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THE SOMATIC CONNECTION |
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SPORT: A Real World Study of Disc Herniation |
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 Top SPORT: A Real World... Measuring Motion at the...Correction of Leg Length...Lumbar Disc Surgery and...Relief of Cervical Spine......And for Whom It... |
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Real world patient behavior played a major role in study implementation and subsequent outcomes. Only 50% of patients randomized to surgical intervention actually received that treatment within 3 months of study enrollment. However, 30% of those assigned to nonoperative care received surgery in the same time period. Cross-over subjects had significant differences in terms of annual income, baseline symptoms, and levels of disability. Patient perceptions of worsening symptoms at trial entry predicted participation in the observational trial as well as elective surgery.
Standard care for nonoperative randomized patients was individualized, though the study design did not allow researchers to determine the efficacy of these alternatives. Eleven percent of patients receiving nonoperative treatments elected chiropractic manipulation; 44%, physical therapy; and 91%, nonsteroidal anti-inflammatory drugs, including cyclooxygenase-2 inhibitors.
Because of the study design and patient noncompliance to assigned treatments, the role and benefits of surgery remain unclear. Even so, this study makes a major contribution to the medical literature, raising important issues on study design (eg, sham surgical intervention). Regardless of the intervention received, most patients seemed satisfied with their medical care. Even in the randomized controlled trial, most subjects received the intervention they preferred. —F.J.R.
Weinstein JN et al. JAMA.2006
;296:2441
-2450.
Weinstein JN et al. JAMA.2006
;296:2451
-2459.
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Measuring Motion at the Cervical-Thoracic Junction |
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TopSPORT: A Real World...Measuring Motion at the...Correction of Leg Length...Lumbar Disc Surgery and...Relief of Cervical Spine......And for Whom It... |
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The cervical-thoracic junction (CTJ) provides a transition between the highly flexible cervical spine and the more rigid thoracic region. While the lower cervical spine and CTJ are disproportionately affected by soft tissue injury, visualization of individual vertebrae in this area is difficult because of obstruction by the scapula and clavicle in lateral radiographic views. Scott Simon, MD, and others at the University of Pennsylvania (Philadelphia) used a multi-slice computed tomographic scanner to obtain images from the base of the occiput to the superior endplate of the third thoracic vertebrae in unembalmed male cadavers (n=7). Areas of interest were assessed with axial traction, sagittal bending, and rotation during flexion and extension.
The CTJ exhibited the least amount of translation with traction. For traction applied to the head, all displaced cervical regions moved in flexion while the CTJ underwent extension. The CTJ is nearly twice as stiff as other cervical spine regions and behaves as a distinct region in tension. For loading during sagittal bending, the CTJ mimics the response of the lower cervical spine, acting as an extension of that region. —F.J.R.
Simon S et al. Spine.2006 ;31:44 -50.[Medline]
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Correction of Leg Length Discrepancies to Relieve Low Back Pain |
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TopSPORT: A Real World...Measuring Motion at the...Correction of Leg Length...Lumbar Disc Surgery and...Relief of Cervical Spine......And for Whom It... |
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Researchers at Tel Aviv University in Israel studied 33 patients with chronic low back pain of at least 6 months' duration. With the patient standing, the highest rim of the femoral head was measured using ultrasonography. All but one patient was found to have leg length discrepancy measuring up to 10 mm. Twenty-two patients were provided corrective shoe inserts. Eleven patients served as control subjects.
Chronic pain was significantly higher at baseline in the treatment group. At follow-up, though there was no significant change among control subjects, pain intensity scores in the treatment group decreased significantly.
This study addresses the possibility that a modest discrepancy may cause or augment LBP and the possibility that correction of leg length discrepancy may be incorporated into LBP treatment. The uniqueness of the study is that leg length discrepancy was measured using ultrasonography and corrected using shoe inserts as opposed to heel lifts. The weaknesses of the study include small sample size and the lack of subject randomization and long-term follow-up. —F.J.R.
Defrin R et al. Arch Phys Med Rehabil. 2005;86:2075 -2080.[Medline]
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Lumbar Disc Surgery and Nonsurgical Spine Clinics |
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TopSPORT: A Real World...Measuring Motion at the...Correction of Leg Length...Lumbar Disc Surgery and...Relief of Cervical Spine......And for Whom It... |
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The multidisciplinary spine clinics were staffed by nurses, occupational therapists, physical therapists, rheumatologists, and social workers. Patients were given practical self-care advice that included exercise guidance using the McKenzie method. The initial patient visit lasted about 3 hours. Favorable prognosis for LBP using conservative treatment was emphasized.
The annual rate of lumbar disc operation in North Jutland County decreased from approximately 60 to 80 per 100,000 prior to 1997, to 40 per 100,000 in 2001. The rate of elective, first-time disc surgeries decreased by approximately two-thirds. In contrast, the annual rate of lumbar disc operations for patients in the rest of the country remained unchanged during that time. —F.J.R.
Rasmussen C et al. Spine.2005 ;30:2469- 2473.[Medline]
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Relief of Cervical Spine Pain: What Works... |
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TopSPORT: A Real World...Measuring Motion at the...Correction of Leg Length...Lumbar Disc Surgery and...Relief of Cervical Spine......And for Whom It... |
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Martinez-Segura and colleagues at the Escuela de Osteopatia de Madrid in Spain compared the immediate effects of spinal manipulative therapy with a control group that received a manual mobilization procedure with gentle flexion and traction. Seventy patients with mechanical neck pain were referred to a private clinic in Alicante, Spain. Dysfunctional vertebrae were identified using a lateral gliding test. Subjects then received a high velocity/low amplitude (HVLA) manipulation at the level of dysfunction. Researchers report that audible articular release accompanied all procedures.
The group of patients who received HVLA manipulation reported a reduction in neck pain at rest and improved neck mobility. In addition, increased range of motion was recorded. Patients in the mobilization control group also described a reduction in pain and an improvement in neck mobility, though the effect size was much smaller among these subjects. —F.J.R.
Martinez-Segura R et al. J Manipulative Physiol Ther. 2006;29:511 -517.[Medline]
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...And for Whom It Works |
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TopSPORT: A Real World...Measuring Motion at the...Correction of Leg Length...Lumbar Disc Surgery and...Relief of Cervical Spine......And for Whom It... |
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Univariate analysis was used to identify potential predictive factors that might distinguish responders from nonresponders. Those who reported an immediate benefit of HVLA manipulation had a pretreatment neck disability index of less than 11.5 with a bilateral involvement pattern. In addition, these patients were not performing sedentary work for more than 5 hours a day. Patients who felt worse when the neck was in full extension tended not to obtain immediate relief from HVLA manipulation, however.
The study was performed by physical therapists who received training in osteopathic manipulative medicine. It was limited by small sample size and a reliance on subjective postintervention reports. In addition, there was no long-term follow-up for the investigation. —F.J.R.
Tseng YL et al. Man Ther.2006 ;11:306 -315.[Medline]
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Footnotes |
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To submit scientific reports for possible inclusion in "The Somatic Connection," readers are encouraged to contact JAOA Associate Editor Felix J. Rogers, DO (fjrogers{at}aol.com), or Michael A. Seffinger, DO (mseffinger{at}westernu.edu).
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