Fw: Update from Dr. Malik Slosberg, D.C., M.S.

[Guest guest]



Dear colleagues,

check out the second paper on suggested guidelines for relative to spinal manipulation for various forms of headaches and then look at the comments as per "Adverse Events."

Cheers,

Vern Saboe, DC

Update from Dr. Malik Slosberg, D.C., M.S.

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July, 2011 Research Update

Today is July 20, it's mid-summer, and time for the July 20011 Research Update. Remember to take a look at my website, www.slosberg.com, to see the many recently posted studies for you to review for free. The details for upcoming Validating Chiropractic seminars are listed there, too. The content of the seminar is continually updated to keep on the cutting-edge of the most recent research. I hope you find the material in this month's update informative and useful. Please let other chiropractors know about this free service.

Here are two new studies. The first is a new paper on recurrent work absence due to low back pain after patients have been treated and managed by either a chiropractor, medical doctor, or physical therapist. You will find the outcome quite enlightening and positive. The second study is a new clinical practice guideline based on the most thorough and current systematic review of the literature to evaluate the effectivess of spinal manipulation, mobilization, exercise, and more for the management of episodic or chronic migraine, tension-type, or cervicogenic headache. I think you will find the following material interesting, supportive of chiropractic and clinically useful.Cifuentes M, MD, PhD, et al. Health Maintenance Care in Work-Related Low Back Pain and Its Association with Disability Recurrence. JOEM 2011 epub ahead of print. This new paper is a study based on data extracted from the administrative records of the Liberty Mutual Insurance Company which represents about 10% of all U.S. workers’ compensation coverage in many states. Claims data from IL, MA, MD, NH, NY, TX, & WI from January through December 2006 were reviewed because claimants in these states can choose their preferred provider to see for work-related injury. The study compares repeated disability episodes (repeated loss time from work due to LBP) across 894 MD, PT, & DC patients followed-up for 1 year. Provider types (MD, PT, DC) were defined for the initial episode of disability (care received while out of work) & subsequent episode of health maintenance care (care received after the Pt had returned to work). See image below.Results: 11% of the Pts experienced recurrent disability because of work-related LBP (n = 98) within the year of follow-up. The risk of disability recurrence was 2x higher for Pts of PTs and 1.6x higher for Pts of MDs than for Pts of DCs (1.0). Provider type during the health maintenance care period was significantly associated with recurrent disability. The only or mostly PT group had the highest proportion of recurrent disability (16.9%) & the only or mostly DC group had the lowest proportion of recurrent disability (6.5%), Pts of MDs were in the middle (12.5%).Conclusion: Pts suffering nonspecific work-related LBP who received health services mostly or only from a DC had a lower risk of recurrent disability than the Pts of MDs or PTs. Findings support the use of chiropractor services, as they generally cost less than services from other providers. If a lower rate of disability recurrence in work-related LBP cases for chiropractors holds true, it is important to identify the mechanism of action. Commentary: This large data review from multiple states indicates that the risk of recurrent loss time for work was significantly less for patients who received the majority or all of the care from chiropractors than from MDs or Pts. Although the exact reasons for this consistently better outcome are not clear, the authors suggest that the doctor-patient relationship, the explanations, attention, and specifics of the interventions used should be seriously investigated to determine if they are exclusive to the chiropractic-patient interchange or can be utilized in the relationship of other health professionals to their patients as well.s R, DC, Descarreaux M, DC, PhD, et al. Evidence-based Guidelines for the Chiropractic Treatment of Adults with Headache. JMPT 2011;34(274-89). This paper is a clinical practice guideline (CPG) to provide evidence-informed practice recommendations for chiropractic treatment (Tx) of migraine, tension-type, & cervicogenic headaches (HAs) in adults based on a systematic literature search of controlled clinical trials (CCTs) thru August 2009. Strength of the evidence (strong, moderate, limited, conflicting) was considered.Results: 21 papers (16 CCTs/RCTs & 5 systematic reviews (SRs) were included in the systematic review. Evidence did not exceed a moderate level for any HA type.Practice Recommendations—Treatment of Migraine: Spinal manipulation (SM) & multimodal multidisciplinary interventions including massage are recommended for management of Pts with episodic or chronic migraine. Moderate evidence to recommend SM for managing episodic (<15 days/mo) or chronic (>15 days/mo) migraine with a Tx frequency of 1 to 2x/wk for 8 wks based on 1 high-quality RCT, 1 low-quality RCT, & 1 high quality systematic review (SR). Moderate evidence to recommend weekly massage (45-min massage w focus on neuromuscular & trigger points of t back, shoulder, neck, & head) to reduce episodic migraine frequency & improving HA pain based on 1 high-quality RCT. Moderate evidence to recommend multimodal multidisciplinary care (exercise, relaxation, stress & nutritional counseling, massage therapy) based on 1 high quality RCT. Insufficient evidence to recommend for or against the use of exercise alone or exercise combined w multimodal PT (aerobic exercise, cervical range of motion [cROM], or whole body stretching) based on 3 low-quality CCTs.Practice Recommendations—Tension-Type Headache (TT HA): SM cannot be recommended for the management of episodic or chronic TT HA. Low-load craniocervical mobilization (MO) may be beneficial for longer-term management. Moderate evidence tt SM after premanipulative soft tissue therapy provides no additional benefit based on 1 high-quality RCT & 4 SRs which suggest no benefit of SM (2x/wk for 6 wks). 1 high quality RCT suggest that SM may be effective for chronic TT HA but the study is difficult to interpret & inconclusive. A recommendation for or against SM cannot be made. Moderate evidence to recommend low-load craniocervical mobilization (eg, Thera-Band) for longer term (6 mo) management based on 1 high-quality RCT wh showed low-load MO significantly reduced Sx of TT HAs in t longer term. Insufficient evidence to recommend for or against t use of manual traction, connective tissue manipulation, Cyriax's mobilization, or exercise/ physical training for episodic or chronic TT HA based on 3 low-quality inconclusive studies, 1 low-quality negative RCT, & 1 SR contribute to this conclusion. Practice Recommendations—Cervicogenic Headache: SM is recommended. Joint MO or deep neck flexor exercises may improve symptoms (Sx). There’s no consistently additive benefit of combining joint MO & deep neck flexor exercises. Moderate evidence to recommend SM based on 1 high-quality RCT (Tx frequency of 2x/ for 3 which showed significantly positive effects & 2 positive SRs. Moderate evidence to recommend Joint MO based on 1 high-quality RCT (8-12 Txs/6 wks) which reported improved HA frequency, intensity, NP & disability & 2 positive SRs. Moderate evidence to recommend deep neck flexor exercises based on a study of 2x/daily for 6 wks. There’s no consistently additive benefit of combining deep neck flexor exercises & joint MO based on 1high-quality RCT & 2 SRs.Adverse events were not addressed in most clinical trials; & if they were, there were none or they were minor. Conclusions: Evidence suggests that chiropractic care, including SM, improves migraine & cervicogenic HAs. The type, frequency, dosage, & duration of Txs should be based on guideline recommendations, clinical experience, & findings. Evidence for the use of SM as an isolated intervention for Pts w tension-type headache remains equivocal.Commentary: This is the most current and thorough systematic review of randomized controlled trials and systematic reviews in order to arrive at an evidence-based clinical practice guideline for the management of migraine, tension-type, and cervicogenic headaches for chiropractors. Its conclusions, which are quite consistent with previously published guidelines and systematic reviews indicates that spinal manipulation is useful for the management of both migraine and cervicogenic headache, but cannot be recommended for tension-type headache due to a paucity of published studies which demonstrate clinical efficacy. More research should be done to evaluate the effectiveness for tension-type headache because they are the most frequent type of headache. It is important that the is now an accumulation of data which clearly indicates that spinal manipulation is helpful for migraines and cervicogenic headaches. In fact in last month’s “Research Update,†the paper by Chaibi et al found that SM was as effective as the standard medications recommended to reduce the frequency and severity of recurrent migraines. It is worth noting that the evidence is only moderate for effectiveness. More, larger and better designed longitudinal studies are needed in the near future to further strengthen the level of evidence. Remember that many headache sufferers do not tolerate the medications commonly prescribed to manage recurrent headaches or would prefer not to take medications at all if possible. A nonpharmaceutical alternative will provide a great benefit to many headache sufferers.

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Don't miss "The Wave"_________________________Upcoming Validating Chiropractic Seminar Dates & LocationsUpcoming 2011 SeminarsJuly 23-24 • South Lake Tahoe, CAAugust 27-28 • Coeur D’Alene, IDCo-sponsored by the WSCA

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