SPORT: A Real World Study of Disc Herniation
The Spine Patients Outcomes Research Trial was initiated to compare the outcomes of surgical and nonoperative treatment for lumbar intervertebral disc herniation, spinal stenosis, or degenerative spondylolisthesis. The trial included both a randomized cohort (n=501) and an observational cohort (n=743) that declined randomization in favor of self-selected treatment plans. All subjects met inclusion criteria.
This research trial was reported in two parts by James N. Weinstein, DO, MSc, and colleagues in November 2006. The research design and study outcomes generated two companion editorials, one of which described the study as a snapshot of patient preferences and clinical outcomes. Patients in both treatment groups improved substantially during the 2-year study period. In the randomized cohort, improvements were consistently in favor of surgery for all follow-up periods, though these improvements were small and lacked statistical significance. In the observational cohort, those who elected surgical intervention reported greater improvements than those who chose nonoperative care.
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.
Measuring Motion at the Cervical-Thoracic Junction
Multi-slice computed tomographic scanning has revolutionized the world of vascular imaging. This new technique allows three-dimensional reconstruction of structures at submillimeter resolution. Its use as a tool to assist researchers in better understanding the anatomy and physiologic motion of the spine is in its early stages of development.
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.
Correction of Leg Length Discrepancies to Relieve Low Back Pain
Several researchers have suggested that leg length discrepancy might be a cause of low back pain (LBP). The mechanism by which a discrepancy causes or augments LBP is unclear, as is the minimum threshold that would result in pain.
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.
Lumbar Disc Surgery and Nonsurgical Spine Clinics
Few studies have addressed initiatives to reduce high rates of lumbar disc surgery by improving the nonsurgical care offered to patients with sciatica and low back pain (LBP). Claus Rasmussen, MD, and colleagues reported on the impact of two nonsurgical spine clinics established in the former North Jutland County (now Region North Jutland), Denmark, in 1997. The clinics targeted patients with sciatica of 1 to 3 months' duration with or without LBP. Data on rates of lumbar disc surgery were then obtained from the Danish National Registry of Patients for North Jutland County for a nationwide corelational study.
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.
Relief of Cervical Spine Pain: What Works...
Mechanical neck pain affects about 50% of the general population at some point during their lives, sometimes resulting in severe pain and disability. The aim of patient treatment in this population is pain reduction and restoration of normal function of the cervical spine.
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.
...And for Whom It Works
Yun-Long Tseng and others in Taipei, Taiwan, evaluated predictors for immediate response to cervical manipulation in a prospective cohort study of patients with neck pain. The patients received cervical manipulation from two manual therapists. A gliding test was used to identify hypomobile segments of the cervical spine. A test of vertebral basilar artery insufficiency was conducted by positioning the subject's head in full extension and then rotating it to its end range. The patient then received high velocity/low amplitude (HVLA) manipulation for the manipulable segments.
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.
“The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of
JAOA—The Journal of the American Osteopathic Association strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.
To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact
JAOA Associate Editor Felix J. Rogers, DO (
fjrogers@aol.com), or Michael A. Seffinger, DO (
mseffinger@westernu.edu).