How often should a Patient be treated with manipulation?

We do not know the answer but early evidence from a small study suggests that high-frequency care initially may have some short-term benefit.

Patients were randomly allocated to visits (1, 2, 3 or 4 visits/week for 3 weeks) and to treatment regimen (spinal manipulation only or spinal manipulation with PM). All patients received high-velocity low-amplitude spinal manipulation. Half received one or two of the following PM at each visit: soft tissue therapy, hot packs, electrotherapy or ultrasound. Pain intensity: At 4 weeks, there was a substantial linear effect of visits favoring a larger number of visits: 5.7 points per 3 visits (SE=2.3, p=.014). At 4 weeks, a visits effect was noted (p=.018); the slope for group means was approximately 5 points per 3 visits. There were no group differences at 12 weeks. CONCLUSIONS: There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.

A similar study was performed with patients diagnosed with cervicogenic headache demonstrating similar results.

Haas, M, Groupp, E, Kraemer, D. F. Dose-response for chiropractic care of chronic low back pain. Spine J 2004;4:574-583.

Disc Herniation and Radiculopathy

After recently attending a workshop on lumbar radiculopathy by Dr. Mir Ali, M.D., of OAD orthopedics, spinal surgery, I was reminded just how many different treatment options there are to this complex problem. Here is an overview of Disc Herniation and its symptoms.


The disc can be viewed a lot like a jelly donut. It is somewhat circular with an outer area and a center or core (nucleus). When the core bulges into the outer layer it is a bulging disc and can press on sensitive nerve structures. When it breaks into the outer layer (like the dough but with the consistency of crab meat) it is a herniation. Sometimes it breaks totally out of the disc and becomes a free fragment which can be a serious condition causing loss of bowel or bladder function or numbness in the groin (cauda equina syndrome)-usually a surgical emergency.


What Causes a Herniated Disc? The causes are many. Basically, weakness in the outer layer of the discs or the inability of the disc to handle the pressure load of the nucleus causes the fibers to rupture allowing the nuclear material to escape its containment. Lifting improperly, traumatic injuries, coughing, sneezing, and straining activities have all resulted in disc herniations.

What are the Symptoms of a Herniated Disc?

•Pain: pain can be severe in the back and leg(s). If the pain is immediately more severe in the leg, we are concerned about a free fragment (sequestered disc). Pain is usually worse with sitting.
•Radiating sciatic pain (radiculopathy).
•Muscle weakness
•Numbness and Tingling
How are disc injuries diagnosed? An orthopedic and neurological and x-ray examination normally needs to be performed to determine other possible sources (piriformis syndrome, osteoarthritic spurring, etc.). A MRI may be necessary to establish the location and severity of the herniation.

What are my Treatment Options?

•In less severe cases, conservative management works effectively including: spinal manipulation (chiropractic), physical medicine modalities for pain control (interferential current, ice, laser, Massage Therapy), acupuncture, rehabilitation exercises, medications.
•More severe cases may require epidural steroid injections, surgical excision of the herniation, disc replacement or fusion.
•Cauda equina symptoms generally require emergency surgery.

Many other conditions may mimic a disc herniation and are effectively treated non-surgically.

In any case a through evaluation is needed by a competent healthcare professional. If you or anyone you know suffers from disc herniation please call 630-474-9500.

-Dr. Blake Schaffnit , D.C.

NSAID Use Associated With Future Stroke

September 8, 2010 (Stockholm, Sweden) — Short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with an increased risk of stroke in a Danish population study including only healthy individuals.
Presenting the study at last week's European Society of Cardiology (ESC) 2010 Congress, Dr Gunnar Gislason (Gentofte University Hospital, Hellerup, Denmark) said the results could have "massive public-health implications."
"First we found an increased risk of MI with NSAIDs. Now we are finding the same thing for stroke. This is very serious, as these drugs are very widely used, with many available over the counter," Gislason told heartwire. "We need to get the message out to healthcare authorities that these drugs need to be regulated more carefully."
Cochair of the session at which the study was presented, Dr Robert Califf (Duke Clinical Research Institute, Durham, NC), agreed that the results raised a major public-health issue, especially in the US, where many NSAIDs were available without a prescription.

For the current study, Gislason and colleagues examined the risk of stroke and NSAID use in healthy individuals living in Denmark. He explained to heartwire that information on each individual in the Danish population is kept in various national registries. His team started with the whole population of Denmark aged over 10 years. To select just the healthy individuals, they excluded anyone admitted to the hospital within the past five years or those prescribed chronic medications for more than two years. This left a population of around half a million, who were included in the study. By linking to prescribing registries, the researchers found that 45% of these healthy individuals had received at least one prescription for an NSAID between 1997 and 2005. They then used stroke data from further hospitalization and death registries and estimated the risk of fatal and nonfatal stroke associated with the use of NSAIDs by Cox proportional-hazard models and case-crossover analyses.

Results showed that NSAID use was associated with an increased risk of stroke. This increased risk ranged from about 30% with ibuprofen and naproxen to 86% with diclofenac.


Risk of Stroke With Various Nsaids
NSAID
HR (95% CI) for risk of stroke

Ibuprofen
1.28 (1.14–1.44)

Diclofenac
1.86 (1.58–2.19)

Rofecoxib
1.61 (1.14–2.29)

Celecoxib
1.69 (1.11–2.26)

Naproxen
1.35 (1.01–1.79)


Gislason noted that there was also a dose-relationship found, with the increased risk of stroke reaching 90% (HR 1.90) with doses of ibuprofen over 200 mg and 100% (HR 2.0) with diclofenac doses over 100 mg. He pointed out that the results were particularly striking, given that this study was conducted in healthy individuals.

He conceded that his results could have some confounding but noted that the data were controlled for age, gender, and socioeconomic status and the patient population did not include those with chronic diseases. "We also have to think about the degree of confounding needed to nullify risk. It would have to increase risk four- to fivefold, which is very unlikely," he commented.

He said he did not find the results that surprising in view of the accumulating evidence of increased MI risk with these drugs, adding that the mechanism was probably the same. There have been several hypotheses about the mechanism linking NSAIDs with cardiovascular events, including increased thrombotic effect on platelets, the endothelium, and/or atherosclerotic plaques; increasing blood pressure; and effect on the kidneys and salt retention.

Gislason told heartwire that there is reluctance among the medical profession to limit the prescribing of these drugs. "The problem is that we don't have randomized trials, and it is very hard to change the habits of doctors. They have been using these drugs for decades without thinking about cardiovascular side effects."

He also stressed that the public needs to be protected by not allowing NSAIDs to be bought without a prescription. He has had some success in this regard in Denmark at least, where diclofenac became available over the counter recently, but after some of the MI data came out, Gislason's group campaigned the health authorities, and it has now become a prescription-only drug again. But he noted that many more NSAIDs are available over the counter in the US.

He believes the harmful effects of these agents are relevant to huge numbers of people. "If half the population takes these drugs, even on an occasional basis, then this could be responsible for a 50% to 100% increase in stroke risk. It is an enormous effect."

These results have been partly published in Circulation: Cardiovascular Quality and Outcomes earlier this year [1]. Gislason told heart wire that the novelty of the results presented at the ESC meeting was that "we had further analyzed our data regarding specific stroke and looked at the risk of ischemic stroke, and we confirmed that the risk of ischemic stroke was substantially elevated." He added: "We are in the process of analyzing these data related to time to risk and the effect of duration of treatment on stroke risk."
-By Sue Hughes

References
1. Fosbøl EL, Folke F, Jacobsen S, et al. Cause-specific CV risk associated with NSAIDs among healthy individuals.
Circ Cardiovasc Qual Outcomes 2010; 3:395-405.

Sue Hughes is a journalist for Medscape. She joined theheart.org, part of the WebMD Professional Network, in 2000. She was previously science editor of Scrip World Pharmaceutical News. Graduating in pharmacy from Manchester University, UK, she started her career as a hospital pharmacist before moving as a journalist to a UK pharmacy trade publication. She can be reached at Shughes@webmd.net.