Chiropractic Safe and Effective for Back Pain During Pregnancy

Low back pain can be a serious problem during pregnancy: studies show that over half of women report back pain at some point during pregnancy. Furthermore, as a new study1 explains, many women experience their first episode of back pain during pregnancy:

“The incidence of low back pain with an onset during pregnancy has been reported to be 61%. It has been shown that among women with low back pain of pregnancy, 75% reported no low back pain before pregnancy. In a study of women with chronic low back pain, up to 28% stated that their first episode of back pain occurred during a pregnancy.”

In this report, the authors studied 17 women with low back pain lasting an average of 21.7 days. The intensity of the back pain was 5.9 on a 1-10 scale, and the onset of pain occurred at 20.6 weeks into the pregnancy.

Each study participant was treated according to the particular symptoms that the patient was experiencing. The authors reported the following:

• About half of the women were self-referred, and the other half were referred by their obstetrician.
• The average time to reach clinically significant pain relief was 4.5 days, while the range was from 0 to 13 days after the initial treatment.
• The average number of treatments necessary to reach clinically relevant pain relief was 1.8.
• The pain levels decreased from the 5.9 at the beginning of the study to 1.5 at the end.
• The patients received between 3 to 15 treatments, with the average being 5.6.
• One patient did not experience clinically significant pain reduction.
• There were no adverse reactions reported by any of the patients.

Low back pain during pregnancy may not seem like a serious problem, but it can have adverse affects on the woman’s health, as the authors explain:

“In most instances, the average pain level is moderate, but severe pain has been reported in 15% of cases. Pain intensity often increases with duration and can result in significant disability. Sleep disturbances have been reported by 49% to 58% of women and impaired daily living by 57% in women with low back pain of pregnancy.

“Despite the apparent impact it has on women, many cases of low back pain of pregnancy go unreported to prenatal providers and/or untreated. Wang et al. found that just 32% of women reported their low back pain of pregnancy to their prenatal providers, and just 25% of these providers recommended a treatment. Skaggs et al. found that among women with low back pain of pregnancy, 80% thought that their providers had not offered treatment for their back pain.”

This study shows that chiropractic effectively reduced pain from low back pain during pregnancy, without any adverse effects.

Lisi AJ. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. Journal of Midwifery & Women’s Health 2006;51:e7-e10.

Chiropractic Treatment of Disc Herniations

This study examined 27 patients in a private chiropractic practice who presented with neck or back pain and who had MRI-documented cervical or lumbar disc herniations that corresponded with clinical findings.

“Patients were treated with a course of chiropractic care consisting of traction for the cervical spine or flexion distraction in the lumbar spine in the acute phase of care, in addition to interferential/ultrasound combination and cryotherapy. In the subacute phase, rotational manipulation was judiciously added, as were isometric and flexibility exercises. In the chronic stage of care, distraction manipulation and rehabilitative exercises were continually employed. Rehabilitative exercise included extension exercises in addition to pelvic tilts, lifts and knee flexion stretching.”

“Treatment frequency was typically four to five times/wk for weeks 1 and 2, then three times/wk with decreasing frequency as the patient progressed. Duration of active care varied from 6 wk to 6 months.”

“When patients reached the point at which their VAS [visual analog scale] score was ?2, their exam findings reversed and their extremity pain resolved, a repeat MRI was obtained. This scenario occurred as early as 6 wk after initiation of care.”

If the patients did not reach these milestones, follow-up MRI was performed 1 year after the initiation of care.

The study found that 22 of 27 (80%) had good clinical outcomes; 17 of the 22 (77%) “had not only good clinical outcome but also evidence of reduced or resolved disc herniation upon repeat MRI scanning.”

Five patients (18.5%) had a marginal or poor outcome, but none had worse clinical signs or pain ratings at the end of the study.
At the beginning of the study, all 27 patients had left work because of the severity of the pain; at follow-up, 21 (78%) were back to work in their former occupations.

VAS scores decreased from an average of 6.9 before treatment to 1.9 following treatment.

One important issue that the author addresses is the controversy of whether manipulation is contraindicated for disc herniation. After reviewing the literature, and from his clinical findings, he concludes that manipulation is indeed safe for disc herniation: “…in the cervical and lumbar spine, rotational manipulation most likely cannot be implicated in disc failure or exacerbation of a disc herniation, and for rotational forces from a manipulation to be involved in disc failure, facet fracture must occur first.” No complications occurred in this study.

BenEliyahu DJ. Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. Journal of Manipulative and Physiological Therapeutics 1996;19(9):597-606.

Chiropractic Treatment of Lumbar Disc Herniation

Over the last few years, it has been recognized in the medical literature that conservative treatment works best for many cases of lumbar disc herniation. For patients with far-lateral, or extreme lateral herniation, however, the effectiveness of conservative care is less certain. This recent case study looked at the outcomes of nonsurgical management of a client with far-lateral disc herniation.

The 60-year-old male client was physically active, and had been seen at a Spine Specialty Center previously for treatment for lower back pain, which resolved. 15 months later, he presented at the Center again with severe back pain (present for 3 weeks), with pain radiating to his right buttock and calf.

Presenting Symptoms:

• Score of 73 (out of 100) on the Oswestry Low Back Questionnaire, and Numerical Pain Ratings of 6 (best) to 10 (worst) on a 1-10 scale.
• Difficulty transitioning from sitting to standing
• Altered gait
• Inability to assume erect position
• Lateral list to left
• Asymmetric static pelvic landmarks (right iliac crest 4 degrees high posteriorly, 2 degrees high anteriorly with standing).
• Pain on right side with lateral and backward bends

Initial treatment included manipulation, traction, and passive movements. This was followed up by instruction in self-correction exercises to be followed at home.

Follow-up consisted of:

2 days later: More traction/passive movement and gradual increase in weight bearing, and the patient was fitted with a back brace.

6 days later: manipulation was performed and the patient returned to work part-time. A MRI and surgical consult were also requested during this fourth visit.

The lumbar MRI showed a lateral L5, S1 disc rupture with L5 nerve impingement; due to patient improvement, surgery was deferred. The patient was at work full-time, with his primary complaint sitting intolerance. With consultation, 1 week later a CT-guided transforaminal lumbar epidural and nerve root steroid injection were performed. Three days later, leg pain was reduced and the patient was sleeping better, was working full-time, and was driving.

The patient was then referred to physical therapy for further rehabilitation.

By the end of 4 weeks of physical therapy—8 weeks after being seen initially for the herniation—the patient had achieved scores of 0 on the Numeric Pain Scale, and of 2 (out of 100) on the Oswestry Low Back Pain Questionnaire.

During 2 follow-up visits at 14 weeks and 20 weeks after the initial complaint, all scores were 0. The patient was exercising by running or alternatively using a stair climbing machine with no pain, and continuing his stabilization exercises. He was asymptomatic 1 year later at follow-up.

The study authors also note that this patient responded well to nonsurgical intervention, but was very fit, motivated, and compliant with treatment. The case study did demonstrate the fact that a multi-disciplinary approach to treatment seems most effective: from manipulation and passive motion/traction, to epidural steroid injection once the effectiveness of these first interventions had plateaued, followed up by physical therapy and ongoing exercises.

Erhard RE, Welch WC, Liu B, Vignovi M. Far-lateral disk herniation: case report, review of the literature, and a description of nonsurgical management. Journal of Manipulative and Physiological Therapeutics 2004;27:e3.

Chiropractic Treatment of Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) is a serious health problem, especially among the elderly. “Spinal stenosis has been defined as any narrowing of the spinal canal or the various tunnels through which nerves and other structures communicate with that canal.” 1 The most common symptoms of LSS are:

• Pain and numbness in the low back.
• Pain and numbness in the legs and buttocks.
• Symptoms are usually worse after walking or extension of the lumbar spine.
• Symptoms improve with flexion of the lower back.

The authors of a new study2 discuss the problem of LSS:

“LSS is one of the most common reasons for spine surgery in older people, although little is known about the efficacy of surgical management of patients with LSS, particularly compared to non-surgical management. It is generally felt that most patients with LSS should be managed non-surgically before considering surgical intervention, but little is also known about what non-surgical approaches are most efficacious.”

The researchers set out to determine if chiropractic is beneficial for these patients. They studied 55 patients with LSS diagnosed by MRI or CT scans. Each patient was given questionnaires to determine disability and pain intensity before treatment and at a 16-month follow-up. In addition, the subjects were questioned regarding improvement every 3 to 4 weeks during treatment.

The patients were treated with the following techniques:

• Distraction Manipulation (DM) – a technique where the patient lies prone on a table that “allows for distraction of the spine through inferiorforward and flexion movement of the lower body.”
• Neural Mobilization (NM) – “a manual and exercise oriented method that is theorized to mobilize nerve roots that are suspected to be the source of nerve root pain.”

Patients were given individual treatment plans, but generally were seen 2-3 times per week for three weeks, then one or two times a week after that. The average number of treatments was 13.3.

The authors reported the following findings at the completion of treatment:

• The average patient-rated improvement was 65.1% from baseline to the end of treatment.
• The average patient improvement in disability was 5.1 points on the Roland Morris Back Pain and Disability (RM) questionnaire.
• There were also significant improvements in “worst pain.”

At the 16 month follow-up:

• The average patient-rated improvement was 75.6%.
• The average improvement in disability was 5.2 points on the RM.
• “Clinically meaningful improvement in disability was seen in 73.2% of patients.”
• The average improvement in “on average pain” was 3.0 points on the RM.
• The average improvement in “at worst pain” was 4.2 points on the RM.
• Only two patients needed surgery by the 16 month follow-up.

Other studies have looked at the natural course of LSS with conservative treatment, and it appears from this study that chiropractic may be more effective than other treatments. A 1996 study3 found that “non-surgical” treatment resulted in improvement of only 1.6 points on the RM after one year.

The authors conclude:

“The combination of DM and NM may be a safe and effective approach for patients with LSS. Because the sample size is relatively small and there is no control group, firm conclusions regarding this cannot be drawn. The outcome of this approach compares favorably with other non-surgical treatments, and treatment with DM and NM may be a viable non-surgical option before considering surgery for LSS.”

1. Nowakowski P, Delitto A, Erhard RE. Lumbar spinal stenosis. Physical Therapy 1996;76:187-190.
2. Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study. BMC Musculoskeletal Disorders 2006;7:16.
3. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study. Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine 1996;21:1787-1795.

Chiropractic Treatment of Spinal Fracture

Two recent studies have been published that discuss the successful management of spinal fractures with chiropractic treatment.

The first¹ describes the case of a 49-year-old man who, after a fall on his buttocks, developed an "oblique (zone III) fracture through the fifth sacral segment with slight anterior displacement of the distal fragment."

"Neurological examination was unremarkable. On orthopaedic examination, the buttock pain was elicited by stressing the sacroiliac (SI) joints, but the distal sacral pain was not aggravated. Patrick's test was negative."

"Palpation revealed marked tenderness of the distal sacrum. Both SI joints were tender and hypermobile. Palpation of the lumbosacral and gluteal musculature did not recreate the patient's symptoms."

"After obtaining the patient's informed consent, the SI joints were manipulated with the patient in side-posture, once on each side, with a contact over the proximal SI joint. Interferential current was applied over the sacrum for analgesia. The patient felt markedly improved immediately."

Further chiropractic treatment consisted of four daily treatments, and then five more treatments during the next two weeks. At that time the patient was discharged.

In the second case², the authors describe the case of a 18-year-old man with a Chance fracture of L3. The man was sitting in the middle rear seat of a car that hit a tree. He was taken by ambulance to the emergency room, where the resident physician told him that radiographic findings were normal. He reported low back pain and paresthesia in the left leg. He was given pain medications and sent home.

The patient had the same symptoms 3 days later, but was again told that everything was normal. An orthopaedic surgeon then evaluated the radiographs and diagnosed a "nondisplaced fracture of L3 confined to the posterior fourth of the vertebral body."

The patient was brought to the chiropractic physician twelve days after the accident. "The chiropractic interpretation of the radiographic examination contradicted the opinion verbally provided by the orthopedist at the hospital. Plain films demonstrated a Chance fracture of L3, extending from both laminae through the pedicles and transverse processes and continuing into the posterior-inferior portion of the vertebral body of L3, passing through the inferior end-plate. It was clear that there was a posterior displacement of the posterior-inferior aspect of the upper part of the L3 vertebral body."

After careful examination of radiographs and CT images, chiropractic treatment was instituted.

"After the second adjustment to L3, the paresthesia to the left leg had resolved and the low back pain had reduced considerably. The patient was adjusted on three occasions at L3 over the course of a week...Approximately 1 month after beginning chiropractic care, the patient reported that the leg symptomatology, including the uncontrollable knee flexion, was very much improved."

At four months after the accident, the patient had no paresthesia in the left leg, and had occasional minor low back pain.

The authors of both studies warn that extreme caution should be observed when working with severe spinal trauma. We recommend that those interested in these studies obtain complete copies for themselves.

1. Steiman I, Grod JP. Spinal manipulation in a case of sacral fracture: presentation in a chiropractic office. Journal of the Canadian Chiropractic Association 1996;40(3):145-149.
2. Plaugher G, Alcantara J, Hart CR. Management of the patient with a Chance fracture of the lumbar spine and concomitant subluxation. Journal of Manipulative and Physiological Therapeutics 1996;19(8):539-551.

Chiropractic Versus Active Exercise for Low Back Pain

Previous studies have shown that chiropractic can be an effective treatment for some patients with low back pain. This new study looked at patients with chronic back pain, with the aim of determining which subgroups of patients find chiropractic beneficial.

For the study, the authors recruited patients from a Chicago suburb; a total of 225 patients met the study requirements. The patients were then randomly assigned to the flexion/distraction (FD) group (123 patients), or the active trunk exercise protocol (ATEP) group (112 patients).

To be included in the study, the subjects had to have pain between L1 and S1 that had lasted at least 3 months.

The authors describe the treatment the subjects received during the study:

“The FD technique was performed on a specially constructed table with a moveable headpiece, a stationary thoraco-lumbar piece, and a moveable lower extremity piece. With the subject lying prone, the clinician placed one hand over the lumbar region at the level of interest and used the other hand to flex, laterally flex, and/or rotate the lower extremity section of the table. FD consisted of two biomechanical components. The first component was a series of traction procedures using the flexion range of motion directed at a specified joint level. The motion from the traction procedure resulted in opening of the posterior joint space and a consequent reduction in intradiscal pressure. The second component was a series of mobilization procedures using a possible combination of ranges of motion targeted again at a specific joint level. Most patients moved from the traction component to the mobilization component within 4 weeks of care.”

“ATEP was administered by licensed physical therapists and consisted of flexion or extension exercises, weight training, flexibility exercises, and cardiovascular exercises dependent on patient symptoms. The aim of the program was to strengthen the muscles surrounding the spine and increase flexibility. Methods used to develop stabilizing exercises were consistent with those of O’Sullivan and colleagues. The therapists in the study met as a group to choose the specific exercise regime for study purposes and met monthly to reinforce treatment consistency. Biomechanically, the ATEP did not concentrate on a specific joint level but sought to impact the lumbar spine as a whole.”

After the course of treatment, the authors examined the data to see how each group fared. They found the following:

• Both sets of patients experienced improvement of their pain and symptoms.
• Subjects in the chiropractic group “had significantly greater relief of pain than those allocated to the exercise program.”
• Patients who had chronic pain categorized “with moderate to severe symptoms, improved most with the flexion-distraction protocol.”
• Patients with recurrent pain and moderate to severe symptoms fared best with ATEP.
• The chiropractic treatment was more effective for patients with radiculopathy.
• “Overall, flexion-distraction provided more pain relief than active exercise…”
• Chiropractic patients were more likely to finish the treatment protocol: 13 patients dropped out from the chiropractic group, while 25 dropped out from the ATEP group.

This study shows that low back pain patients cannot be simply lumped into one group and all treated in the same manner:

“The differences in treatment results according to subgroup analyses make biological sense. The FD intervention was intended to provide motion and forces directed at specific intervertebral level. The ATEP on the other hand was intended to concentrate more on strengthening the muscles surrounding the spine and increasing flexibility. As such, a greater decrease in VAS among patients with radiculopathy should be expected for the FD group where changes in disc pressure may be most important.”

These findings can be helpful to clinicians who are trying to determine the best treatment choice for patients.

Gudavalli MR, Cambron JA, McGregor M, et al. A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. European Spine Journal.