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shoulder pain manual therapyShoulder pain is one of the most common musculoskeletal disorders. The lifetime prevalence is estimated to be in the range of 6.7–66.7%. Shoulder pain and stiffness may reduce family life or social life functions as well as reduce productive activities. It also has a strong statistical correlation with somatizing tendency and poor mental health. There are many cases of shoulder pain that have not improved over time, remain persistent, or occur repeatedly. The prognosis becomes poorer the longer the illness is present.  A review of the effectiveness of conservative nondrug, nonsurgical interventions, either alone or in combination, for conditions of the shoulder was published in the Journal of Manipulative and Physiological Therapeutics in June, 2017. Shoulder conditions addressed in the article were shoulder impingement syndrome (SIS), rotator cuff-associated disorders (RCs), adhesive capsulitis (AC), and nonspecific shoulder pain. Eligibility criteria for the scientific studies included randomized controlled trials (RCTs), systematic reviews, or meta-analyses. Treatments included nondrug, nonsurgical procedures. Results indicated low- to moderate-quality evidence supporting the use of manual therapies for all 4 shoulder conditions. Exercise, particularly combined with physical therapy protocols, was beneficial for SIS and AC. For SIS, moderate evidence supported several passive modalities. For RC, physical therapy protocols were found beneficial but not superior to surgery in the long term. Moderate evidence supported extracorporeal shockwave therapy for calcific tendinitis RC. Low-level laser was the only modality for which there was moderate evidence supporting its use for all 4 conditions.

Bottom line:

  • Manual therapy is beneficial for common shoulder conditions.
  • Low-level laser therapy is beneficial for common shoulder conditions.
  • Exercise protocols are beneficial for SIS and AC.

 

adobestock_42898239Infantile colic is one of the significant challenges of parenthood.  It is one of the common reasons for pediatrician visits during the child’s first 3 months of life. Infantile colic is a prevalent and distressing condition for which there is no proven standard therapy, which motivates parents to seek alternatives.  It is defined as paroxysms of crying lasting more than 3 hours a day, occurring more than 3 days in any week for 3 weeks (aka rule of 3) in a healthy baby aged 2 weeks to 4 months. Colic remains a poorly understood phenomenon affecting up to 30% of babies, with underlying organic causes of excessive crying accounting for less than 5% of cases.  Laboratory tests and radiological examinations are unnecessary if the infant is gaining weight normally and has a normal physical examination.

To date, several randomized trials examining chiropractic care for children with colic have been reported, and although these trials demonstrate some reduction in crying, weaknesses in study methodologies have limited the evidence they provide.  Based on these previous studies, there is some but not definitive evidence to make a recommendation of manual therapy for the excessively crying baby.

The purpose of this study was to try to address methodological weaknesses in the scientific literature by conducting a single-blind, randomized controlled trial comparing chiropractic manual therapy with no treatment and to determine whether parents’ knowledge of treatment biases their report of change in infant crying.

Infants with unexplained persistent crying (colic) verified by a baseline crying diary of 3 days or more and presenting to the Anglo-European College of Chiropractic were included in the study. Other inclusion criteria included: patients had to be younger than 8 weeks, born at a gestational age of 37 weeks or later, and had a birth weight of 2500 grams or more and show no signs of other conditions or illness.  One hundred and four infants participated.

Parents completed a questionnaire (baseline) and their child was then randomized to 1 of 3 groups.  In 2 of the 3 groups, infants received treatment, and in the third, no treatment was administered.  For one of the treatment groups, the parent was able to observe the treatment and knew that the infant was being treated.  Parents in the other two groups were seated behind a screen and could not observe their child. Therefore, parents in these two groups were ‘blind’ as to whether their infant received treatment or not.  To be clear, the 3 groups were: (i) infant treated/parent aware, (ii) infant treated/parent unaware (blinded), and (iii) infant not treated/parent unaware (blinded).

Chiropractic care was delivered by a chiropractic intern and involved low force tactile pressure to spinal joints and paraspinal muscles where dysfunction was noted on palpation. The manual therapy, estimated at 2 N of force, was given at the area of involvement without rotation of the spine. Treatment duration lasted up to 10 days, and the number of treatments during this period were influenced by examination findings and parent reports. Treatment was stopped if parents reported their infant was symptom-free. Infants in the blinded groups were placed by the parent on the examination table and then parents sat behind a screen that blinded observation. Patients in the no-treatment group were not touched by the intern and/or clinician.

Outcome measures included crying time as assessed by a 24 hour crying diary ending either 10 days after baseline or at discharge – whichever was sooner.  Crying time was extracted from the diaries.  A global improvement scale (GIS) was completed at either 10 days or discharge by parents and assessed their ratings of change since baseline (e.g., worse to much improvement).

Key findings of this study were:

  • Compared with baseline, by day 10, there was a significant decrease in crying time -44.4%,  51.2%, and 18.6% in the treatment groups ([Blinded] and [Not Blinded]) and the no-treatment group, respectively
  • In parents blinded to treatment allocation, using 2 or less hours of crying per day to determine a clinically significant improvement in crying time, the increased odds of improvement in treated infants compared with those not receiving treatment were statistically significant at day 8 (adjusted odds ratio [OR], 8.1) and at day 10 (adjusted OR, 11.8)
  • There was a similar greater odds of improvement with treatment compared with no treatment using the global improvement scale
  • The number needed to treat was 3 (indicating that 3 infants need to be treated to gain one additional improvement in crying time over no treatment)

In summary, this study found that excessively crying infants were at least 5 times less likely to cry if they were treated with chiropractic manual therapy than if they were not treated.  Infants who were treated were equally likely to improve, whether the parents were blinded to treatment or not.

Reference:  Miller JE, Newell D, Bolton JE. Efficacy of chiropractic manual therapy on infant colic: a pragmatic single-blind, randomized controlled trial. J Manipulative Physiol Ther. 2012 Oct;35(8):600-7.

 

 

 

 

Hip ArthritisChiropractic care holds potential value for the treatment of a variety of limb conditions.  For patients with osteoarthritis (OA) of the hip, a combined intervention of manual therapy provided by a chiropractor and patient education was more effective than a minimal control intervention.

A recent article by Poulsen et al (2013) contributes to our understanding of the literature regarding chiropractic and lower extremity conditions – particularly hip osteoarthritis. Hip osteoarthritis (OA) is a common joint disease and when symptomatic can have significant impact on regular daily activities.  Recently, hip OA has been linked to higher mortality rates.  In end stage hip OA, joint replacement surgery is an appropriate and cost-effective treatment but a long-term cohort study has documented that only 20% of patients with radiographic hip OA have had surgery 11-28 years after the initial diagnosis.  Therefore, non-surgical interventions with documented effectiveness become essential for patients who do not need, or choose not to have surgery.

Although guidelines recommend patient education (PE) programs as a core intervention, systematic reviews are contradictory in conclusions regarding their effectiveness on pain and function in hip OA. Manual therapy (MT) has been proposed as an adjunct intervention to exercise for patients with hip OA but evidence is based on a single randomized clinical trial (RCT).  The authors of the current study realized this gap in the literature and decided to investigate the effectiveness of a patient education (PE) program with or without the added effect of manual therapy (MT) compared to a minimal control intervention (MCI).

The design of this study was a single-center proof-of-principle three-arm parallel group RCT.  Inclusion criteria were: Unilateral hip pain >3 months’ duration, age 40-80 years, radiographic hip OA defined as minimal joint space width (JSW) measurement <2.00 mm or a side difference in minimal JSW >10%, and, ability to speak and read Danish.  The study took place at the Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Denmark.

During the first 2 months of recruitment, 3 exclusion criteria were added to the original criteria: patients who had had MT within the previous twelve months; patients who rated their pain severity as 1 or 2 on the numerical rating scale (NRS); patients with polyarthritis.

The 3 groups in the study were: 1) MCI; 2) PE; 3) PE + MT.

For the MCI group, a nurse provided written advice on a home stretching program derived from the PE program together with 5-10-min instruction.

The PE group, originally termed ‘Hip School’ was taught by a physiotherapist with 11 years experience. The PE program included two individual sessions and three group sessions.

In the combined PE and MT group, manual therapy was administered by a chiropractor with 20 years of clinical experience. MT was scheduled twice a week for the 6-week intervention period and treatment was individualized to each patient depending on examination findings. MT consisted of: trigger point release therapy (TPPR), muscular stretching by muscle energy technique (MET) and joint manipulation.

The primary outcome was pain severity rated on an 11-box NRS, measured after 6 weeks of intervention. Patients were asked to rate the worst pain experienced during the previous week. Secondary outcome measures were the Hip Disability and Osteoarthritis Outcome Score (HOOS) ranging from 0-100, worst to best; patients’ perceived global effect of interventions, percentage in each group having classified themselves as improved; passive hip range of motion (ROM); use of pain medication at 12 months and hip replacement surgery within the 12 month follow-up period.

Results:

  • A total of 111 patients were included in the analyses at the primary end point at 6 weeks
  • In the combined group (PE + MT), a clinically relevant reduction in pain severity compared to the MCI of 1.90 points was achieved
  • Effect size (Cohen’s d) for the PE + MT minus the MCI was 0.92 (large effect)
  • The number of patients in each group experiencing pain reduction of at least 25% from baseline to 6 weeks was PE = 8, PE +MT = 21 and MCI = 7
  • Number needed to treat for PE + MT was 3
  • No difference was found between the PE and MCI groups
  • At 12 months, not including patients receiving hip surgery the statistically significant difference favoring PE + MT was maintained
  • All HOOS (pain, symptoms, ADLs, Sport/Rec, QOL) subscales demonstrated clinically relevant and statistically significant superiority, p < 0.05 for the PE + MT group when compared to the MCI group
  • Mean differences between PE and MCI were small (range 4 to 1) and not statistically significant, p > 0.05
  • Effect sizes for HOOS subscales for PE + MT minus MCI ranged between 0.75 and 1.08
  • No changes in hip ROM noted between groups

Key Findings:

  • For primary care patients with OA of the hip, a combined intervention of manual therapy provided by a chiropractor and patient education was more effective than a minimal control intervention
  • Note that patient education alone was not superior to the minimal control intervention

So, what does this study tell us?  This trial demonstrated clinical and statistically significant improvements in pain, symptoms and disability for a combined intervention consisting of manual therapy provided by a chiropractor and patient education when compared to a minimal control intervention including home stretching.

 

Reference: Poulsen E, Hartvigsen J, Christensen HW, Roos EM, Vach W, Overgaard S. Patient education with or without manual therapy compared to a control group in patients  with osteoarthritis of the hip. A proof-of-principle three-arm parallel group randomized clinical trial. Osteoarthritis Cartilage. 2013 Oct;21(10):1494-503.

postconcussionsyndromeMuch is known about the injury mechanisms of concussion injuries in the acute phase, but there is little evidence to support many of the theories regarding postconcussion syndrome (PCS).  A potential, and very treatable, cause of this chronic condition is cervical spine dysfunction due to co-existing whiplash-type injury.  Based on previously established tissue injury thresholds, acceleration/deceleration of the head and neck sufficient to cause traumatic brain injury is also likely to cause  injury to the joints and soft tissues of the neck. It has also been well established that injury and/or dysfunction of the cervical spine can result in numerous signs and symptoms synonymous with concussion, including headaches, dizziness, cognitive as well as visual dysfunction.  Given our current level of evidence, skilled, manual therapy-related assessment and rehabilitation of cervical spine dysfunction should be considered for chronic symptoms following concussion injuries.

http://www.ncbi.nlm.nih.gov/pubmed/26138797

 

Podcast

Geoffrey Bove, DC, PhD, and I discuss his research regarding inflammation within peripheral nerves, chiropractic principles, manual therapies, repetitive motion disorders and much more.  Dr. Bove is a graduate of Hampshire College, Canadian Memorial Chiropractic College, and the University of North Carolina, Chapel Hill.  He is currently a professor at the University of New England, in Biddeford Maine (USA).  Dr. Bove’s research has focused on the effect of inflammation on small diameter axons within peripheral nerves, a topic directed by founding chiropractic principles.  He also studies the effects of manual therapies on common painful conditions, such as repetitive motion disorders and postoperative visceral adhesions.

Visit Dr. Bove’s research gate profile.

Here are the links to Dr. Bove’s articles we discuss in this interview:

 

1. Time course of ongoing activity during neuritis and following axonal transport disruption.
Satkeviciute I, Goodwin G, Bove GM, Dilley A.
J Neurophysiol. 2018 May 1;119(5):1993-2000. doi: 10.1152/jn.00882.2017. Epub 2018 Feb 21.
PMID: 29465329 [PubMed – in process]
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2. Group IV nociceptors develop axonal chemical sensitivity during neuritis and following treatment of the sciatic nerve with vinblastine.
Govea RM, Barbe MF, Bove GM.
J Neurophysiol. 2017 Oct 1;118(4):2103-2109. doi: 10.1152/jn.00395.2017. Epub 2017 Jul 12.
PMID: 28701542 [PubMed – indexed for MEDLINE] Free PMC Article
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3. Attenuation of postoperative adhesions using a modeled manual therapy.
Bove GM, Chapelle SL, Hanlon KE, Diamond MP, Mokler DJ.
PLoS One. 2017 Jun 2;12(6):e0178407. doi: 10.1371/journal.pone.0178407. eCollection 2017.
PMID: 28574997 [PubMed – indexed for MEDLINE] Free PMC Article
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4. A model for radiating leg pain of endometriosis.
Bove GM.
J Bodyw Mov Ther. 2016 Oct;20(4):931-936. doi: 10.1016/j.jbmt.2016.04.013. Epub 2016 Apr 14.
PMID: 27814877 [PubMed – indexed for MEDLINE] Free PMC Article
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5. A Novel Method for Evaluating Postoperative Adhesions in Rats.
Bove GM, Chapelle SL, Boyle E, Mokler DJ, Hartvigsen J.
J Invest Surg. 2017 Apr;30(2):88-94. doi: 10.1080/08941939.2016.1229367. Epub 2016 Oct 3.
PMID: 27690703 [PubMed – indexed for MEDLINE]
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6. Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury.
Bove GM, Harris MY, Zhao H, Barbe MF.
J Neurol Sci. 2016 Feb 15;361:168-80. doi: 10.1016/j.jns.2015.12.029. Epub 2015 Dec 24.
PMID: 26810536 [PubMed – indexed for MEDLINE] Free PMC Article
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7. Disruption of fast axonal transport in the rat induces behavioral changes consistent with neuropathic pain.
Dilley A, Richards N, Pulman KG, Bove GM.
J Pain. 2013 Nov;14(11):1437-49. doi: 10.1016/j.jpain.2013.07.005. Epub 2013 Sep 12.
PMID: 24035352 [PubMed – indexed for MEDLINE]
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8. Focal nerve inflammation induces neuronal signs consistent with symptoms of early complex regional pain syndromes.
Bove GM.
Exp Neurol. 2009 Sep;219(1):223-7. doi: 10.1016/j.expneurol.2009.05.024. Epub 2009 May 27.
PMID: 19477176 [PubMed – indexed for MEDLINE]
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9. Inflammation induces ectopic mechanical sensitivity in axons of nociceptors innervating deep tissues.
Bove GM, Ransil BJ, Lin HC, Leem JG.
J Neurophysiol. 2003 Sep;90(3):1949-55. Epub 2003 Apr 30.
PMID: 12724363 [PubMed – indexed for MEDLINE] Free Article
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10. Disruption of axoplasmic transport induces mechanical sensitivity in intact rat C-fibre nociceptor axons.
Dilley A, Bove GM.
J Physiol. 2008 Jan 15;586(2):593-604. Epub 2007 Nov 15.
PMID: 18006580 [PubMed – indexed for MEDLINE] Free PMC Article
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Dr. Craig Moore, Chiropractic, HeadachesDr. Craig Moore discusses the role of chiropractors in the management of headaches. Some areas of discussion we touch upon include the societal impact and costs associated with headaches; prevalence of headaches in the community; prevalence of headache in chiropractic clinical settings; why do people turn to chiropractors; current level of evidence for chiropractic treatment of different headache types; what do the headache guidelines recommend for each headache; what should a chiropractor consider when examining a headache patient (history and examination).

Dr. Craig Moore is the director of a multi-disciplinary allied-health clinic in Crows Nest, Sydney. His clinic focus is toward the diagnosis and management of musculoskeletal disorders and in headache disorders in particular (migraine, tension-type headache, cervicogenic headache).

Dr. Moore has completed a Masters of Clinical Trials Research and is currently enrolled at the University of Technology Sydney, doing a PhD in Public Health – focused on the chiropractic management of headache disorders. As a founding member of the Australian Chiropractic Research Network (ACORN) he has a strong interest in supporting the development of chiropractic research through the utilization of this practice-based research network project. He has numerous publications in the scientific literature in such journals as Spine, BMC Neurology, JMPT, BMC Musculoskeletal Disorders and Headache to name a few. Dr. Moore is also a CARL Fellow!

See Dr. Moore’s research at researchgate.net.

Here are the articles we mentioned during the podcast:

1. The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors.
Moore C, Adams J, Leaver A, Lauche R, Sibbritt D.
BMC Complement Altern Med. 2017 Dec 4;17(1):519. doi: 10.1186/s12906-017-2026-3.
PMID: 29202816 [PubMed – indexed for MEDLINE] Free PMC Article
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2. A cross-sectional examination of the profile of chiropractors recruited to the Australian Chiropractic Research Network (ACORN): a sustainable resource for future chiropractic research.
Adams J, Peng W, Steel A, Lauche R, Moore C, Amorin-Woods L, Sibbritt D.
BMJ Open. 2017 Sep 29;7(9):e015830. doi: 10.1136/bmjopen-2017-015830.
PMID: 28965091 [PubMed – in process] Free PMC Article
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3. The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey.
Adams J, Peng W, Cramer H, Sundberg T, Moore C, Amorin-Woods L, Sibbritt D, Lauche R.
Spine (Phila Pa 1976). 2017 Dec 1;42(23):1810-1816. doi: 10.1097/BRS.0000000000002218.
PMID: 28459779 [PubMed – in process]
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4. A critical review of manual therapy use for headache disorders: prevalence, profiles, motivations, communication and self-reported effectiveness.
Moore CS, Sibbritt DW, Adams J.
BMC Neurol. 2017 Mar 24;17(1):61. doi: 10.1186/s12883-017-0835-0. Review.
PMID: 28340566 [PubMed – indexed for MEDLINE] Free PMC Article
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5. A workforce survey of Australian chiropractic: the profile and practice features of a nationally representative sample of 2,005 chiropractors.
Adams J, Lauche R, Peng W, Steel A, Moore C, Amorin-Woods LG, Sibbritt D.
BMC Complement Altern Med. 2017 Jan 5;17(1):14. doi: 10.1186/s12906-016-1542-x.
PMID: 28056964 [PubMed – indexed for MEDLINE] Free PMC Article
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