERTEBRAL DISCS AS EVALUATED BY PROTEIN EXPRESSION, MAGNETIC RESONANCE IMAGING, AND MESSENGER RIBONUCLEIC ACID EXPRESSION

ANALYSIS. SPINE (PHILA PA 1976). 2006 JUL 1;31(15):1658-65.

• GUEHRING ET AL: DISC DISTRACTION SHOWS EVIDENCE OF REGENERATIVE POTENTIAL IN DEGENERATED INTERVERTEBRAL DISCS AS EVALUATED BY PROTEIN EXPRESSION, MAGNETIC RESONANCE IMAGING, AND MESSENGER RIBONUCLEIC ACID EXPRESSION ANALYSIS. DISTRACTION RESULTS IN DISC REHYDRATION, STIMULATED EXTRACELLULAR MATRIX GENE EXPRESSION, AND INCREASED NUMBERS OF PROTEIN-EXPRESSING CELLS.

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NEMOTO W, YAMADA K, OGATA Y, NAKAGAWASAI O, ONODERA K, SAKURAI H, TAN-NO K: CHONDROITIN SULFATE ATTENUATES FORMALIN-

INDUCED PERSISTENT TACTILE ALLODYNIA. J PHARMACOL SCI 2016;S1347-8613(16)30091-3 [EPUB AHEAD OF PRINT]

• CHONDROITIN SULFATE (CS) IS USED IN THE TREATMENT OF OSTEOARTHRITIS AND JOINT PAIN. IT HAS ALSO SHOWN RELIEF OF TACTILE ALLODYNIA IN MOUSE STUDIES. THESE FINDINGS SUGGEST THAT CS ATTENUATES FORMALIN-INDUCED TACTILE ALLODYNIA THROUGH THE INHIBITION OF P38 MAPK PHOSPHORYLATION AND SUBSEQUENT UP-REGULATION OF C-FOS EXPRESSION IN THE DORSAL LUMBAR SPINAL CORD.

• Editor note: First what is tactile allodynia? It is pain caused by touch such as clothing against the skin. It is pain caused by so little irritation it would not be considered to cause pain.

CHIROPRACTIC POSITIVE TREATMENT STUDIES

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KIM DG1, CHUNG SH2, JUNG HB3. THE EFFECTS OF NEURAL MOBILIZATION ON CERVICAL RADICULOPATHY PATIENTS' PAIN, DISABILITY, ROM, AND DEEP FLEXOR ENDURANCE. J BACK MUSCULOSKELET REHABIL. 2017 APR 14. DOI: 10.3233/BMR-140191. [EPUB AHEAD OF PRINT]

• NEURAL MOBILIZATION WITH MANUAL CERVICAL TRACTION (NMCT) COMPARED WITH MANUAL CERVICAL TRACTION (MCT) ON PAIN, FUNCTIONAL DISABILITY, MUSCLE ENDURANCE, AND RANGE OF MOTION (ROM) IN INDIVIDUALS WITH CERVICAL RADICULOPATHY (CR). CONCLUSIONS: THESE RESULTS SUGGEST THAT THE NMCT CAN PAIN RELIEF, RECOVERY FROM NECK DISABILITY, ROM, AND DEEP FLEXOR ENDURANCE FOR PATIENTS WITH CR.

BASSON A1, OLIVIER B1, ELLIS R2, COPPIETERS M3,4, STEWART A1, MUDZI W1. THE EFFECTIVENESS OF NEURAL MOBILIZATION FOR NEURO-MUSCULOSKELETAL

CONDITIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS. J ORTHOP SPORTS PHYS THER. 2017 JUL 13:1-76. DOI: 10.2519/JOSPT.2017.7117. [EPUB AHEAD OF PRINT]

• NEURAL MOBILIZATION (NM) OR NEURODYNAMICS IS A MOVEMENT-BASED INTERVENTION AIMED AT RESTORING THE HOMEOSTASIS IN AND AROUND THE NERVOUS SYSTEM.

• FOR CHRONIC LOW BACK PAIN, DISABILITY AND PAIN IMPROVED FOLLOWING NM. FOR CHRONIC NECK-ARM PAIN, PAIN IMPROVED FOLLOWING NM.

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MURPHY D, HURWITZ E, GREGORY A, CLARY R: A NON-SURGICAL APPROACHTO THE MANAGEMENT OF LUMBAR SPINAL STENOSIS: A PROSPECTIVE

OBSERVATIONAL COHORT STUDY. BIOMEDCENTRALPAGE BMC MUSCULOSKELETAL DISORDERS RESEARCH ARTICLE OPEN ACCESS

• DISTRACTION MANIPULATION AND NEURAL MOBILIZATION IN THE TREATMENT OF 57 PATIENTS WITH LUMBAR SPINAL STENOSIS SHOWED THE MEAN PATIENT-RATED PERCENTAGE IMPROVEMENT FROM BASELINE TO THE END TO TREATMENT WAS 65.1%.

CHOI J1, LEE S2, JEON C3. EFFECTS OF FLEXION-DISTRACTION MANIPULATION THERAPY ON PAIN AND DISABILITY IN PATIENTS WITH LUMBAR SPINAL

STENOSIS. J PHYS THER SCI. 2015 JUN;27(6):1937-9. DOI: 10.1589/JPTS.27.1937. EPUB 2015 JUN 30.

1DEPARTMENT OF PHYSICAL THERAPY, GRADUATE SCHOOL OF PHYSICAL THERAPY, DAEGU UNIVERSITY, REPUBLIC OF KOREA.2DEPARTMENT OF PHYSICAL THERAPY, YOUNGDONG UNIVERSITY, REPUBLIC OF KOREA.

3DEPARTMENT OF PHYSICAL THERAPY, THE MOST HOLY TRINITY HOSPITAL, REPUBLIC OF KOREA.

• COX® FLEXION DISTRACTION EFFECT FOR TREATMENT OF SPINAL LUMBAR STENOSIS OVER OTHER CONSERVATIVE THERAPIES.

• 30 PATIENTS WITH LUMBAR SPINAL STENOSIS WERE DIVIDED INTO TWO GROUPS: A CONSERVATIVE TREATMENT GROUP (N=15) AND A FLEXION-DISTRACTION MANIPULATION GROUP (N=15). THE CONSERVATIVE TREATMENT GROUP RECEIVED CONSERVATIVE PHYSICAL THERAPY, AND THE FLEXION-DISTRACTION GROUP RECEIVED BOTH CONSERVATIVE PHYSICAL THERAPY AND FLEXION-DISTRACTION MANIPULATION THERAPY. BOTH GROUPS RECEIVED TREATMENT 3 TIMES A WEEK FOR 6 WEEKS.

• THE DECREASE IN PAIN WAS MORE SIGNIFICANT IN THE FLEXION-DISTRACTION GROUP COMPARED TO PHYSICAL THERAPY.

• FLEXION-DISTRACTION MANIPULATION APPEARS TO BE AN EFFECTIVE INTERVENTION FOR PAIN AND DISABILITY AMONG PATIENTS WITH LUMBAR SPINAL STENOSIS.

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AXÉN I1, LEBOEUF-YDE C2. "TYPICAL" CHIROPRACTIC PATIENTS- CAN THEY BE DESCRIBED IN TERMS OF RECOVERY PATTERNS? CHIROPR MAN THERAP. 2017 AUG

9;25:23. DOI: 10.1186/S12998-017-0152-0. ECOLLECTION 2017.

AUTHOR INFORMATION1 INSTITUTE OF ENVIRONMENTAL MEDICINE, UNIT OF INTERVENTION AND IMPLEMENTATION RESEARCH FOR WORKER HEALTH, KAROLINSKA

INSTITUTET, NOBELS VÄG 13, 171 77 STOCKHOLM, SWEDEN.2 INSTITUTE FOR REGIONAL HEALTH RESEARCH, UNIVERSITY OF SOUTHERN DENMARK, B.WINSLØWS VEJ, 19, DK 5000 ODENSE C, DENMARK.

• 41% OF CHIROPRACTIC LOW BACK PAIN PATIENTS REPORTED TO BE RECOVERED. 176 OF 262 PATIENTS WITH NON-SPECIFIC LBP SHOWED 1) 20% OF PATIENTS MADE A FULL SUSTAINED RECOVERY. 2) 20% RECOVERED INITIALLY BUT EXPERIENCED A RELAPSE, FOLLOWED BY AT LEAST ONE NEW PERIOD OF FULL RECOVERY. 3) 23% FAILED TO RECOVERY INITIALLY BUT EXPERIENCED RECOVERY SOME TIME DURING THE STUDY. 4) 37% HAD NO PERIODS OF RECOVERY, AND WERE THEREFORE CLASSIFIED AS HAVING A NON-FAVORABLE COURSE. AT THE END OF THE STUDY, 41% WERE CLASSIFIED AS RECOVERED.

HAAVIK H1, NIAZI IK2, JOCHUMSEN M3, UGINČIUS P4, SEBIK O4, YıLMAZ G4, NAVIDMS5, ÖZYURT MG4, TÜRKER KS4. CHIROPRACTIC SPINAL MANIPULATION ALTERS TMS

INDUCED I-WAVE EXCITABILITY AND SHORTENS THE CORTICAL SILENT PERIOD. J ELECTROMYOGR KINESIOL. 2018 JUN 19;42:24-35. DOI: 10.1016/J.JELEKIN.2018.06.010.

[EPUB AHEAD OF PRINT]

• SPINAL MANIPULATION CAN BE USED TO STRENGTHEN MUSCLES AS SHOWN BY ANTERIOR TIBIALIS MUSCLE INCREASED STRENGTH FOLLOWING SPINAL MANIPULATION. THIS IS SHOWN ON EMG.

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ALONSO-PEREZ JL1, LOPEZ-LOPEZ A2, LA TOUCHE R3, LERMA-LARA S4, SUAREZ E5, ROJAS J6, BISHOP MD7, VILLAFAÑE JH8, FERNÁNDEZ-CARNERO J9. HYPOALGESIC

EFFECTS OF THREE DIFFERENT MANUAL THERAPY TECHNIQUES ON CERVICAL SPINE AND PSYCHOLOGICAL INTERACTION: A RANDOMIZED CLINICAL TRIAL. J BODYW MOV THER.

2017 OCT;21(4):798-803. DOI: 10.1016/J.JBMT.2016.12.005. EPUB 2016 DEC 22.

• HIGH VELOCITY LOW AMPLITUDE TECHNIQUE (HVLA), JOINT MOBILIZATION, OR CERVICAL LATERAL GLIDE MOBILIZATION (CLGM) WERE COMPARED FOR PAIN RELIEF AND PSYCHOLOGICAL INTERACTION IN TREATING NECK PAIN.

• MOBILIZATION INDUCES MORE HYPOALGESIC EFFECTS. INTERACTION BETWEEN CATASTROPHIZING AND HVLA TECHNIQUE

• JMC note: Cox® long y axis distraction manipulation combines distraction and physiological range of motion on a designed professional instrument with certified chiropractors in its delivery.

DE ROOIJ JD1, GADJRADJ PS, HUYGEN FJ, LUIJSTERBURG PA, HARHANGI BS. MANAGEMENT OF SYMPTOMATIC CERVICAL DISK HERNIATION: A SURVEY

AMONG DUTCH NEUROSURGEONS. SPINE (PHILA PA 1976). 2016 JUN 21.

• HOW LONG IS CONSERVATIVE CARE USED BEFORE NECK SURGERY? A MINIMUM DURATION OF 8 TO 12 WEEKS OF RADICULAR ARM PAIN WAS CONSIDERED TO BE THE OPTIMAL TIMING TO PERFORM SURGERY FOR CDH BY THE MAJORITY OF THE NEUROSURGEONS.

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CHO J1, LEE E1, LEE S2. UPPER THORACIC SPINE MOBILIZATION AND MOBILITY EXERCISE VERSUS UPPER CERVICAL SPINE MOBILIZATION AND STABILIZATION EXERCISE IN

INDIVIDUALS WITH FORWARD HEAD POSTURE: A RANDOMIZED CLINICAL TRIAL. BMC MUSCULOSKELET DISORD. 2017 DEC 12;18(1):525. DOI: 10.1186/S12891-017-1889-2.

• THE COMBINATION OFUPPER THORACIC SPINE MOBILIZATION AND MOBILITY EXERCISE DEMONSTRATED BETTER OVERALL SHORT-TERM OUTCOMES IN CRANIOVERTEBRAL ANGLE, CERVICAL EXTENSION, CERVICAL RANGE OF MOTION, NUMERIC PAIN RATING SCALE (NPRS), PRESSURE PAIN THRESHOLD, NECK DISABILITY INDEX (NDI), AND GLOBAL RATING OF CHANGE (GRC) COMPARED WITH UPPER CERVICAL SPINE MOBILIZATION AND STABILIZATION EXERCISE IN INDIVIDUALS WITH FORWARD HEAD POSTURE.

LILLIE GR1. RESOLUTION OF LOW BACK AND RADICULAR PAIN IN A 40-YEAR-OLD MALE UNITED STATES NAVY PETTY OFFICER AFTER COLLABORATIVE MEDICAL AND

CHIROPRACTIC CARE. J CHIROPR MED. 2010 MAR;9(1):17-21. DOI: 10.1016/J.JCM.2009.12.006.

• FLEXION – DISTRACTION SPINAL MANIPULATION USED TO RELIEVE AN L4-L5 DISK EXTRUSION CAUSING L5 NERVE ROOT RADICULOPATHY IN A 40 YEAR OLD NAVAL OFFICER

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YU P, JIANG F, LIU J, JIAN J: OUTCOMES OF CONSERVATIVE TREATMENT FOR RUPTURED LUMBAR DISC HERNIATION. ACTA ORTHOP BELG 2013 (DEC);

79(6):726-30

• 72 OF 89 PATIENTS WITH LUMBAR DISC HERNIATION GOT WELL UNDER CONSERVATIVE CARE. THE PROTRUSION VOLUME DECREASED AND THE FINAL RESORPTION RATE CORRELATED WITH EXCELLENT AND GOOD OUTCOMES.

ROENZ D1, BROCCOLO J1, BRUST S1, BILLINGS J1, PERROTT A1, HAGADORN J1, COOK C2, CLELAND J1. THE IMPACT OF PRAGMATIC VS. PRESCRIPTIVE STUDY DESIGNS ON

THE OUTCOMES OF LOW BACK AND NECK PAIN WHEN USING MOBILIZATION OR MANIPULATION TECHNIQUES: A SYSTEMATIC REVIEW AND META-ANALYSIS.

J MAN MANIP THER. 2018 JUL;26(3):123-135. DOI: 10.1080/10669817.2017.1398923. EPUB 2017 NOV 20.

• LOW BACK AND NECK PAIN PATIENTS IMPROVED WITH NO DIFFERENCE BETWEEN MOBILIZATION AND MANIPULATION

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XIA T, LONG C, GUDAVALLI R, WILDER D, VINING R, ROWELL R, REED W: SIMILAR EFFECTS OF THRUST AND NON-THRUST SPINAL MANIPULATION FOUND IN ADULTS WITH

SUBACUTE AND CHRONIC LOW BACK PAIN – A CONTROLLED TRIAL WITH ADAPTIVE ALLOCATION. SPINE (PHILA PA 1976) . 2016 JUNE ; 41(12): E702–E709.

DOI:10.1097/BRS.0000000000001373. .

• THRUST AND NON-THRUST SM PROCEDURES WITH DISTINCTLY DIFFERENT JOINT LOADING CHARACTERISTICS DEMONSTRATED SIMILAR EFFECTS IN SHORT-TERM LBP IMPROVEMENT AND BOTH WERE SUPERIOR TO A WAIT LIST CONTROL

HONDRAS M, LONG C, CAO Y, ROWELL R, MEEKER W: A RANDOMIZED CONTROLLED TRIAL COMPARING 2 TYPES OF SPINAL MANIPULATION AND MINIMAL CONSERVATIVE

MEDICAL CARE FOR ADULTS 55 YEARS AND OLDER WITH SUBACUTE OR CHRONIC LOW BACK PAIN. J MANIPULATIVE PHYSIOL THER 2009;32:330-343

• HVLA AND LVVA SPINAL MANIPULATION GAVE SIMILAR POSITIVE OUTCOMES IN TREATING PATIENTS WITH SUBACUTE OR CHRONIC NON RADICULAR LOW BACK PAIN

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CHUNG TS1, YANG HE, AHN SJ, PARK JH.HERNIATED LUMBAR DISKS: REAL-TIME MR IMAGING EVALUATION DURING

CONTINUOUS TRACTION. RADIOLOGY. 2015 JAN 22:141400.

• CONTINUOUS TRACTION ON HERNIATED LUMBAR DISKS AND SURROUNDING STRUCTURES RESULTED IN CHANGE IN DISK SHAPE, DISK REDUCTION WITH OPENING IN THE INTERVERTEBRAL DISK, REDUCTION OF HERNIATED DISK VOLUME, SEPARATION OF THE DISK AND ADJOINING NERVE ROOT, AND WIDENING OF THE FACET JOINT.

• THE REAL-TIME EFFECTS OF CONTINUOUS TRACTION ON HERNIATED LUMBAR INTERVERTEBRAL DISKS AND THEIR SURROUNDING STRUCTURES CAN BE VISUALIZED BY USING MR IMAGING. © RSNA, 2015.

SONG XJ1, HUANG ZJ2, SONG WB3, SONG XS2, FUHR AF4, ROSNER AL5, NDTAN H6, RUPERT RL5. ATTENUATION EFFECT OF SPINAL MANIPULATION ON NEUROPATHIC AND

POSTOPERATIVE PAIN THROUGH ACTIVATING ENDOGENOUS ANTI-INFLAMMATORY CYTOKINE INTERLEUKIN 10 IN RAT SPINAL CORD. J MANIPULATIVE PHYSIOL THER. 2016

JAN 30. PII: S0161-4754(15)00211-0. DOI: 10.1016/J.JMPT.2015.12.004.

• CHRONIC COMPRESSION AND DECOMPRESSION OF THE DORSAL ROOT GANGLION SHOWED BEHAVIORAL AND NEUROCHEMICAL SIGNS OF NEUROPATHIC PAIN WITH INCREASED LEVEL OF IL-1Β AND TNF-Α IN DRG AND THE SPINAL CORD.

• THESE FINDINGS SHOW THAT SPINAL MANIPULATION MAY ACTIVATE THE ENDOGENOUS ANTI-INFLAMMATORY CYTOKINE IL-10 IN THE SPINAL CORD AND THUS HAS THE POTENTIAL TO ALLEVIATE NEUROPATHIC AND POSTOPERATIVE PAIN.

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DIMITRIADIS Z1, KAPRELI E2, STRIMPAKOS N3, OLDHAM J4. RESPIRATORY DYSFUNCTION IN PATIENTS WITH CHRONIC NECK PAIN: WHAT IS THE

CURRENT EVIDENCE? J BODYW MOV THER. 2016 OCT;20(4):704-714. DOI: 10.1016/J.JBMT.2016.02.001. EPUB 2016 FEB 8.

• MAXIMAL VOLUNTARY VENTILATION, STRENGTH OF RESPIRATORY MUSCLES, CHEST MECHANICS AND PARTIAL PRESSURE OF ARTERIAL CARBON DIOXIDE ARE AFFECTED IN PATIENTS WITH CHRONIC NECK PAIN.

NDETAN, H, RUPERT R, BAE S, SINGH, K: PREVALENCE OF MUSCULOSKELETAL INJURIES SUSTAINED BY STUDENTS WHILE ATTENDING A CHIROPRACTIC

COLLEGE. JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS 2009;32(2):140-48

• COX® FLEXION DISTRACTION SHOWED ALMOST NO ADVERSE SIDE EFFECTS IN ITS CLINICAL APPLICATION OF MANIPULATION TO DOCTOR AND 1 IN 54 OF PATIENTS BEING MANIPULATED.

• Distributions of injuries associated with adjusting techniques and specifically training-related activities at Parker College of Chiropractic, 2006 (student perception of injury sources)

• Adjusting Technique• Diversified 280 cases 61 injuries to doctor 74 injuries to patient• Thompson 142 cases 3 25• Gonstead 135 cases 31 39• Cox F/D 54 cases 0 1

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SEMINOWICZ, DA; WIDEMAN, TH; NASO, L; HATAMI-KHOROUSHAHI, Z; FALLATAH, S; WARE, MA; JARZEM, P; BUSHNELL, MC; SHIR, Y; OUELLET, JA; STONE, LS. TREATMENT OF CHRONIC LOW BACK PAIN IN HUMANS REVERSES ABNORMAL BRAIN ANATOMY AND

FUNCTION. JOURNAL OF NEUROSCIENCE 31 (20). MAY 18 2011. P.7540-7550

• DORSOLATERAL PREFRONTAL CORTEX (DLPFC), WHICH WAS THINNER BEFORE TREATMENT OF CHRONIC LOW BACK PAIN PATIENTS SHOWED INCREASED THICKNESS AFTER TREATMENT COMPARED WITH CONTROLS SUGGESTING THAT TREATING CHRONIC PAIN CAN RESTORE NORMAL BRAIN FUNCTION IN HUMANS

CHARLES W. GAY, DC, MICHAEL E. ROBINSON PHD, STEVEN Z. GEORGE PT, PHD, WILLIAM M. PERSTEIN PHD, MARK D. BISHOP PT, PHD. IMMEDIATE CHANGES AFTER

MANUAL THERAPY IN RESTING-STATE FUNCTIONAL CONNECTIVITY AS MEASURED BY FUNCTIONAL MAGNETIC RESONANCE IMAGING IN PARTICIPANTS WITH INDUCED LOW

BACK PAIN. JOURNAL OF MANIPULATIVE AND PHYSIOLOGICAL THERAPEUTICS 2014;37(9): 614-27

• Functional magnetic resonance imaging of brain regions to investigate the immediate changes in functional connectivity (FC) between brain regions that process and modulate the pain experience after 3 different types of manual therapies (MT) and to identify reductions in experimentally induced myalgia and changes in local and remote pressure pain sensitivity.

• Twenty-four participants (17 men; mean age ± SD, 21.6 ± 4.2 years) who completed an exercise-injury protocol to induce low back pain were randomized into 3 groups: chiropractic spinal manipulation (n = 6), spinal mobilization (n = 8), or therapeutic touch (n = 10).

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FACTS FROM THE GAY PAPER

• Pain relief following manual therapy is documented. Research shows neurophysiological changes following MT and reduced pain is accompanied by functional changes in the CNS

• Functional MRI (fMRI) estimates cortical alterations following MT. • Functional connectivity is an fMRI measurement of such change and is defined as “the temporal

correlation of a neurophysiologic index measured in different brain areas. “• BOLD (blood-oxygen-level-dependent) contrast imaging to estimate cortical function before and after

MT was performed on the following brain regions - somatosensory cortex, secondary somatosensory cortex, thalamus, anterior and posterior cingulate cortices, anterior and poster insula, and periaqueductal gray matter. These regions are collectively termed the PAIN PROCESSING NETWORK (PPN)

• It is cited that Sparks, following thoracic manipulation, several brain areas demonstrated decreased BOLD activity. These areas were the cingulate, insular, motor, amygdala and somatosensory cortices and periaqueductal gray matter.

• No difference in the type of MT given was noted

GAY SUMMARY

• Functional connectivity between brain regions is found following MT and suggests MT stimulus influences pain perception.

• Functional connectivity between the anterior insular cortex and periaqueductal gray matter showed change following MT

• Functional connectivity changes between the insula and somatosensory cortex and periaqueductal gray matter may subserve reduced peak BOLD levels

• Activity in the insular region of the brain and pain perception are important relationships in the study of pain reduction following MT.

• BRAIN REGIONS REPRESENTING THE PAIN PROCESSING NETWORK (PPN) SHOWED FUNCTIONAL CONNECTIVITY CHANGES IMMEDIATELY FOLLOWING MANUAL THERAPY.

• NEUROPHYSIOLOGICAL CHANGES AFTER MT MAY BE AN UNDERLYING MECHANISM OF PAIN RELIEF.

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MINIMAL CLINICAL IMPROVEMENT DETERMINATIONMCID

ANNE G. COPAY, PHD , BRIAN R. SUBACH, MD , STEVEN D. GLASSMAN, MD DAVID W. POLLY, JR., MD , THOMAS C. SCHULER, MD. UNDERSTANDING THE MINIMUM

CLINICALLY IMPORTANT DIFFERENCE: A REVIEW OF CONCEPTS AND METHODS. THE SPINE JOURNAL7, 2007: 541-6

•‘‘the smallest change that is important to patients’’

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JOURNAL OF CLINICAL EPIDEMIOLOGY. SEPTEMBER 2018VOLUME 101, PAGES 87–106.E2TO READ THIS ARTICLE IN FULL, PLEASE REVIEW YOUR OPTIONS FOR GAINING ACCESS AT THE

BOTTOM OF THE PAGE.MINIMUM CLINICALLY IMPORTANT DIFFERENCES IN CHRONIC PAIN VARY CONSIDERABLY BY

BASELINE PAIN AND METHODOLOGICAL FACTORS: SYSTEMATIC REVIEW OF EMPIRICAL STUDIESMETTE FRAHM OLSEN, BRITTA TENDAL, JØRGEN HILDEN, ASBJØRN HRÓBJARTSSON,

DOI: HTTPS://DOI.ORG/10.1016/J.JCLINEPI.2018.05.007

THE MINIMUM CLINICALLY IMPORTANT DIFFERENCE (MCID) IS USED TO INTERPRET THE RELEVANCE OF TREATMENT EFFECTS. SYSTEMATIC REVIEW OF PUBMED, EMBASE, AND COCHRANE LIBRARY FOR 66 ELIGIBLE STUDIES (31.254 PATIENTS). MEDIAN ABSOLUTE MCID WAS 23 MM ON A 0–100 MM SCALE (INTERQUARTILE RANGE [IQR] 12–39) AND MEDIAN RELATIVE MCID WAS 34% (IQR 22–45) AMONG STUDIES USING THE MEAN CHANGE APPROACH. MEDIAN ABSOLUTE MCID WAS 20 MM (IQR 15–30) AND RELATIVE MCID WAS 32% (IQR 15–41).

KIKA KONSTANTINOU, PHD, REUBEN OGOLLAH, PHD, MARTYN LEWIS, PHD, DANIELLE VAN DER WINDT, PHD, ELAINE M. HAY, MD ON BEHALF OF THE ATLAS STUDY TEAM.

PROGNOSIS OF SCIATICA AND BACK-RELATED LEG PAIN IN PRIMARY CARE: THE ATLAS COHORT. THE SPINE JOURNAL. JUNE 2018VOLUME 18, ISSUE 6, PAGES 1030–1040

• A STUDY OF 609 PATIENTS SEEING THEIR PRIMARY CARE PHYSICIAN FOR BACK RELATED LEG PAIN AND SCIATICA SHOWED THAT AT 1 YEAR, 55% RECEIVING CURRENT BEST THERAPY SHOWED A MINIMAL CLINICAL IMPROVEMENT OF 30% IN DISABILITY

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POST SURGICAL CONTINUED PAIN PATIENTSaka PSCP or FBSS

MACHADO GC1, MAHER CG, FERREIRA PH, HARRIS IA, DEYO RA, MCKAY D, LI Q, FERREIRA ML. TRENDS, COMPLICATIONS, AND COSTS FOR HOSPITAL

ADMISSION AND SURGERY FOR LUMBAR SPINAL STENOSIS. SPINE (PHILA PA 1976). 2017 APR 24. DOI: 10.1097/BRS.0000000000002207. [EPUB AHEAD OF

PRINT]

• IN AUSTRALIA, DECOMPRESSION RATES FOR LUMBAR SPINAL STENOSIS INCREASED FROM 2003-2013. THE FASTEST INCREASING SURGICAL PROCEDURE WAS COMPLEX FUSION. THIS PROCEDURE INCREASED THE RISK OF MAJOR COMPLICATIONS AND RESOURCE, THOUGH RECENT EVIDENCE SUGGEST FUSION PROVIDES NO ADDITIONAL BENEFITS TO THE TRADITIONAL DECOMPRESSION SURGERY.

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CLANCY C, QUINN A, WILSON F. THE AETIOLOGIES OF FAILED BACK SURGERY SYNDROME: A SYSTEMATIC REVIEW. J BACK MUSCULOSKELET REHABIL. 2016

SEP 23. [EPUB AHEAD OF PRINT]

• 4 T0 50% OF LUMBAR SPINE SURGERY PATIENTS WILL DEVELOP FAILED BACK SURGERY SYNDROME (FBSS). REPEATED SURGERIES LEAD TO ESCALATING COSTS AND SUBSEQUENT DECREASES IN SUCCESS RATE.

OHTORI S1, ORITA S1, YAMAUCHI K1, EGUCHI Y1, AOKI Y1, NAKAMURA J1, ISHIKAWA T1, MIYAGI M1, KAMODA H1, SUZUKI M1, KUBOTA G1, INAGE K1, SAINOH T1, SATO J1,

SHIGA Y1, ABE K1, FUJIMOTO K1, KANAMOTO H1, INOUE G1, TAKAHASHI K1. CLASSIFICATION OF CHRONIC BACK MUSCLE DEGENERATION AFTER SPINAL SURGERY

AND ITS RELATIONSHIP WITH LOW BACK PAIN. ASIAN SPINE J. 2016 JUN;10(3):516-21. DOI: 10.4184/ASJ.2016.10.3.516.

• AFTER SPINE SURGERY, MRI REVEALED MUSCLE DEGENERATION IN ALL PATIENTS. MODIC CLASSIFICATION WAS USED TO DESCRIBE IT. AFTER SURGERY (TYPE 1, 6%; TYPE 2, 82%; AND TYPE 3, 12%).

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HLUBEK RJ1,2,3, MUNDIS GM JR4,5. TREATMENT FOR RECURRENT LUMBAR DISC HERNIATION. CURR REV MUSCULOSKELET MED. 2017 NOV 4. DOI: 10.1007/S12178-017-

9450-3. [EPUB AHEAD OF PRINT]

• CONSERVATIVE TREATMENT FOR RECURRENT LUMBAR DISC HERNIATION IS ADVOCATED. AVAILABLE EVIDENCE SUGGESTS THAT SOME PATIENTS MAY RESPOND TO NONOPERATIVE INTERVENTIONS AND AVOID THE NEED FOR REOPERATION. FOR THOSE THAT FAIL A TRIAL OF CONSERVATIVE MANAGEMENT OR PRESENT WITH NEUROLOGIC DEFICIT, BOTH REPEAT LUMBAR DISCECTOMY AND INSTRUMENTED FUSION APPEAR TO EFFECTIVELY TREAT PATIENTS WITH SIMILAR COMPLICATION RATES AND CLINICAL OUTCOMES.

DEMIREL A1, YORUBULUT M2, ERGUN N1. REGRESSION OF LUMBAR DISC HERNIATION BY PHYSIOTHERAPY. DOES NON-SURGICAL SPINAL DECOMPRESSION THERAPY MAKE DIFFERENCE?

DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL. J BACK MUSCULOSKELET REHABIL. 2017 MAY 5. DOI: 10.3233/BMR-169581. [EPUB AHEAD OF PRINT]

• 20 PATIENTS DIAGNOSED AS LUMBAR HERNIATED NUCLEUS PULPOSUS (LHNP) AND SUFFERING FROM PAIN AT LEAST 8 WEEKS WERE ALLOCATED IN STUDY (SG) AND CONTROL GROUPS (CG) RANDOMLY. BOTH GROUPS RECEIVED COMBINATION OF ELECTROTHERAPY, DEEP FRICTION MASSAGE AND STABILIZATION EXERCISE FOR FIFTEEN SESSION. SG RECEIVED ADDITIONALLY NON SURGICAL DISTRACTION THERAPY (NSDT) DIFFERENT FROM CG.

• PATIENTS WITH LHNP RECEIVED PHYSIOTHERAPY HAD IMPROVEMENT BASED ON CLINICAL AND RADIOLOGIC EVIDENCE. NSDT CAN BE USED AS ASSISTIVE AGENT FOR OTHER PHYSIOTHERAPY METHODS IN TREATMENT OF LUMBAR DISC HERNIATION.

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AMMENDOLIA C1, CÔTÉ P2, SOUTHERST D3, SCHNEIDER M4, BUDGELL B3, BOMBARDIER C5, HAWKER G5, RAMPERSAUD YR6. COMPREHENSIVE NON-SURGICAL TREATMENT

VERSUS SELF-DIRECTED CARE TO IMPROVE WALKING ABILITY IN LUMBAR SPINAL STENOSIS: A RANDOMIZED TRIAL. ARCH PHYS MED REHABIL. 2018 JUN 20. PII: S0003-

9993(18)30362-9. DOI: 10.1016/J.APMR.2018.05.014. [EPUB AHEAD OF PRINT]

• TO COMPARE THE EFFECTIVENESS OF A COMPREHENSIVE NON-SURGICAL TRAINING PROGRAM TO A SELF-DIRECTED APPROACH IN IMPROVING WALKING ABILITY IN LUMBAR SPINAL STENOSIS, A TOTAL OF 104 PARTICIPANTS WITH NEUROGENIC CLAUDICATION AND IMAGING CONFIRMED LSS WERE RANDOMIZED. THE MEAN AGE WAS 70.6 YEARS

• A COMPREHENSIVE CONSERVATIVE PROGRAM DEMONSTRATED SUPERIOR, LARGE AND SUSTAINED IMPROVEMENTS IN WALKING ABILITY AND CAN BE A SAFE NON-SURGICAL TREATMENT OPTION FOR PATIENTS WITH NEUROGENIC CLAUDICATION DUE TO LSS.

MOVASSAGHI K1, BASQUES BA1, LOUIE PK1, KHAN JM1, DERMAN PB1, NOLTE MT1, PAUL JC2, GOLDBERG EJ1, AN HS1. THE DURATION OF SYMPTOMS DOES NOT IMPACT CLINICAL OUTCOMES FOLLOWING LUMBAR DECOMPRESSION SURGERY.

SPINE (PHILA PA 1976). 2018 JUL 27. DOI: 10.1097/BRS.0000000000002818. [EPUB AHEAD OF PRINT]

• THE DURATION OF SYMPTOMS DOES NOT IMPACT CLINICAL OUTCOMES FOLLOWING LUMBAR DECOMPRESSION SURGERY. NON-OPERATIVE TREATMENT OF LUMBAR SPINAL STENOSIS IS OFTEN SUCCESSFUL BUT MAY DELAY OPERATIVE INTERVENTION. HOWEVER, RESULTS OF THIS STUDY SUGGEST THE DELAY DOES NOT NEGATIVELY IMPACT SURGICAL OUTCOMES.

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MILLHOUSE PW1, SCHROEDER GD, KURD MF, KEPLER CK, VACCARO AR, SAVAGE JW. MICRODISCECTOMY FOR A PARACENTRAL LUMBAR HERNIATED DISK. J SPINAL DISORD

TECH. 2015 DEC 24. [EPUB AHEAD OF PRINT]

• Surgical intervention is reserved for patients who have significant pain that is refractory to at least 6 weeks of conservative care, patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction.

EARHART, JS; ROBERTS, D; ROC, G; GRYZLO, S; HSU, W: EFFECTS OF LUMBAR DISK HERNIATION ON THE CAREERS OF PROFESSIONAL BASEBALL PLAYERS

(ARTICLE, ENGLISH). ORTHOPEDICS 35 (1). JAN 2012. P.43-49

• 69 PROFESSIONAL BASEBALL PLAYERS TREATED SURGICALLY AND NON SURGICALLY FOR LUMBAR DISC HERNIATION FOUND 97% RETURNED TO PLAY AT AN AVERAGE OF 6.6 MONTHS. THOSE TREATED NON SURGICALLY RETURNED IN 3.6 MONTHS AND THOSE SURGICALLY TREATED RETURNED IN 8.7 MONTHS.

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MUSCLE DEGENERATION ON CT AND MRI

MITSUTAKE T1, SAKAMOTO M, CHYUDA Y, OKA S, HIRATA H, MATSUO T, OISHI T, HORIKAWA E.GREATER CERVICAL MUSCLE FAT INFILTRATION EVALUATED BY MAGNETIC

RESONANCE IMAGING IS ASSOCIATED WITH POOR POSTURAL STABILITY IN PATIENTS WITH CERVICAL SPONDYLOTIC RADICULOPATHY. SPINE (PHILA PA 1976). 2015 OCT 15.

• FAT INFILTRATION WITHIN MUSCLE COULD LEAD TO INHIBITION OF NORMAL ACTIVITY OF MUSCULATURE. FAT WITHIN CERVICAL MULTIFIDUS MUSCLE COULD DIRECTLY CAUSE POSTURAL INSTABILITY IN STATIC STANDING, EVEN THOUGH THE PROPRIOCEPTIVE INFORMATION HAS NORMAL LOWER LIMBS. GREATER CERVICAL MUSCLE FAT INFILTRATION EVALUATED BY MAGNETIC RESONANCE IMAGING IS ASSOCIATED WITH POOR POSTURAL STABILITY IN PATIENTS WITH CERVICAL SPONDYLOTIC RADICULOPATHY.

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LET’S LOOK AT SPINAL MANIPULATION WE USE IN TREATING SPINE CONDITIONS, BOTH RADICULAR AND NON RADICULARTREATMENT DEMONSTRATIONJames M. Cox, DC, DACBR

UP-COMING WEBINARS

• The DRG• September 26, 2018

• Myelopathy• November 14, 2018

• Osteopathic Techniques Incorporated into the Cox® Technic System

• December 4, 2018

• ONLINE/ON DEMAND 24/7 – CE available• https://coxtechnic.digitalchalk.com/dc/guest/login

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THANK YOU FOR STUDYING WITH ME, FOR BEING THE BACK PAIN SPECIALIST YOU ARE AND INCORPORATING COX® TECHNIC INTO YOUR PRACTICE!info@CoxTechnic.com

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