Chiropractic Headache Management: Approaching a Mainstream...

FCER Teleconference SeriesTranslating Research Into PracticeApril 28, 2005

Anthony L. Rosner, Ph.D., LL.D. [Hon.]Director of Research and EducationFoundation for Chiropractic Education and Research

Presentation Copyright © 2005 Foundation for Chiropractic Education and Research

Chiropractic Headache Management: Approaching a Mainstream Alternative

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OUTLINE OF PRESENTATION

1. Cervicogenic and tension-type headache.2. Connective tissue bridges: Mechanism.3. Neck pain.4. Whiplash:

a. Old wives’ tales and redefinition.b. Outcomes.

5. Repetitive stress/carpal tunnel disorders.

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RESPONSES OF TENSION-TYPE HEADACHE TO MANIPULATION OR MEDICATION1

1Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitryptyline for the treatment of chronic tension-type headache: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1995; 18(3): 148-154.

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TREATMENT OF TENSION-TYPE HEADACHE1

1Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: A randomized controlled trial. Journal of the American Medical Association 1998; 280(18): 1576-1579.

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CERVICOGENIC HEADACHE: Trend Toward Improvement with SMT1

1Nilsson N. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1995; 18(7): 435-440.

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DISTINCTION OF TENSION-TYPE AND CERVICOGENIC HEADACHES1

1Nilsson N, Bove G. Evidence that tension-type headache and cervicogenic headache are distinct disorders. Journal of Manipulative and Physiological Therapeutics 2000; 23(4): 288-289.

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CERVICOGENIC HEADACHE: RESPONSE TO EXERCISE, MANIPULATION1

1. 200 cervicogenic headache participants randomized into 4 groups:a. Manipulative therapy: Maitland low- and high-velocity protocol.2b. Exercise therapy: Low-load endurance to train muscles of cervicoscapular area.c. Combined therapy.d. Control:

2. Outcomes [Post-treatment, 3 months, 6 months, 12 months]:a. Frequency.b. Intensity [VAS].c. Duration [hours].d. Neck pain [Northwick Park Neck Pain Questionnaire].

3. Results:a. Each active intervention showed significant reduction in all measures.b. Combined therapies not significantly superior to either therapy alone,

but 10% more patients gained relief with the combination.c. Effect sizes were moderate and clinically relevant.

1Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27(17): 1835-1843.2Maitland GD, Hengeveld E, Banks K, et al. Maitland's Vertebral Manipulation, 6th Edition. London, UK: Butterworth, 2000.

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CERVICOGENIC HEADACHE: RESPONSE TO EXERCISE, MANIPULATION1

1Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27(17): 1835-1843.

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CHIROPRACTIC TREATMENT OF CERVICOGENIC HEADACHE1

1Whittingham W, DaCosta C, McCrossin P, Whittingham B. Randomized placebo controlled clinical trial for efficacy of chiropractic treatment for chronic cervicogenic headaches. Symposium Proceedings, World Federation of Chiropractic 6th Biennial Congress, Paris, FRANCE, May 21-26, 2001, pp. 231-232.

1. Patients and Setting: 105 patients over 16 years of age, fulfilling the IHS criteria for cervicogenic headache and suffering this for over 6 months. Treated at Philip Chiropractic Research Centre, RMIT, Bundoora Campus, Melbourne, Australia.

2. Outcome Measures: Sickness impact profile [SPI], Neck Disability Index [NDI], computerized pain drawings, diaries, pressure algometry of head and neck, cervical ROM using a goniometer.

3. Interventions:a. TREATMENT: 3 adjustments/week x 3 weeks = 9, consisting of an upper cervical [C1 or C2] toggle

recoil adjustment.b. PLACEBO: 3 sham adjustments/week x 3 weeks = 9, consisting of inactivated Pettibon adjustment.

4. Results:a. TREATMENT group showed 30% reduction in headache frequency, 30% reduction in headache

duration, 28% reduction in headache severity, 36% reduction in medication consumption,improvements in area of headache pain, NDI scores, ROM.

b. PLACEBO group showed no significant improvement from baseline in 5 out of 6 outcome measures.c. TREATMENT group at 8 months and 24 months showed continued improvements in headache

frequency, severity, use of medications.d. No side-effects or complications were reported.

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CERVICOGENIC HEADACHE CHIROPRACTIC DOSE-RESPONSE: A PILOT STUDY1

1. 24 adults with cervicgoenic headache reported to chiropractic practice [half in college outpatient clinic, half in private practice in community]:a. Randomly allocated to 1,3 or 4 visits/per week over 3-week period.b. All patient received high-velocity low amplitude spinal manipulation.c. D.C.s could also apply up to 2 physical modalities at each visit, including heat and soft tissue therapy. d. D.C.s could also recommend rehabilitative exercises, modifications of daily activities.

2. Outcomes: a. 100-point Modified Van Korff pain and disability scales.b. Headaches in last 4 weeks.

3. Results:a. Substantial benefit in pain relief for 9 and 12 treatments vs 3:

1] At 4 weeks:a] 13.8 for 3 visits/week.b] 18.7 for 4 visits/week.

2] At 12-weeks follow-up:a] 19.4 for 3 visits/week.b] 18.1 for 4 visits/week.

b. Similar data obtained for disability.

1Haas M, Groupp E, Aickin M, Fairweather A, Ganger B, Attwood M, Cummins C, Baffes L. Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: A randomized pilot study. Journal of Manipulative and Physiological Therapeutics 2004; 27(9): 547-553.

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ADJUSTED MEAN PAIN SCORES

1Haas M, Groupp E, Aickin M, Fairweather A, Ganger B, Attwood M, Cummins C, Baffes L. Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: A randomized pilot study. Journal of Manipulative and Physiological Therapeutics 2004; 27(9): 547-553.

CERVICOGENIC HEADACHE CHIROPRACTIC DOSE-RESPONSE: A PILOT STUDY1

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RANDOMIZED CONTROLLED TRIAL OF CMT FOR MIGRAINE1

1Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. Journal of Manipulative and Physiological Therapeutics 2000; 23(2): 91-95.

1. 127 volunteers were recruited; 83 in the treatment group [diversified SMT] and 40 in the control group [detuned interferential therapy] completed the study.

2. The 6-month trial was divided into 3 stages:a. 2 months baseline before treatment;b. 2-month treatment [maximum 16 treatments]; andc. 2-month followup period.

3. Outcomes measured were:a. Frequency.b. Duration.c. Disability.d. Medication use.

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TREATMENT OF MIGRAINE HEADACHE1

1Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics 1998; 21(8): 511-519.

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RANDOMIZED CONTROLLED TRIAL OF CMT FOR MIGRAINE1

aEpisodes: #hours/month; VAS scores: 100mm scale for average episode; Duration: hours for an average episode; Disability: hours before return to normal activities for average episode; Medications: average number of medications taken/month.1Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. Journal of Manipulative and Physiological Therapeutics 2000; 23(2): 91-95.

1. Significant improvements were seen in the treatment group in:a

Control Treatment P Valuea. Frequency 7.3/6.9 7.1/4.1 <.005b. Duration 22.6/19.8 23.3/14.8 <.01c. Disability 18.9/15.6 19.8/13.0 <.05d. Medication use 20.1/16.2 21.3/9.8 <.001e. VAS scores 7.9/6.2 8.0/6.9 NS

2. 18 [22%] of treatment group reported >90% reduction of migraines.

3. 5 [4%] reported that migraine episodes were worse after 2-month treatment, but this was not sustained at follow-up.

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CHIROPRACTIC TREATMENT OF PEDIATRIC HEADACHE

Author n Age[yr] Diagnosis Diagnostic Procedues Adjustive Procedures

Haney1 1 11 Subluxation X-ray, AK muscle Diversified

Hewitt2 1 13 TTH Passive MP Diversified

Kastner3 12 Unspecified TTH, M, U Unspecified Unspecified SMT

Cochran4 1 10 M X-ray, MP Thompson, diversifiedAnderson-Peacock5 5 6-15 CEH [2] ROM, xray, MP Diversified

M [3]

Lisi6 1 8 CEH ROM, MP DiversifiedModified rotary breakSide posture mammilarypushMyofasical release

Legend: CEH, cervicogenic headache; M, migraine headache; TTH, tension-type headache; U, unspecific; ROM, range of motion, AK, applied kinesiology; MP, motion palpation; SMT, spinal manipulative therapy.

1Haney V. Chronic pediatric migraine-type headache treated by long-term inderol prior to chiropractic care: A case report. Proceedings of the National Conference on Chiropractic Pediatrics, Palm Beach, FL, October 1993, pp. 132-140.2Hewitt EG. Chiropractic care of a 13-year old with headache and neck pain: A case report. Journal of the Canadian Chiropractic Association 1994; 34(3): 160-162. 3Kastner U, Deutsch J, Lackner R. Chronic headache in children and chiropractic manipulation. Conference Proceedings of the Chiropractic Centennial Foundation, Washington, DC, July 1995, pp. 286-287.4Cochran JA. Chiropractic treatment of childhood migraine headache: A case study. Proceedings of the National Conference on Chiropractic Pediatrics, Vancouver, British Columbia, CANADA, October 1994, pp. 85-90.5Anderson-Peacock ES. Chiropractic care of children with headaches: Five case reports. Journal of Clinical Chiropractic Pediatrics 1996; 1(1): 18-27.6Lisi AJ, Dabrowski Y. Chiropractic spinal manipulation for cervicogenic headache in an 8-year old. Journal of the Neuromusculoskeletal System 2002; 19(3): 98-103.

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RANDOMIZED RCTS ON ROLE OF SMT IN CHRONIC HEADACHE: EFFECT SIZE DIFFERENCES1

1Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headaches: A systematic review. Journal of Manipulative and Physiological Therapeutics 2001; 24(7): 457-466.

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SIGNIFICANCE OF DUKE TTH AND CVG HEADACHE STUDY1

1. Duke is 1 of 12 research centers given the EPC trademark status by the U.S. Department of Health and Human Services.

2. The 19 member interdisciplinary panel that did the literature review is of extremely high caliber.

3. The evidence review was comprehensive, encompassing all behavioral and physical treatments for both tension-type and cervicogenic headache.

4. The systematic review was a rigorous scientific process.

5. Non-pharmacological treatments are of growing importance:“If effective and available...these nonpharmacologic treatments may be the first choice for most patients.”

“Pharmacological treatments are not suitable for all patients, nor are they universally effective. Drug treatments may also produce undesired side effects.”

1McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence report: Behavioral and physical treatments for tension-type and cervicogenic headache. Des Moines, IA: Foundation for Chiropractic Education and Research, Product No. 2085, 2001.

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LINK OF MUSCLE TENSION AND HEADACHES

1. Consecutive patients [31/39] who underwent forehead rejuvenation procedures encompassing resection of the corrugator supercilli muscle from 1989-1999 displayed total elimination or improvement of migraine headaches with improvements lasting at least 47 months.1

2. Neck muscles have been monitored in patients with tension-type headaches, producing a distinct EMG gradient.2

1Gayuron B, Vargha A, Michelow BJ, Thomas T, Davis J. Corrugator supercilii muscle reaction and migraine headaches. Plastic and Reconstructive Surgery 2000; 106: 429-434.2Malmo RB, Malmo HP. On electromyographic [EMG] gradients and movement-related brain activity: Significance for motor control, cognitive functions, and certain psychopathologies. International Journal of Psychophysiology 2000; 38(2): 145-209.

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PROPOSED ORIGIN OF CERVICOGENIC HEADACHE: THE UPPER CERVICAL JOINT COMPLEX1

1Hack GD, Koritzer RT, Robinson WL, Hallgren RC, Greenman PE. Anatomic relation between the rectus capitis posterior minor muscle and the dura mater. Spine 1995; 20:2484-2486.

A = Connective tissue

B = Dura

C = Occipital bone

D = Rectus capitis posterior minor muscle

E = First cervical vertebra

F = First cervical nerve root

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CONNECTIVE TISSUE BRIDGES BETWEEN MUSCLE AND DURA1 IN UPPER CERVICAL SPINE

1Hack G, Dunn G, Toh MY. The anatomist's new tools. 1998 Medical and Health Annual, Chicago, IL: Encyclopedia Britannica, 1997, pp. 16-29

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PROPOSED MECHANISM OF CERVICOGENIC HEADACHE

1. A connective tissue bridge exists between the rectus capitus posterior minor muscle and the dorsal spinal dura at the atlanto-occipital junction.

2. The dura-muscular connection transmit forces from the cervical spine joint complex to the pain-sensitive dura.

3. Trauma to the upper spine could result in rectus capitis posterior minor muscular atrophic changes.

4. This proposed mechanism resulting from adverse tension in the spinal dura could further substantiate the role of spinal manipulation as a viable treatment for cervicogenic headache.

5. Further research is needed to better define the possible relationships between the dura-muscular, dura-ligamentum nuchae connections and referred headache pain.

1Hack GD, Koritzer RT, Robinson WL, Hallgren RC, Greenman PE. Anatomic relation between the rectus capitis posterior minor muscle and the dura mater. Spine 1995; 20:2484-2486.

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CONNECTIVE TISSUE ATTACHMENTS TO CERVICAL SPINAL DURA MATER1

1. Evaluation done in 30 cadaveric specimens, correlating with MRIs in 4:a. Originated from both rectus capitis posterior minor muscle [RCPM] and ligamentum nuchae [LN]

in all 30 specimens:1] RCPM attachments originated between C1-C2.2] LN attachments originated between occipital bone and C1.

b. Attachments from LN to RCPM also identified.

2. Attachments to cervical dura mater may prevent damage to the spinal cord due to puckering of thedura mater during movements [especially extension] of the occiput and upper cervical spine, generating sufficient tension to prevent anterior dural movements.2-4

3. Propose that LN attachments exercise postural control and that their tearing during whiplash contributes to head and neck pain.

1Humphreys BK, Kenin S, Hubbard BB, Cramer GD. Investigation of connective tissue attachments to the cervical spinal dura mater. Clinical Anatomy 2003; 16: 152-159.2Von Lanz T. Uber die Ruckenmarkshaute I. Die konstruktive Form der harten haut des menschlichenRuckenmarkes und ihrer Bander. Arch Entwickl Mech Org 1929; 118: 252-307.

3Rutten HP, Szpak K, van Mameren H, TenHolter J, de Jong JC. 1997. Letter to the editor. Spine 1997; 21:2081-2088.4Mitchell BS, Humphreys BK, O'Sullivan E. Attachments of the ligamentum nuchae to cervical posterior spinal dura and the lateral part of the occipital bone. Journal of Manipulative and Physiological Therapeutics 1998; 21(3): 145-148.

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ANNUAL INCIDENCE AND COURSE OF NECK PAIN: A COHORT STUDY1

1Cote P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and course of neck pain in the general population: A population-based cohort study. Pain 2004; 112: 267-273.

1. 1100 randomly chosen Saskatchewan adults: Mail survey in September 1995 with followup at 6 and 12 months.

2. Statistics derived:a. Annual incidence of neck pain = 14.6%.b. Each year 0.6% of population develops neck pain.c. Annual rate of resolution of neck pain = 36.6%.d. Of those reporting neck pain at baseline, 22.8% report recurrent episode.e. Women more likely to have neck problems:

1] Report neck pain moreoften than men: Incidence ratio = 1.67.2] Report persistent neck problems: Incidence ratio = 1.19.3] Less likely to experience resolution: Incidence ratio = 0.75.

f. Most individuals with neck pain do not experience complete resolution of their symptoms and disability, contrary to popular belief.

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SHOULDER PAIN: MANIPULATION PLUSMEDICATION1

1. 150 patients with shoulder symptoms and dysfunction of shoulder girdle in general practice facility in the Netherlands randomized:a. 71 given ususual medical care: Information, oral analgesics or NSAIDS if necessary,

corticosteroid injections [28%], referral to physiotherapy [23%].b. 79 given usual medical care as agbove + manipulation: High-velocity, low-amplitude

manipulations, low-velocity high-amplitude mobilizations, maximum of 6 treatment sessions over 12-week period.

2. Outcomes: Patient perceived recovery, severity of main complaint, shoulder pain, shoulder disability, general health:a. During and end of treatment period [6 and 12 weeks].b. Followup [26 and 52 weeks].

3. Results:a. 6 weeks: No significant differences.b. 12 weeks: Full patient-perceived recovery: 43% manipulation group, 21% control.c. Followup: Similar to 12 weeks [52% vs. 35%].d. During intervention and followup: Consistent favoring of manipulation in severity of main

complaint, shoulder pain and disability, and general health.4. Conclusion: Spinal manipulation accelerates recovery of shoulder symptoms.5. Uniqueness: First trial to ADD SMT to the cervicothoracic spine to usual medical care for treatment

of shoulder symptoms.1Bergman GJD, Winters JC, Gronier KH, Pol JJM, Meyhboom-de-Jong B, Postema K, van der Heijden GJMG. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain. Annals of Internal Medicine 2004; 141(6): 432-436.

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RANDOMIZED, CONTROLLED TRIAL FOR NECK PAIN1

1. 183 patients, 18-70 years of age, who had nonspecific neck pain for >2 weeks randomized to 6 weeks of:a. Manual therapy: Use of passive movements, specific articular mobilization techniques,

coordination or stabilization techniques [HVLA spinal manipulations were NOT included]. [Mean #treatments = 6].

b. Physical therapy: Exercise therapy, manual traction or stretching, massage, PT methods such as heat or interferential current [Specific manual mobilization techniques NOT included in this protocol] [Median #treatments = 9].

c. Continued care by general practitioner: Advice on prognosis and self-care [including heat applications, home exercises], ergonomics, medication including paracetamol or NSAIDs [Median #treatments = 2].

2. Practitioners given free reign for 6-week period:a. Number of treatments up to a maximum.b. Performed own evaluations.c. Treated individual patients according to their own findings.

1Hoving JL, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, van Mameren H, Deville WLJM, Pool JJM, Scholten RJPM, Bouter LM. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Annals of Internal Medicine 2002; 136(10): 713-722.

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Primary Outcome Results at 7 Weeks of Follow-Up


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SECONDARY OUTCOMES:

1. Range of motion improved more markedly for those receiving manual care or physical therapy.

2. General health perception on the self-rated Euro Quality of Life scale showed a statistically significant difference in favor or manual therapy.

3. Absences from work were fewer for patients undergoing manual therapy.4. Analgesic use was less for manual therapy and physical therapy patients.

CONCLUSION:

"In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner."


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WHIPLASH OLD WIVES' TALES: LACK OF SCIENTIFIC BASIS1

As a result of a literature critique, there is currently no scientific or epidemiologic basis for the following statements:

1. Acute whiplash injuries do not lead to chronic pain.2. Chronic pain resulting from whiplash injuries is usually psychogenic.3. Whiplash injuries are unlikely to result in chronic pain in countries lacking compensatory

mechanisms for injury.4. Rear-impact collisions that do not result in vehicle damage are unlikely to cause injury.5. Whiplash trauma is biomechanically comparative with common movements of daily living.6. Chronic pain following acute whiplash injury is caused or worsened by treatment and

diagnostic testing.7. The risk of chronic neck pain among acutely injured whiplash victims

= prevalence of chronic neck pain in the general population.

1Freeman MD, Croft AC, Rossignol AM, Weaver DS, Reiser M. A review and methodologic critique of the literature refuting whiplash syndrome. Spine 1999; 24(1): 86-98.

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REDEFINING WHIPLASH AND CRITIQUING THE QUEBEC TASK FORCE1

1. The publications of the Quebec Task Force on Whiplash-Associated Disorders2

were evaluated by the authors of this report for methodologic error and bias.2. The QTF concluded that whiplash injuries:2

a. Result in “temporary discomfort.”b. Are “usually self-limiting.”c. Have a “favorable prognosis.”d. Have “pain which is not harmful.”

3. Five distinct categories of methodologic errors were found:a. Selection bias.b. Information bias.c. Confusing and unconventional use of terminology.d. Unsupported conclusions/recommendations.e. Inappropriate generalizations from Quebec Cohort Study.

4. Although the QTF set out to clarify contentious issues in its study, its publications instead have confused the subject further.

1Freeman MD, Croft AC, Rossignol AM. "Whiplash associated disorders: redefining whiplash and its management" by the Quebec Task Force. Spine 1998; 23(9): 1043-1049.2Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: Redefining "whiplash" and its management. Spine 1995; 20(Suppl): S1-73.

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CHRONIC WHIPLASH AND RESPONSE TO CHIROPRACTIC MANIPULATION1

1. 100 consecutive referrals for chronic whiplash were reviewed, 7 lost to follow-up.2. 3 groups of patients compared:

a. Group 1: Isolated neck pain associated with restricted ROM.b. Group 2: Neurological symptoms or signs associated with restricted ROM.c. Group 3: Severe neck pain, full ROM.

3. Initial symptoms, range of neck movement, focal neurological signs [involvement of specific myotomes, dermatomes, or peripheral nerves] documented:a. Grade A: Absent.b. Grade B: Nuisance.c. Grade C: Intrusive.d. Grade D: Disabling.

4. Patients underwent spinal manipulation, HVLA thrust to specific vertebral segment with mean of 19.3 treatments.

5. Results:a. Group 1: 72% [36/50] responded to SMT:

1] 24% became asymptomatic.2] 24% improved by 2 grades.

b. Group 2: 94% [30/32] responded to SMT:1] 38% became asymptomatic.2] 43% improved by 2 grades.

c. Group 3: 27% [3/11] responded to SMT:1] 0% became asymptomatic.2] 9% improved by 2 grades.

1Khan S, Cook J, Gargan M, Bannister G. Symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 1999; 21(1): 22-25.

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MUSCLE STRENGTH IMPROVEMENT IN ACUTEWHIPLASH1

1. Patients and Setting: 23 patients [mean age 35.8 years] with subsacute WAD, 3 days-6 weeks post-injury.

2. Outcome Measures: Muscle strength [sphygmomanometer dynamometer] during maximal effort neck flexion/extension, arm abduction/adduction, cervical range ofmotion [goniometer], pressure pain threshold [algometry] of upper tranpezius andsternocleidomastoid [SCM].

3. Interventions:a. TREATMENT: Cevical spine adjustment with no involvement of muscle work.

4. Results:a. CROM: Increase total head excursion from 244o to 288o.b. PRESSURE-PAIN THRESHOLD: Increase by 19% for SCM, 28% for trapezius.c. FORCE INCREASES during flexion [+16%], extension [+15%], adduction [+6%].

1Suter E, Harris S, Rosen M, Peterson D. Cervical spine adjustment improves muscle strength of the upper extremities in patients with subacute whiplash. Symposium Proceedings, World Federation of Chiropractic 6th Biennial Congress, Paris, FRANCE, May 21-26, 2001, pp. 229-230.

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INCIDENCE OF CTD

1. According to the Bureau of Labor Statistics, 1996:1,2

a. Cases of reported lost-time CTD: 1981: 23,000 1991: 223,000

b. Proportion of all occupational illnesses attributed to CTD:1981: 18%1991: 61%

2. In 1994 there were over 38,000 separate cases of CTS with lost work-time reported, with CTS accounting for:a. About 50% of CTD; andb. 29% of all lost-time from occupational illnesses reported that year.2

3. The annual cost of CTD estimated by Liberty Mutual Insurance Company [a major carrier of workmen’s compensation insurance]: $563,000.000.1

1Webster BS, Snook SH. The cost of compensable upper extremity cumulative trauma disorders. Journal of Occupational Medicine 1994; 36(7): 713-717.2Bureau of Labor Statistics, Characteristics of injuries and illness resulting in absences from work. Washington, DC: U.S. Department of Labor, 1996.

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CONSERVATIVE MEDICAL SYNDROME

1Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998; 21(5): 317-326.

1. Self-reported physical and mental distress decreased significantly for both groups from baseline to end of treatment, no significant differences between groups.

2. Changes in NCS and vibrometry indicated overall treatment effects from baseline to end of treatment w/o group effects.

3. Adverse medical effects were noted in 10 [22%] of medical cohort, reflecting intolerance to ibuprofen within first 2 weeks of treatment:

a. 5 experienced intense GI symptoms, headache or nausea and had to discontinue taking medication.

b. 5 others took ibuprofen + liquid antacid.4. Improvements of SF-36 scores were not apparent in either group.

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SUMMARY OF LEADING CLINICAL TRIALS INVOLVING REPETITIVE STRESS DISORDERS AND SMTAuthor Branches #Subj Complaint Outcomes FU

Davis1 SMT + splints 45 CTS Phys/Mental distr 9 wk-1moIbuprofen + splints 46 Nerve conduction

Vibrometry

Winters2 SMT 29 Shoulder pain Pain scores 11 wkPT 29 [girdle]SMT 32 Shoulder painPT 35 [synovial]Corticosteroid inj 47

Strait3 TCT + OMT 13 CTS EMG/NCS 2 mosTCT 10

1Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998; 21(5): 317-326.2Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de-Jong B. Comparison of physiotherapy, manipulation and corticosteroid injection for treating shoulder complaints in general practice: Randomised, single blind study. British Medical Journal 1997; 314: 1320-1325.3Strait BW, Kuchera ML. Osteopathic manipulation for patients with confirmed, mild, modest, and moderate carpal tunnel syndrome. Journal of the American Osteopathic Association 1994; 94(8): 673.

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AND IN CONCLUSION . . .

“Thank you for making this day necessary.”--Yogi Berra

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