Efficacy of spinal manipulation for chronic headache: a systematic review.
Author(s): Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L.
Department of Research, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, MN 55431, USA.

BACKGROUND:
Chronic headache is a prevalent condition with substantial socioeconomic impact. Complementary or alternative therapies are increasingly being used by patients to treat headache pain, and spinal manipulative therapy (SMT) is among the most common of these.

OBJECTIVE:
To assess the efficacy/effectiveness of SMT for chronic headache through a systematic review of randomized clinical trials.

STUDY SELECTION:
Randomized clinical trials on chronic headache (tension, migraine and cervicogenic) were included in the review if they compared SMT with other interventions or placebo. The trials had to have at least 1 patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified through a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from the Cumulative Index of Nursing and Allied Health Literature, the Chiropractic Research Archives Collection, and the Manual, Alternative, and Natural Therapies Information System were used, as well as material gathered through the citation tracking, and hand searching of non-indexed chiropractic, osteopathic, and manual medicine journals.

DATA EXTRACTION:
Information about outcome measures, interventions and effect sizes was used to evaluate treatment efficacy. Levels of evidence were determined by a classification system incorporating study validity and statistical significance of study results. Two authors independently extracted data and performed methodological scoring of selected trials.

DATA SYNTHESIS:
Nine trials involving 683 patients with chronic headache were included. The methodological quality (validity) scores ranged from 21 to 87 (100-point scale). The trials were too heterogeneous in terms of patient clinical characteristic, control groups, and outcome measures to warrant statistical pooling. Based on predefined criteria, there is moderate evidence that SMT has short-term efficacy similar to amitriptyline in the prophylactic treatment of chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft-tissue massage for episodic tension-type headache. There is moderate evidence that SMT is more efficacious than massage for cervicogenic headache. Sensitivity analyses showed that the results and the overall study conclusions remained the same even when substantial changes in the prespecified assumptions/rules regarding the evidence determination were applied.

Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations.
Author(s): BenEliyahu DJ

OBJECTIVE:
To prospectively investigate the effect of chiropractic management on clinical and anatomical outcome of disc pathomorphology in previously magnetic resonance imaging (MRI)-documented disc herniation of the cervical and lumbar spine.
SETTING: Private practice.

SUBJECTS:
Twenty-seven patients with MRI-documented and symptomatic disc herniations of the cervical or lumbar spine. A prospective clinical case series.

DESIGN:
All patients were evaluated before commencement of chiropractic care by MRI scans for presence of disc herniations. Precare evaluations also included clinical examination and visual analog scores. Patients were then treated with a course of care that included traction, flexion distraction, spinal manipulative therapy, physiotherapy and rehabilitative exercises. All patients were re-evaluated by postcare follow-up MRI scans, clinical examination and visual analog scores. Percentage of disc shrinkage on repeat MRI, resolution of clinical examination findings, reduced visual analog pain scores and whether the patient returned to work were all recorded.

RESULTS:
Clinically, 80% of the patients studied had a good clinical outcome with postcare visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p < .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their predisability occupations.

CONCLUSION:
This prospective case series suggests that chiropractic care may be a safe and helpful modality for the treatment of cervical and lumbar disc herniations. A random, controlled, clinical trial is called for to further substantiate the role of chiropractic care for the nonoperative clinical management of intervertebral disc herniation.

Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials.
Author(s): Howard Vernon, DC, PhD, Kim Humphreys, DC, PhD, Carol Hagino, MBA
Canadian Memorial Chiropractic College, Toronto, ON, Canada.

OBJECTIVE:  
This study provides a systematic analysis of group change scores in randomized clinical trials of chronic neck pain not due to whiplash and not including headache or arm pain treated with manual therapy.

METHODS:  
A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2005. Only clinical trials scoring above 11.5 (Amsterdam-Maastricht Scale) were included in the analysis.

RESULTS:  
From 1980 citations, 19 publications were selected. Of the 16 trials analyzed (3 were rejected for poor quality), 9 involved spinal manipulation (12 groups), 5 trials (5 groups) were for spinal mobilization or nonmanipulative manual therapy (1 trial overlapped), and 2 trials (2 groups) involved massage therapy. No trials included trigger point therapy or manual traction of the neck. For manipulation studies, the mean effect size (ES) at 6 weeks for 7 trials (10 groups) was 1.63 (95% confidence interval [CI], 1.13-2.13); 1.56 (95% CI, 0.73-2.39) at 12 weeks for 4 trials (5 groups); 1.22 (95% CI, 0.38-2.06) from 52 to 104 weeks for 2 trials (2 groups). For mobilization studies, 1 trial reported an ES of 2.5 at 6 weeks, 2 trials reported full recovery in 63.8% to 71.7% of subjects at 7 to 52 weeks, and 1 trial reported greater than 2/10 point pain score reduction in 78.3% of subjects at 4 weeks. For massage studies, 1 reported an ES of 0.03 at 6 weeks, whereas the other reported mean change scores of 7.89/100 and 14.4/100 at 1 and 12 weeks of, respectively.

Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up.
Author(s): Olav Frode Aure, PT ; Jens Hoel Nilsen, PT ; Ottar Vasseljen, PhD

STUDY DESIGN: 
A multicenter, randomized, controlled trial with 1-year follow-up.

OBJECTIVES: 
To compare the effect of manual therapy to exercise therapy in sick-listed patients with chronic low back pain (>8 wks).

SUMMARY AND BACKGROUNG DATE:  
The effect of exercise therapy and manual therapy on chronic low back pain with respect to pain, function, and sick leave have been investigated in a number of studies. The results are, however, conflicting.

METHODS:  
Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 6 months were included. A total of 49 patients were randomized to either manual therapy (n = 27) or to exercise therapy (n = 22). Sixteen treatments were given over the course of 2 months. Pain intensity, functional disability (Oswestry disability index), general health (Dartmouth COOP function charts), and return to work were recorded before, immediately after, at 4 weeks, 6 months, and 12 months after the treatment period. Spinal range of motion (Schober test) was measured before and immediately after the treatment period only.

RESULTS:  
Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. Immediately after the 2-month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work (P < 0.01), a relative difference that was maintained throughout the follow-up period.

Effectiveness of spinal manipulative therapy in the treatment of mechanical thoracic spine pain: A pilot randomized clinical trial
Author(s): Schiller L.

BACKGROUND:
To date, no substantiated studies have been performed to investigate the efficacy of spinal manipulative therapy on thoracic spinal syndromes.

OBJECTIVE:
To investigate the effectiveness of spinal manipulative therapy in the treatment of mechanical thoracic spine pain.

STUDY DESIGN:
A single-blind, randomized, comparative, controlled pilot study.

SETTING:
Technikon Natal Chiropractic Clinic in Durban, South Africa.

PARTICIPANTS:
Thirty subjects selected from the general population (from 16 to 60 years old) were randomly divided into two different treatment groups of 15 each.

METHODS:
The objective measurements collected were the thoracic spine ranges of motion with the BROM II goniometer and pain threshold with an algometer. The subjective information required completion of the Oswestry Back Pain Disability Index, short-form McGill Pain Questionnaire, and Numerical Pain Rating Scale-101 Questionnaire by the patient. These 3 forms and objective measurements were collected before the first and final treatment and again at the 1-month follow-up consultation. The data gathered were then statistically analyzed with use of a 95% confidence level. The nonparametric Mann-Whitney U test and the Wilcoxon signed-rank test were used to compare intergroup and intragroup data, respectively. This was conducted at the alpha =.05 level of confidence. Further assessment of the data was conducted by use of power analysis.

INTERVENTIONS:
The treatment group received thoracic spinal manipulation. The placebo group received nonfunctional ultrasound application only. The research project was carried out so that both groups received 6 treatments over a period of 2 to 3 weeks. A 1-month follow-up appointment was scheduled after the final treatment to assess the relative long-term benefits of the two different treatments.

RESULTS:
Statistically significant results (P < or = .025) were noted for the percentage of pain experienced (Numerical Pain Rating Scale) and for right and left lateral flexion during intergroup comparison after the final treatment. The final treatment results were maintained at the 1-month follow-up consultation; however, there were no further statistically significant results. It was noted that the power was weak, so the probability of committing type II error (falsely accepting the null hypothesis) for the other measurements was high. The intragroup analysis showed statistically significant improvements in the group that received spinal manipulative therapy in both subjective and objective measurements between the first to final treatment and the first treatment to the 1-month follow-up consultation. The placebo group analysis showed a statistically significant improvement in sensory pain only (subjective measurement) between the first treatment and the final treatment.

Effect of cervical spinal adjustments on lumbar paraspinal muscle tone: evidence for facilitation of intersegmental tonic neck reflexes.
Author(s): Nansel DD, Waldorf T, Cooperstein R.

OBJECTIVES:
To determine whether spinal adjustments, delivered to the upper vs. lower cervical spine, might result in tonic neck reflex-induced alterations in the activity of the lumbar paraspinal musculature.

DESIGN:
Randomized, double-blind, before/after treatment comparisons.
SETTING: Cervical Ergonomics Laboratory, Palmer College of Chiropractic-West, Sunnyvale, CA.

SUBJECTS:
Healthy, nonsymptomatic chiropractic college students, about evenly divided with respect to gender and ranging from 23-38 yr of age.

INTERVENTION:
Modified "diversified" spinal adjustments, delivered bilaterally to either the upper (C2) or lower (C7) cervical region.

MAIN OUTCOME MEASURE:
Tissue compliance measures using a tissue compliance meter, obtained from each subject at sites 2 cm on either side of the spinous processes of L1, L2, L3, L4 and L5 both prior to and within 15 min following treatments.

RESULTS:
Upper cervical adjustments produced changes in lumbar tissue compliance which were only slight (p < .05) and not significantly different from that which occurred following upper cervical sham manipulation (p > .1). However, lower cervical adjustments induced increases in tissue compliance (decreases in tone) which were highly significant (p < .001) and relatively robust compared to those found following upper cervical adjustments (p < .01). Furthermore, the greatest effects were observed on either side of the L4 and L5 spinous processes, suggesting influences on the gluteal musculature in particular.

Improvement of lower extremity electrodiagnostic findings following a trial of spinal manipulation and motion-based therapy
Author(s): Mark W Morningstar
Pettibon Institute 3416-A 57th St Ct NW Gig Harbor WA, USA 98335

BACKGROUND:  
Lumbar disc herniation is a problem frequently encountered in manual medicine. While manual therapy has shown reasonable success in symptomatic management of these cases, little information is known how manual therapy may affect the structure and function of the lumbar disc itself. In cases where lumbar disc herniation is accompanied by radicular symptoms, electrodiagnostic testing has been used to provide objective clinical information on nerve function. This report examines the treatment rendered for a patient with lower extremity neurological deficit, as diagnosed on electrodiagnostic testing. Patient was treated using spinal manipulation and exercises performed on a Pettibon Wobble Chairtrade mark, using electrodiagnostic testing as the primary outcome assessment.

CASE PRESENTATION: 
An elderly male patient presented to a private spine clinic with right-sided foot drop. He had been prescribed an ankle-foot orthosis for this condition. All sensory, motor, and reflex findings in the right leg and foot were absent. This was validated on prior electromyography and nerve conduction velocity testing, performed by a board certified neurologist. Patient was treated using spinal manipulation twice-weekly and wobble chair exercises three times daily for 90 days total. Following this treatment, the patient was referred for follow-up electrodiagnostic studies. Significant improvements were made in these studies as well as self-rated daily function.

Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial
Author(s): Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, de Vet HC, Koes BW, Vondeling H, Bouter LM

OBJECTIVE: 
To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. DESIGN: Economic evaluation alongside a randomised controlled trial.

SETTING:  
Primary care.

PARTICIPANTS:  
183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs).

MAIN OUTCOME MEASURES: 
Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques.

RESULTS: 
The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). These differences were significant: P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care.

Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation.
Author(s): Giles LG, Muller R
National Unit for Multidisciplinary Studies of Spinal Pain, The University of Queensland, The Townsville Hospital, Australia.

STUDY DESIGN: 
  A randomized controlled clinical trial was conducted.

OBJECTIVE: 
To compare medication, needle acupuncture, and spinal manipulation for managing chronic (>13 weeks duration) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain.

SUMMARY OF BACKGROUND DATA:  
Between February 1999 and October 2001, 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital's multidisciplinary spinal pain unit.

METHODS: 
One of three separate intervention protocols was used: medication, needle acupuncture, or chiropractic spinal manipulation. Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index (Oswestry), the Neck Disability Index (NDI), the Short-Form-36 Health Survey questionnaire (SF-36), visual analog scales (VAS) of pain intensity and ranges of movement. These instruments were administered again at 2, 5, and 9 weeks after the beginning of treatment.

RESULTS: 
Randomization proved to be successful. The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%). Manipulation achieved the best overall results, with improvements of 50% (P = 0.01) on the Oswestry scale, 38% (P = 0.08) on the NDI, 47% (P < 0.001) on the SF-36, and 50% (P < 0.01) on the VAS for back pain, 38% (P < 0.001) for lumbar standing flexion, 20% (P < 0.001) for lumbar sitting flexion, 25% (P = 0.1) for cervical sitting flexion, and 18% (P = 0.02) for cervical sitting extension. However, on the VAS for neck pain, acupuncture showed a better result than manipulation (50% vs 42%).