A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-back Pain in a National Health Service Outpatient Clinic

OBJECTIVE: To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain (CLBP) when managed in a hospital by either a regional pain clinic or a chiropractor. DESIGN: The study was a pragmatic, randomized, controlled trial.

SETTING: The trial was performed at a National Health Service (NHS) hospital outpatient clinic (pain clinic) in the United Kingdom.

SUBJECTS AND INTERVENTIONS: Patients with CLBP (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an NHS hospital setting.

OUTCOME MEASURES: The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student's t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated.

RESULTS: Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023).

CONCLUSIONS: This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with chronic low-back pain.

Original article published by: Wilkey A, Gregory M, Byfield D, McCarthy PW. J Altern Complement Med. Jun 2008; 14(5): 465-473.

Dr. David P. Chen
Chiropractor at Laurel Regional Chiropractic
Laurel, Maryland

Barefoot running may be better

Years ago, a friend from karate showed me a magazine ad for a shoe designed to be worn for karate. "But we're all barefoot! Everyone runs, jumps, breaks boards and (outside of when we kick trees) no one's needed them in the history of the art before. Grandmaster's been stomping around for 50 some years barefoot, and he doesn't need any shoes. Why would someone need them now?" My answer is that it wasn't driven by anyone's need for shoes, but by someone's desire to sell shoes. Recent research bears me out. It has been suggested that for running, conventional "neutral" running shoes may cause some of the knee/leg/ankle/hip problems that some runners see. This article in the American Academy of Physical Medicine and Rehabilitation suggests that barefoot runners may have less torque, suggesting less damage, to critical areas in the ankle, knee and hip. The article recommended that future design be closer to barefoot than current conventional running shoe design. In my practice, my goal for patients who exercise is always to find a way for them to keep exercising the way they wish to. I'm grateful that advancing research keeps giving insight into how to make this possible.

Enhancement of in vitro interleukin-2 production in normal subjects following a single spinal manipulative treatment

This wonderful study demonstrates that the immune system can be positively effected with an adjustment. Empirical evidence has suggested this for years, but it's nice to see some objective studies starting to back it up. In Takoma Park, MD I make sure to tell my patients to get adjusted when they feel a cold "coming on".

-PT

Background

Increasing evidence supports somato-visceral effects of manual therapies. We have previously demonstrated that a single spinal manipulative treatment (SMT) accompanied by audible release has an inhibitory effect on the production of proinflammatory cytokines in asymptomatic subjects. The purpose of this study is to report on SMT-related changes in the production of the immunoregulatory cytokine interleukin 2 (IL-2) and to investigate whether such changes might differ with respect to the treatment approach related to the presence or absence of an audible release (joint cavitation).

Methods

Of 76 asymptomatic subjects, 29 received SMT with cavitation (SMT-C), 23 were treated with SMT without cavitation (SMT-NC) and 24 comprised the venipuncture control (VC) group. The SMT-C and SMT-NC subjects received a single, similar force high velocity low amplitude manipulation, in the upper thoracic spine. However, in SMT-NC subjects, positioning and line of drive were not conducive to cavitation. Blood and serum samples were obtained before and then at 20 and 120 min post-intervention. The production of IL-2 in peripheral blood mononuclear cell cultures was induced by activation for 48 hr with Staphylococcal protein A (SPA) and, in parallel preparations, with the combination of phorbol ester (TPA) and calcium ionophore. The levels of IL-2 in culture supernatants and serum were assessed by specific immunoassays.

Results

Compared with VC and their respective baselines, SPA-induced secretion of IL-2 increased significantly in cultures established from both SMT-C and SMT-NC subjects at 20 min post-intervention. At 2 hr post-treatment, significant elevation of IL-2 synthesis was still apparent in preparations from SMT-treated groups though it became somewhat attenuated in SMT-NC subjects. Conversely, IL-2 synthesis induced by TPA and calcium ionophore was unaltered by either type of SMT and was comparable to that in VC group at all time points. No significant alterations in serum-associated IL-2 levels were observed in any of the study groups.

Conclusion

The present study demonstrates that, the in vitro T lymphocyte response to a conventional mitogen (SPA), as measured by IL-2 synthesis, can become enhanced following SMT. Furthermore, within a period of time following the manipulative intervention, this effect may be independent of joint cavitation. Thus the results of this study suggest that, under certain physiological conditions, SMT might influence IL-2-regulated biological responses.

-Dr. Paul Tetro

Chiropractor

Takoma Park, MD

Professional Athletes Utilize Chiropractic Care

NFL Game Day Morning recently included on the show how Jacksonville Jaguar running back Maurice Jones-Drew utilizes chiropractic care to help him heal and perform better. Although the coverage was great, this is nothing new when it comes to professional athletes incorporating chiropractic.

In the recent past, chiropractic care has been utilized by many professional athletes, including Muhammad Ali, Nolan Ryan, Kareem Abdul-Jabbar, Carl Lewis, Barry Bonds, Emmitt Smith, and Joe Montana. Jerry Rice once stated that "chiropractic care has been instrumental in my life, both on and off the field. . ."

As someone that races mountain bikes on a non-professional level, even I have been quite grateful to have immediate chiropractic care after a race. The jarring during a long ride or race can often cause my upper neck to tighten, leading to a headache. Having someone help correct the damage I know I am inflicting on myself with the sport I enjoy is certainly helpful!

But the question is why everyone, regardless of sport activity level, doesn't utilize chiropractic care. I'm not just referring to reducing symptoms, but providing a boost in performance. We may not all get to play for the Jacksonville Jaguars, but we all have people that depend on us.

Brian Lancaster, D.C.
Valley Chiropractic
Frederick, MD

Kinesio Tape in Alexandria VA

What is Kinesio Tape?

For over 25 years, Kinesio has provided comfort and stability to our loyal users. Kinesio Tape offers patients a more gentle approach to rehabilitation than those provided by conventional athletic tape.  On the heels of our unprecedented publicity and positive feedback from the 2008 Olympic Games in Beijing, we here at Kinesio would like to invite you to experience what athletes and medical practitioners around the world are calling the rehabilitative and enhancement tool. I have worked with Kinesio tape for over 10 Years and am a certified Kinesio taping practitioner.

Kinesio Tape is a Latex free, non-medicated, thin, porous cotton fabric with a medical grade acrylic  adhesive. The tape is comprised of elastic qualities which are designed for a 30-40% longitudinal only stretch when applied. Our bodies were designed to move and the Kinesio Taping Technique promotes movement and motion. With Kinesio Tape, we are not only limited to supporting and stabilizing musculature, but allowed to provide rehabilitation while encouraging movement!

How it Works:

The technique relies heavily on insertions and origins of muscles. The built-in stretch of the tape can help stabilize injured muscles, support fatigued, weakened and/or strained muscles, and can also help facilitate a stretch for those muscles in spasm.

In addition to muscle support, Kinesio Tape can lift the skin to increase the space between the skin and muscle. This reduced localized pressure in the affected area helps promote circulation, lymphatic drainage, and lessen the irritation on the subcutaneous neural pain receptors. As an end result, the Kinesio Taping Technique reduces pain and inflammation.

Since the introduction of Kinesio Tape in the United States, medical practitioners such as PTs, ATCs, OTs, DCs, MTs and MDs have recognized and embraced this effective, safe and best of all, easy-to-use modality. The method and tape allow the individual to receive the therapeutic benefits 24 hours a day with both comfort and ease because it can be worn for several days per application. Currently,  Kinesio Tape is being used in hospitals, clinics, high schools, colleges, professional sports teams, and even at the Olympic level

Alexandria, VA

Arthritis Treatment

Another great article from ACA today...

Don't Take Arthritis Lying Down

Years ago, doctors hardly ever told rheumatoid arthritis patients to "go take a hike" or "go for a swim." Arthritis was considered an inherent part of the aging process and a signal to a patient that it's time to slow down. But not so anymore. Recent research and clinical findings show that there is much more to life for arthritis patients than the traditional recommendation of bed rest and drug therapy.

What Is Rheumatoid Arthritis?
The word "arthritis" means "joint inflammation" and is often used in reference to rheumatic diseases. Rheumatic diseases include more than 100 conditions, including gout, fibromyalgia, osteoarthritis, psoriatic arthritis, and many more. Rheumatoid arthritis is also a rheumatic diseases, affecting about 1 percent of the U.S. population (about 2.1 million people.)1 Although rheumatoid arthritis often begins in middle age and is more frequent in the older generation, it can also start at a young age.

Rheumatoid arthritis causes pain, swelling, stiffness, and loss of function in the joints. Several features distinguish it from other kinds of arthritis:
-Tender, warm, and swollen joints.
-Fatigue, sometimes fever, and a general sense of not feeling well.
-Pain and stiffness lasts for more than 30 minutes after a long rest.
-The condition is symmetrical. If one hand is affected, the other one is, too.
-The wrist and finger joints closest to the hand are most frequently affected. Neck, shoulder, elbow, hip, knee, ankle, and feet joints can also be affected.
-The disease can last for years and can affect other parts of the body, not only the joints.2
-Rheumatoid arthritis is highly individual. Some people suffer from mild arthritis that lasts from a few months to a few years and then goes away. Mild or moderate arthritis have periods of worsening symptoms (flares) and periods of remissions, when the patient feels better. People with severe arthritis feel pain most of the time. The pain lasts for many years and can cause serious joint damage and disability.

Should Arthritis Patients Exercise?
Exercise is critical in successful arthritis management. It helps maintain healthy and strong muscles, joint mobility, flexibility, endurance, and helps control weight. Rest, on the other hand, helps to decrease active joint inflammation, pain, and fatigue. For best results, arthritis patients need a good balance between the two: more rest during the active phase of arthritis, and more exercise during remission.2 During acute systematic flares or local joint flares, patients should put joints gently through their full range of motion once a day, with periods of rest. To see how much rest is best during flares, patients should talk to their health care providers.3

The following exercises are most frequently recommended for patients with arthritis:*

Type of Exercise Benefits Frequency of Exercise
Range-of-motion exercises, e.g. stretching and dance Help maintain normal joint movement and increase joint flexibility. Can be done daily and should be done at least every other day.
Strengthening exercises, e.g. weight lifting Help improve muscle strength, which is important to support and protect joints affected by arthritis. Should be done every other day, unless pain and swelling are severe.

Aerobic or endurance exercises, e.g. walking, bicycle riding, and swimming Help improve the cardiovascular system and muscle tone and control weight. Swimming is especially valuable because of its minimal risk of stress injuries and low impact on the body. Should be done for 20 to 30 minutes three times a week unless pain and swelling are severe.

Range-of-motion exercises, e.g. stretching and dance Help maintain normal joint movement and increase joint flexibility. Can be done daily and should be done at least every other day. Strengthening exercises, e.g. weight lifting Help improve muscle strength, which is important to support and protect joints affected by arthritis. Should be done every other day, unless pain and swelling are severe. Aerobic or endurance exercises, e.g. walking, bicycle riding, and swimming Help improve the cardiovascular system and muscle tone and control weight. Swimming is especially valuable because of its minimal risk of stress injuries and low impact on the body. Should be done for 20 to 30 minutes three times a week unless pain and swelling are severe.

* Adapted from Questions and Answers about Arthritis and Exercise.3

If patients experience
Unusual or persistent fatigue,
Increased weakness,
Decreased range of motion,
Increased joint swelling, or
Pain that lasts more than one hour after exercising,
they need to talk to their health care provider.3 Doctors of chiropractic will help arthritis patients develop or adjust their exercise programs to achieve maximum health benefits with minimal discomfort and will identify the activities that are off limits for this particular arthritis patient.

Nutrition for the Rheumatoid Arthritis Patient
Arthritis medications help suppress the immune system and slow the progression of the disease. But for those who prefer an alternative approach, nutrition may provide complementary support. Some evidence shows that nutrition can play a role in controlling the inflammation, and possibly also in slowing the progression of rheumatoid arthritis.

Some foods and nutritional supplements can be helpful in managing arthritis:
Fatty-acid supplements: eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and gamma linolenic acid (GLA). Several studies point to the effectiveness of these fatty acid supplements in reducing joint pain and swelling, and lessening reliance on corticosteroids.4,5

Deep-sea fish, such as salmon, tuna, herring, and halibut, are sources of EPA and DHA. GLA is found in very few food sources, such as black currants and borage seed.

Turmeric, a spice that's used to make curry dishes, may also be helpful. A 95 percent curcuminoid extract has been shown to significantly inhibit the inflammatory cascade and provide relief of joint inflammation and pain.

Ginger extract has been shown to be beneficial in terms of inflammation.

Nettle leaf extract may inhibit some inflammatory pathways.

A vegetarian or low-allergen diet can help with the management of rheumatoid arthritis as well.

The benefits and risks of most of these agents are being researched. Before taking any dietary supplement, especially if you are using medication to control your condition, consult with your health care provider.

What Can Your Doctor of Chiropractic Do?
If you suffer from rheumatoid arthritis, your doctor of chiropractic can help you plan an individualized exercise program that will:
Help you restore the lost range of motion to your joints.
Improve your flexibility and endurance.
Increase your muscle tone and strength.
Doctors of chiropractic can also give you nutrition and supplementation advice that can be helpful in controlling and reducing joint inflammation.


Chiropractor Fairfax, VA 22031

Prediction of Treatment Outcome in Patients with Low Back Pain Treated by Chiropractors - does the psychological profile matter?

It is generally thought that a patient's psychological status can serve as a boost or a hindrance to their recovery. In this interesting Swedish study, the investigators found no link between psychological status and the outcome of their chiropractic care. In Greenbelt, MD we find that by boosting patient morale, we achieve better, longer lasting results.

Background

It is clinically important to be able to select patients suitable for treatment and to be able to predict with some certainty the outcome for patients treated for low back pain (LBP). It is not known to what degree outcome among chiropractic patients is affected by psychological factors. Objectives: To investigate if some demographic, psychological, and clinical variables can predict outcome with chiropractic care in patients with LBP.

Method

A prospective multi-center practice-based study was carried out, in which demographic, clinical and psychological information was collected at base-line. Outcome was established at the 4th visit and after three months. The predictive value was studied for all base-line variables, individually and in a multivariable analysis.

Results

In all, 55 of 99 invited chiropractors collected information on 731 patients. At the 4th visit data were available on 626 patients and on 464 patients after 3 months. Fee subsidization (OR 3.2; 95% CI 1.9-5.5), total duration of pain in the past year (OR 1.5; 95% CI 1.0-2.2), and general health (OR 1.2; 95% CI 1.1-1.4) remained in the final model as predictors of treatment outcome at the 4th visit. The sensitivity was low (12%), whereas the specificity was high (97%). At the three months follow-up, duration of pain in the past year (OR 2.1; 95% CI 1.4-3.1), and pain in other parts of the spine in the past year (OR1.6; 1.1-2.5) were independently associated with outcome. However, both the sensitivity and specificity were relatively low (60% and 50%). The addition of the psychological variables did not improve the models and none of the psychological variables remained significant in the final analyses. There was a positive gradient in relation to the number of positive predictor variables and outcome, both at the 4th visit and after 3 months.

Conclusion

Psychological factors were not found to be relevant in the prediction of treatment outcome in Swedish chiropractic patients with LBP.

-Dr. Louis S. Crivelli II

Chiropractor

Greenbelt, MD