Rehabilitation of back pain in the pediatric population: a mixed studies systematic review.

BACKGROUND: A significant proportion of children and adolescents experience back pain. However, a comprehensive systematic review on the effectiveness of rehabilitation interventions is lacking. OBJECTIVES: To evaluate benefits and harms of rehabilitation interventions for non-specific low back pain (LBP) or thoracic spine pain in the pediatric population. METHODS: Seven bibliographic electronic databases were searched from inception to June 16, 2023. Moreover, reference lists of relevant studies and systematic reviews, three targeted websites, and the WHO International Clinical Trials Registry Platform were searched. Paired reviewers independently conducted screening, assessed risk of bias, and extracted data related to study characteristics, methodology, subjects, and results. Certainty of evidence was evaluated based on the GRADE approach. RESULTS: We screened 8461 citations and 307 full-text articles. Ten quantitative studies (i.e., 8 RCTs, 2 non-randomized clinical trials) and one qualitative study were included. With very low to moderate certainty evidence, in adolescents with LBP, spinal manipulation (1-2 sessions/week over 12 weeks, 1 RCT) plus exercise may be associated with a greater likelihood of experiencing clinically important pain reduction versus exercise alone; and group-based exercise over 8 weeks (2 RCTs and 1 non-randomized trial) may reduce pain intensity. The qualitative study found information provided via education/advice and compliance of treatment were related to effective treatment. No economic studies or studies examining thoracic spine pain were identified. CONCLUSIONS: Spinal manipulation and group-based exercise may be beneficial in reducing LBP intensity in adolescents. Education should be provided as part of a care program. The overall evidence is sparse. Methodologically rigorous studies are needed. TRIAL REGISTRATION: CRD42019135009 (PROSPERO).

Chronic Low Back Pain in Adults: Evaluation and Management.

Chronic low back pain, defined as lumbar pain persisting for 12 weeks or more, occurs in about 13% of U.S. adults. Patients with chronic low back pain should have a history and physical examination to identify red flags that may indicate serious conditions that warrant immediate intervention or yellow flags (i.e., psychological, environmental, and social factors) that indicate risk of disability. The examination should include an evaluation for radicular symptoms. Routine imaging is not recommended but is indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy. Patients should avoid bed rest. Nonpharmacologic treatment is first-line management and may include therapies with varying evidence of support, such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy. Pharmacologic interventions are second-line treatment. Nonsteroidal anti-inflammatory drugs are the initial medication of choice; duloxetine may also be beneficial. Evidence is inconclusive to recommend the use of benzodiazepines, muscle relaxants, antidepressants, corticosteroids, insomnia agents, anticonvulsants, cannabis, acetaminophen, or long-term opioids. Epidural corticosteroid injections are not recommended except for short-term symptom relief in patients with radicular pain. Most patients with chronic low back pain will not require surgery; evaluation for surgery may be considered in those with persistent functional disabilities and pain from progressive spinal stenosis, worsening spondylolisthesis, or herniated disk. Physicians should consider prevention of chronic low back pain when patients present with acute back pain. Screening tools are available to predict the progression from acute to chronic low back pain, and targeted treatment strategies are beneficial for preventing progression.

Association between spinal manipulative therapy and lumbar spine reoperation after discectomy: a retrospective cohort study.

BACKGROUND: Patients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up. METHODS: We searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits. RESULTS: Following propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6). CONCLUSIONS: This study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture. REGISTRATION: Open Science Framework ( https://osf.io/vgrwz ).

Dosing of lumbar spinal manipulative therapy and its association with escalated spine care: A cohort study of insurance claims.

OBJECTIVE: The objective of this study was to evaluate the relationship between three distinct spinal manipulative therapy dose groups and escalated spine care by analyzing insurance claims from a cohort of patients with low back pain. METHODS: We compared three distinct spinal manipulative therapy dose groups (low = 1 SMT visits, moderate = 2-12 SMT visits, high = 13+ SMT visits), to a control group (no spinal manipulative therapy) regarding the outcome of escalated spine care. Escalated spine care procedures include imaging studies, injection procedures, emergency department visits, surgery, and opioid medication use. Propensity score matching was performed to address treatment selection bias. Modified Poisson regression modeling was used to estimate the relative risk of spine care escalation among three spinal manipulative therapy doses, adjusting for age, sex, retrospective risk score and claim count. RESULTS: 83,025 claims were categorized into 11,114 unique low back pain episodes; 8,137 claims had 0 spinal manipulative therapy visits, with the remaining episodes classified as low dose (n = 404), moderate dose (n = 1,763) or high dose (n = 810). After propensity score matching, 5,348 episodes remained; 2,454 had 0 spinal manipulative therapy visits with the remaining episodes classified as low dose (n = 404), moderate dose (n = 1,761), or high dose (n = 729). The estimated relative risk (vs no spinal manipulative therapy) for any escalated spine care was 0.45 (95% confidence interval 0.38, 0.55, p <0.001), 0.58 (95% confidence interval 0.53, 0.63, p <0.001), and 1.03 (95% confidence interval 0.95, 1.13, p = 0.461) for low, moderate, and high dose spinal manipulative therapy groups, respectively. CONCLUSIONS: For claims associated with initial episodes of low back pain, low and moderate dose spinal manipulative therapy groups were associated with a 55% and 42% reduction, respectively, in the relative risk of any escalated spine care.

Spinal Manipulative Therapy for Nonspecific Low Back Pain: Does Targeting a Specific Vertebral Level Make a Difference?: A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to examine whether targeting spinal manipulative therapy (SMT), by applying the intervention to a specific vertebral level, produces superior clinical outcomes than a nontargeted approach in patients with nonspecific low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, Scopus, PEDro, and Index to Chiropractic Literature were searched up to May 31, 2023. STUDY SELECTION CRITERIA: Randomized controlled trials comparing targeted SMT (mobilization or manipulation) to a nontargeted approach in patients with nonspecific low back pain, and measuring the effects on pain intensity and patient-reported disability. DATA SYNTHESIS: Data extraction, risk of bias, and evaluation of the overall certainty of evidence using the GRADE approach were performed by 2 authors independently. Meta-analyses were performed using the restricted maximum likelihood method. RESULTS: Ten randomized controlled trials (n = 931 patients) were included. There was moderate-certainty evidence of no difference between targeted SMT and a nontargeted approach for pain intensity at postintervention (weighted mean difference = -0.20 [95% CI: -0.51, 0.10]) and at follow-up (weighted mean difference = 0.05 [95% CI: -0.26, 0.36]). For patient-reported disability, there was moderate-certainty evidence of no difference at postintervention (standardized mean difference = -0.04 [95% CI: -0.36, 0.29]) and at follow-up (standardized mean difference = -0.05 [95% CI: -0.24, 0.13]). Adverse events were reported in 4 trials, and were minor and evenly distributed between groups. CONCLUSION: Targeting a specific vertebral level when administering SMT for patients with nonspecific low back pain did not result in improved outcomes on pain intensity and patient-reported disability compared to a nontargeted approach. J Orthop Sports Phys Ther 2023;53(9):1-11. Epub: 28 July 2023. doi:10.2519/jospt.2023.11962.

Investigating force-time characteristics of prone thoracic SMT and self-reported patient outcome measures: a feasibility study.

BACKGROUND: Spinal manipulative therapy (SMT) is commonly used to treat musculoskeletal conditions, including thoracic spine pain. Applying patient-specific force-time characteristics are believed to be important to improve SMT's effectiveness. Investigating SMT as part of a multimodal approach is fundamental to account for the complexity of chiropractic clinical practice. Therefore, pragmatic investigations balancing minimal disruptions to the clinical encounter at the same time as ensuring a robust data quality with rigorous protocols are needed. Consequently, preliminary studies are required to assess the study protocol, quality of data recorded and the sustainability of such investigation. Therefore, this study examined the feasibility of investigating SMT force-time characteristics and clinical outcome measures in a clinical setting. METHODS: In this mixed-methods study, providers recorded thoracic SMT force-time characteristics delivered to patients with thoracic spinal pain during regular clinical encounters. Self-reported clinical outcomes of pain, stiffness, comfort during the SMT (using an electronic visual analogue scale), and global rating of change scale were measured before and after each SMT application. Feasibility was quantitatively assessed for participant recruitment, data collection and data quality. Qualitative data assessed participants' perceptions on the impact of data collection on patient management and clinical flow. RESULTS: Twelve providers (58% female, 27.3 ± 5.0 years old) and twelve patients (58% female, 37.2 ± 14.0 years old) participated in the study. Enrolment rate was greater than 40%, data collection rate was 49% and erroneous data was less than 5%. Participant acceptance was good with both providers and patients reporting positive experience with the study. CONCLUSIONS: Recording SMT force-time characteristics and self-reported clinical outcome measures during a clinical encounter may be feasible with specific modification to the current protocol. The study protocol did not negatively impact patient management. Specific strategies to optimize the data collection protocol for the development of a large clinical database are being developed.

Clinician approaches to spinal manipulation for persistent spinal pain after lumbar surgery: systematic review and meta-analysis of individual patient data.

BACKGROUND: This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners. METHODS: Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval. RESULTS: 71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results. CONCLUSIONS: Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039).

Effectiveness of spinal manipulation in addition to pharmacological treatment in fibromyalgia: A blinded randomized trial.

BACKGROUND: It has been suggested that spinal manipulation may alter sensorimotor integration in the central nervous system and therefore may be used to treat central sensitization syndromes. OBJECTIVE: To investigate the effectiveness of spinal manipulation in addition to pharmacological treatment in patients with fibromyalgia. DESIGN: A single-center, randomized, and placebo-controlled trial with three parallel arms SETTING: Outpatient clinics at a tertiary health care facility. PARTICIPANTS: Female patients aged 18-55 years receiving pharmacological treatment. INTERVENTIONS: Spinal manipulation, sham manipulation, and control groups. Patients in the spinal manipulation group received high-velocity low-amplitude manipulation treatment twice a week for 3 weeks. Patients in the sham group received an application that was very similar to the active treatment but was not expected to have any real therapeutic effect. Patients in the control group continued to receive pharmacological therapy. MAIN OUTCOME MEASURES: The primary outcome, pain score (visual analog scale), and secondary outcomes, pressure pain threshold (PPT), Revised Fibromyalgia Impact Questionnaire (FIQR), Widespread Pain Index (WPI), and Fibromyalgia Severity Score (FSS) were measured before, 1 month, and 3 months after randomization. RESULTS: Sixty patients with a mean age of 41.7 years (SD = 8.0) were enrolled in the study. A mixed-design repeated analysis of covariance was used to test the data. At 1 month after randomization, pain scores did not differ between groups. At 3 months after randomization, the spinal manipulation group had a significantly lower pain score (adjusted mean = 4.3 cm, SE: 0.4) than the control group (adjusted mean = 6.8 cm, SE: 0.4) and the sham manipulation group (adjusted mean = 5.7 cm, SE: 0.4). PPT did not differ between groups at any time point. FIQR, WPI, and FSS showed some improvement 1 or 3 months after randomization in favor of the spinal manipulation group. CONCLUSIONS: Spinal manipulation used in addition to pharmacological treatment in young/middle-aged female patients with fibromyalgia could be an effective treatment for pain, disease severity, and functionality.

Identifying Patient Characteristics Associated With the Occurrence of Post Treatment Non-serious Adverse Events After Cervical Spine Manual Therapy Treatment in Patients With Neck Pain.

OBJECTIVES: To compare prevalence rates of serious and non-serious adverse events after manipulation and mobilization and to identify risk factors of serious and non-serious adverse events following 4 types of manual therapy treatment in patients with neck pain. DESIGN: A prospective cohort study in primary care manual therapy practice. PARTICIPANTS: Patients with neck pain (N=686) provided data on adverse events after 1014 manipulation treatments, 829 mobilization treatments, 437 combined manipulation and mobilization treatments, and 891 treatments consisting of "other treatment modality". INTERVENTIONS: Usual care manual therapy. MAIN OUTCOME MEASURES: A chi-square test was performed to explore differences in prevalence rates. Logistic regression analysis was performed within the 4 treatment groups. A priori we defined associations between patient-characteristics and adverse events of odds ratio (OR)>2 or OR<0.5 as clinically relevant. RESULTS: No serious adverse events, such as cervical artery dissection or stroke, were reported. With regard to non-serious adverse events, we found that these are common after manual therapy treatment: prevalence rates are ranging from 0.3% to 64.7%. We found a statistically significant difference between the 4 types of treatments, detrimental to mobilization treatment. Logistic regression analysis resulted in 3 main predictors related to non-serious adverse events after manual therapy treatment: smoking (OR ranges from 2.10 [95% confidence interval [CI] 1.37-3.11] to 3.33 [95% CI 1.83-5.93]), the presence of comorbidity (OR ranges from 2.32 [95% CI 1.22-4.44] to 3.88 [95% CI 1.62-9.26]), and female sex (OR ranges from 0.22 [95% CI 0.11-0.46] to 0.49 [95% CI 0.28-0.86]). CONCLUSION: There is a significant difference in the occurrence of non-serious adverse events after mobilization compared with manipulation or a combination of manipulation and mobilization. Non-serious adverse events in manual therapy practice are common and are associated with smoking and the presence of comorbidity. In addition, women are more likely to report non-serious adverse events.

Analysis of the decompressive treatment of the vertebral canal through the trans-spinal approach / Análise do tratamento descompressivo do canal vertebral pela via transespinhosa / Análisis del tratamiento descompresivo del canal vertebral mediante el enfoque transespinal

ABSTRACT Objective: The spinous process separation technique is a less invasive surgical technique for treating lumbar canal stenosis. The objective is to evaluate this technique's results in treating lumbar canal stenosis. Method: Thirty patients with lumbar spinal canal stenosis underwent surgical treatment using the spinous process separation technique and were evaluated in the 3-year postoperative period using the Denis Pain and Work Scale and by the SF-36 questionnaire and radiographic evaluation of the operated segment. Results: In the evaluation of the Denis pain scale, 21 (70%) patients had no pain (P1), and nine (30%) patients reported minimal low back pain, not needing medication (P2). Denis' work schedule showed that nine (30%) patients had restrictions on returning to their previous work activity (W2), and 21 (70%) patients were classified as W1. The SF-36 questionnaire showed results of 81.25 for physical aspects (PA), 81.9 for functional capacity (FC), 81.3 for emotional aspects (EA), 64.3 for vitality (V), 65.9 for mental health (MH), 81.98 for social aspects (SA), 75.6 for pain (P) and 68.1 for general health status (GHS). In addition, there were no radiographic signs of instability of the operated vertebral segment in the radiographic evaluation. Conclusion: The decompression of the lumbar spinal canal using the spinous process separation technique showed good results in the evaluated patients three years after the operation. Level of Evidence II, Retrospective Comparative Study.

Resumo: Objetivo: A técnica de separação do processo espinhoso é uma técnica cirúrgica menos invasiva para o tratamento da estenose do canal lombar. O objetivo é avaliar os resultados dessa técnica no tratamento da estenose do canal lombar. Método: Trinta pacientes portadores de estenose do canal vertebral lombar foram submetidos ao tratamento cirúrgico por meio da técnica da separação do processo espinhoso, tendo sido avaliados no período de três anos de pós-operatório, por meio da escala de dor e de trabalho de Denis, pelo questionário SF-36 e avaliação radiográfica do segmento operado. Resultados: Na avaliação da escala de dor de Denis, 21 (70%) pacientes não apresentavam dor (P1) e nove (30%) pacientes relataram dor mínima lombar, não necessitando medicação (P2). A escala de trabalho de Denis evidenciou que nove (30%) pacientes apresentavam restrições ao retorno à atividade prévia de trabalho (W2) e 21 (70%) pacientes foram classificados como W1. O questionário SF-36 apresentou resultados 81,25 para aspectos físicos (AF), 81,9 para capacidade funcional (CF), 81,3 para aspectos emocionais (AE), 64,3 para vitalidade(V), 65,9 para saúde mental (SM), 81,98 para aspectos sociais (AS), 75,6 para dor (D) e 68,1 para estado geral de saúde (EGS). Não foram observados sinais radiográficos de instabilidade do segmento vertebral operado na avaliação radiográfica. Conclusão: A descompressão do canal vertebral lombar por meio da técnica de separação do processo espinhoso apresentou bons resultados na avaliação num período de três anos de pós-operatório dos pacientes avaliados. Nível de Evidência II, Estudo Retrospectivo Comparativo.

Resumen: Objetivo: La técnica de separación de la apófisis espinosa es una técnica quirúrgica menos invasiva para el tratamiento de la estenosis del canal lumbar. El objetivo es evaluar los resultados de esta técnica en el tratamiento de la estenosis del canal lumbar. Método: Treinta pacientes con estenosis del conducto raquídeo lumbar fueron intervenidos quirúrgicamente mediante la técnica de separación de la apófisis espinosa, y fueron evaluados en el postoperatorio de tres años mediante la Escala de Dolor y Trabajo de Denis, mediante el cuestionario SF-36 y evaluación radiográfica del segmento operado. Resultados: En la evaluación de la escala de dolor de Denis, 21 (70%) pacientes no presentaron dolor (P1) y nueve (30%) pacientes refirieron dolor lumbar mínimo, sin necesidad de medicación (P2). La escala de trabajo de Denis mostró que nueve (30%) pacientes tenían restricciones para regresar a su actividad laboral anterior (W2) y 21 (70%) pacientes fueron clasificados como W1. El cuestionario SF-36 arrojó resultados 81,25 para aspectos físicos (AF), 81,9 para capacidad funcional (CF), 81,3 para aspectos emocionales (AE), 64,3 para vitalidad (V), 65,9 para salud mental (SM), 81,98 para aspectos sociales (AS), 75,6 para dolor (D) y 68,1 para estado general de salud (EGS). No hubo signos radiográficos de inestabilidad del segmento vertebral intervenido en la evaluación radiográfica. Conclusión: La descompresión del canal espinal lumbar mediante la técnica de separación de apófisis espinosa mostró buenos resultados en la evaluación de un período de 3 años después de la operación de los pacientes evaluados.

Association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States' data.

OBJECTIVES: Chiropractic spinal manipulative therapy (CSMT) and lumbar discectomy are both used for lumbar disc herniation (LDH) and lumbosacral radiculopathy (LSR); however, limited research has examined the relationship between these therapies. We hypothesised that adults receiving CSMT for newly diagnosed LDH or LSR would have reduced odds of lumbar discectomy over 1-year and 2-year follow-up compared with those receiving other care. DESIGN: Retrospective cohort study. SETTING: 101 million patient US health records network (TriNetX), queried on 24 October 2022, yielding data from 2012 query. PARTICIPANTS: Adults age 18-49 with newly diagnosed LDH/LSR (first date of diagnosis) were included. Exclusions were prior lumbar surgery, absolute indications for surgery, trauma, spondylolisthesis and scoliosis. Propensity score matching controlled for variables associated with the likelihood of discectomy (eg, demographics, medications). INTERVENTIONS: Patients were divided into cohorts according to receipt of CSMT. PRIMARY AND SECONDARY OUTCOME MEASURES: ORs for lumbar discectomy; calculated by dividing odds in the CSMT cohort by odds in the cohort receiving other care. RESULTS: After matching, there were 5785 patients per cohort (mean age 36.9±8.2). The ORs (95% CI) for discectomy were significantly reduced in the CSMT cohort compared with the cohort receiving other care over 1-year (0.69 (0.52 to 0.90), p=0.006) and 2-year follow-up (0.77 (0.60 to 0.99), p=0.040). E-value sensitivity analysis estimated the strength in terms of risk ratio an unmeasured confounding variable would need to account for study results, yielding point estimates for each follow-up (1 year: 2.26; 2 years: 1.92), which no variables in the literature reached. CONCLUSIONS: Our findings suggest receiving CSMT compared with other care for newly diagnosed LDH/LSR is associated with significantly reduced odds of discectomy over 2-year follow-up. Given socioeconomic variables were unavailable and an observational design precludes inferring causality, the efficacy of CSMT for LDH/LSR should be examined via randomised controlled trial to eliminate residual confounding.

The effect of lumbar spinal manipulation on biomechanical factors and perceived transient pain during prolonged sitting: a laboratory-controlled cross-sectional study.

BACKGROUND: Spinal manipulation has been shown to affect muscle activity, posture, and pain. To date, no studies have examined the effect of manipulation on biomechanical factors during sitting. Therefore, the purpose of this study was to investigate the immediate effect of lumbar spinal manipulation on trunk muscle activation, spine posture and movements, and perceived ratings of transient pain in asymptomatic adults during prolonged office sitting. METHODS: Twenty healthy adults were recruited for a single laboratory session that included a standardized office sitting/data entry protocol (120 min total, 3 blocks of 40 min). Data were collected between July and August 2012. The first block (baseline) was immediately followed by two experimental blocks. Prior to the start of each experimental block, participants were transferred to a therapy plinth and placed side lying (right side down), and a random presentation of either a control or high velocity low amplitude thrust directed at L4/L5 was delivered. Continuous measures of muscle activity, spine posture, and spine movements were recorded throughout the sitting trials. Perceived transient pain was measured by visual analogue scale at 10-min intervals (including immediately before and after the randomized maneuvers). RESULTS: There were no significant differences in spine or pelvic posture or perceived back pain following either the manipulation or control maneuvers. Significantly reduced muscle activity and increased shifts of the lumbar spine angle were identified in the block following manipulation compared to both baseline and post control blocks. CONCLUSIONS: Spinal manipulation does not appear to have an immediate impact on spine or pelvic posture in healthy adults but does appear to reduce muscle activity and increase spine movement during sitting. Future work should replicate this study with a larger population in a field setting. It may be worthwhile to explore the implication of reduced muscle activation and increased spine movements during prolonged sitting for office workers that receive manipulations or mobilizations during their workday.

Effectiveness of Multimodal Chiropractic Care Featuring Spinal Manipulation for Persistent Spinal Pain Syndrome Following Lumbar Spine Surgery: Retrospective Chart Review of 31 Adults in Hong Kong.

BACKGROUND The term "persistent spinal pain syndrome type 2" (PSPS-2) has been proposed by the International Association for the Study of Pain to replace the term "failed back surgery syndrome". This retrospective study aimed to evaluate effectiveness of multimodal care featuring chiropractic spinal manipulation (CSMT) in 31 adults in Hong Kong with PSPS-2. MATERIAL AND METHODS We identified new adult patients with PSPS-2 receiving CSMT from 2016 to 2018. Demographic and clinical data and baseline/follow-up numeric pain rating scale (NPRS) and Oswestry Disability Index (ODI) scores were extracted. Multiple linear regression was used to examine posttreatment NPRS and ODI reduction, with clinical variables as covariates. RESULTS Of 6589 patients with low back pain, 31 met criteria (mean age 52.2±13.7 years). Surgeries included laminectomy (81%), discectomy (13%), and fusion (6%). Mean baseline NRPS was 6.6±1.9; ODI was 43.8±15.1%. Patients received CSMT (100%), drop technique (81%), passive modalities (65%), soft tissue manipulation (13%), flexion-distraction (13%), and mechanical traction (13%). Mean posttreatment NPRS was 0.6±1.0; ODI was 2.4±3.3%. All patients had a minimum clinically important difference for NPRS (≥2/10) and ODI (≥30%). One year after treatment, 48% maintained improvement, 42% experienced recurrence; in 10%, follow-up was unavailable. Regression analysis identified younger age, shorter symptom duration, and greater baseline NPRS as predictors of NPRS reduction; and greater baseline ODI as a predictor of ODI reduction (all P<0.05). CONCLUSIONS Patients with PSPS-2 improved with multimodal care featuring CSMT, which was more effective in patients with younger age, shorter symptom duration, and higher baseline pain or disability levels.

Effects of Distinct Force Magnitude of Spinal Manipulative Therapy on Blood Biomarkers of Inflammation: A Proof of Principle Study in Healthy Young Adults.

OBJECTIVES: The purpose of this preliminary study was to determine the influence of thoracic spinal manipulation therapy (SMT) of different force magnitudes on blood biomarkers of inflammation in healthy adults. METHODS: Nineteen healthy young adults (10 female, age: 25.6 ± 1.2 years) were randomized into the following 3 groups: (1) control (preload only), (2) single thoracic SMT with a total peak force of 400N, and (3) single thoracic SMT with a total peak force of 800N. SMT was performed by an experienced chiropractor, and a force-plate embedded treatment table (Force Sensing Table Technology) was used to determine the SMT force magnitudes applied. Blood samples were collected at pre intervention (baseline), immediately post intervention, and 20 minutes post intervention. A laboratory panel of 14 different inflammatory biomarkers (pro, anti, dual role, chemokine, and growth factor) was assessed by multiplex array. Change scores from baseline of each biomarker was used for statistical analysis. Two-way repeated-measures analysis of variance was used to investigate the interaction and main effects of intervention and time on cytokines, followed by Tukey's multiple comparison test (P ≤ .05). RESULTS: A between-group (800N vs 400N) difference was observed on interferon-gamma, interleukin (IL)-5, and IL-6, while a within-group difference (800N: immediately vs 20 minutes post-intervention) was observed on IL-6 only. CONCLUSION: In this study, we measured short-term changes in plasma cytokines in healthy young adults and found that select plasma pro-inflammatory and dual-role cytokines were elevated by higher compared to lower SMT force. Our findings aid to advance our understanding of the potential relationship between SMT force magnitude and blood cytokines and provide a healthy baseline group with which to compare similar studies in clinical populations in the future.

Analgesic Effects of Two Types of Spinal Manipulation in Acute Lumbar Radiculopathy Model Rats.

OBJECTIVE: To compare the analgesic effects of two types of spinal manipulation (SM) in acute lumbar radiculopathy (ALR) model rats induced by self-transplantation of autologous nucleus pulposus (ANP), and clarify the therapeutic mechanism. METHODS: Totally 108 male Sprague-Dawley rats were randomly divided into 6 groups by a random number table (18 rats in each group), including a blank group with no interference, a sham operation group with a surgery by making a local soft tissue incision on the left side of L5-6 vertebral segment, a model group with ALR of L5 extraforaminal nerve by ANP self-transplantation without other interference, a sham manipulation (SMA) group with simulating physical rotation, as well as a mobilization (MOB) group with simulating low-velocity and variable-amplitude rotation and a manipulation (MAN) group with simulating high-velocity and low-amplitude rotation. The interventions in SMA, MOB, and MAN groups started 1 day after modeling followed by another 5 treatments at days 3, 5, 8, 10 and 12. Rats in the other 3 groups did not receive any special intervention. Behavioral pain tests of 50% mechanical pain withdrawal threshold (50% PWT) and paw withdrawal latency (PWL) were conducted 1 day before operation followed by another 10 tests on days 1-7, 10, 12 and 14. Immunohistochemical expression of nitric oxide synthase (NOS) was investigated on days 5 and 12 after operation. RESULTS: After 3 experimental SM interventions, 50% PWT and PWL were higher in the MAN group than the SMA group on days 6 and 7, and higher on days 10, 12 and 14 postoperatively (P<0.05 or P<0.01), while the same indices were significantly higher in the MOB group than MAN group on days 1-4 (P<0.05 or P<0.01). The expression of NOS was lower in the MAN and MOB groups than SMA group on day 12 postoperatively (P<0.01). CONCLUSIONS: Both manipulation and mobilization produced better results than sham interference in relieving pain by reducing neuroinflammation possibly. At the early period, compared with manipulation, mobilization presented less sensitive response to pain until later visit. SM may inhibit the overexpression of NOS, thereby alleviating severe radiculopathy.

Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries.

STUDY DESIGN: We combined elements of cohort and crossover-cohort design. OBJECTIVE: The objective of this study was to compare longterm outcomes for spinal manipulative therapy (SMT) and opioid analgesic therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP). SUMMARY OF BACKGROUND DATA: Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain. METHODS: We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP. RESULTS: SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% confidence interval 2.64-2.69, P < .0001). CONCLUSION: Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.Level of Evidence: 3.

Minimally invasive laminar lift and posterior cervical laminoplasty via the intermuscular approach: a canine model study

Purpose: This study aimed to develop a minimally invasive surgical procedure for laminar lift and posterior cervical laminoplasty via the intermuscular approach using a canine model. Methods: Six Alaskan dogs were used for developing the surgical approach. The bilateral laminae of C3-7 were cut with an ultrasonic osteotome and fixed with bilateral plates to maintain the lamina lifting and reshape a wider spinal canal. The important structures, such as ligaments, supraspinous ligaments, interspinous ligaments, and ligamentum flavum were preserved. The therapeutic effect was evaluated by preoperative and postoperative imaging results and neck mobility. Results: The surgical procedures were all successfully performed in the 6 animals. All the dogs survived well within 1 year of postoperative follow-up. The postoperative neck mobility was as good as the preoperative one. Computed tomography results showed that the anteroposterior diameter of the spinal canal was successfully enlarged and maintained well. Conclusions: The minimally invasive surgical procedure for laminar lift and posterior cervical laminoplasty via the intermuscular approach was feasible in a canine model, which might be applied in clinical practice.

Impact of the covid-19 pandemic on the surgical treatment of spine pathologies in sus / Impacto da pandemia da covid-19 no tratamento cirúrgico de patologias de coluna no sus / Impacto de la pandemia de covid-19 en el tratamiento quirúrgico de patologías de la columnavertebral enel sus

ABSTRACT Objective: To evaluate the impact of the COVID-19 pandemic on spine surgeries performed by SUS. To identify changes in surgical volume, as well as which procedures and regions of Brazil were most affected. To correlate such changes with literature data. Methods: A retrospective, descriptive study was conductedwith an analysis of the databases available to the public on the performance of spinal surgical procedures by SUS during the period from 2017 to 2021. The databases were created from variables of interest available in the SIH (Hospital Information System) of the SUS Information Technology Department website (DATASUS; http://datasus.saude.gov.br). The procedures were grouped according to type of surgery, topography, and access route for the construction of tables and statistical analysis. Results: In the years of the pandemic, a greater drop in surgical volume was observed, with a total of 13,276 procedures in 2020 and 12,158 in 2021, equivalent to -28.51% and -34.53%, respectively, of the average of the previous period. Conclusions: Given the paramount importance of attention to the fight against the pandemic, maintaining the level of assistance for spinal pathologies proved to be a great challenge, especially in relation to elective surgical pathologies that, when delayed too much, can seriously impact the quality of life and outcomes of future treatments. Level of Evidence: IV; Retrospective, descriptive.

RESUMO Objetivo: Avaliar o impacto da pandemia de COVID-19 na realização de cirurgias de coluna no SUS. Identificar mudanças do volume de cirurgias, bem como quais procedimentos e regiões do Brasil foram mais afetados. Correlacionar tais mudanças com dados da literatura. Métodos: Realizou-se um estudo retrospectivo, descritivo, com análise de banco de dados disponíveis para o público sobre a realização de procedimentos cirúrgicos de coluna pelo SUS no período de 2017 a 2021. Os bancos de dados foram criados a partir das variáveis de interesse disponíveis no SIH (Sistema de Informações Hospitalares) do site do Departamento de Informática do SUS (DATASUS; http://datasus.saude.gov.br). Os procedimentos foram agrupados de acordo com tipo de cirurgia, topografia e via de acesso para construção das tabelas e análise estatística. Resultados: Nos anos da pandemia observou-se uma queda maior no volume cirúrgico com um total de 13.276 procedimentos em 2020 e 12.158 em 2021, equivalentes a -28,51% e -34,53% com relação à média do período anterior, respectivamente. Conclusões: Diante da importância primordial da atenção ao combate da pandemia, a manutenção da assistência às patologias de coluna revela-se um grande desafio, principalmente com relação a patologias cirúrgicas eletivas que, quando postergadas em demasia, podem impactar de maneira grave a qualidade de vida e resultados de tratamentos futuros. Nível de EvidênciaIV; Estudo RetrospectivoDescritivo.

RESUMEN Objetivo: Evaluar el impacto de la pandemia de COVID-19 en larealización de cirugías de columna en el SUS. Identificar cambios en el volumen de cirugías, así como qué procedimientos y regiones de Brasil se vieron más afectados. Correlacionar dichos cambios con datos de la literatura. Métodos: Se realizó un estudio retrospectivo, descriptivo, con análisis de bases de datos disponibles públicamente sobre la realización de procedimientos quirúrgicos de columna vertebral por el SUS en el período comprendido entre 2017 y 2021. Las bases de datos fueron creadas a partir de las variables de interés disponibles en el SIH (Sistema de Información Hospitalaria) del sitio web del Departamento de Informática del SUS (DATASUS; http://datasus.saude.gov.br). Los procedimientos fueron agrupados según tipo de cirugía, topografía y vía de acceso para la elaboración de tablas y análisis estadístico. Resultados: En los años de pandemia se observó un mayor descenso en el volumen quirúrgico, con un total de 13.276 procedimientos en 2020 y 12.158 en 2021, equivalentes a -28,51% y -34,53% respecto a la media del periodo anterior, respectivamente. Conclusiones: Dada la trascendental importancia de la atención en el combate a la pandemia, mantener la asistencia a las patologías de la columna resulta un gran desafío, especialmente en lo que respecta a las patologías quirúrgicas electivas que, cuando se demoran demasiado, pueden repercutir gravemente en la calidad de vida y en los resultados de futuros tratamientos. Nivel de evidencia: IV; Estudio Retrospectivo Descriptivo.

Impact of obesity on the clinical outcomes of spinal surgery by transpsoas lateral fusion / Impacto da obesidade sobre os desfechos clínicos da cirurgia da coluna por artrodese lateral via transpsoas / Impacto de la obesidad en los resultados clínicos de la cirugía de columna mediante fusión lateral transpsoas

ABSTRACT Introduction: Obesity is a global phenomenon that affects the quality of life of the population. In addition to being a factor that can lead to cases of degeneration in the spine, it can also influence the clinical outcomes of spine surgeries. However, with the development of minimally invasive techniques, the impact of obesity has become uncertain. Methods: A single-center, non-randomized, comparative, observational study, here clinical and surgical outcomes and postoperative complications were analyzed between obese and non-obese patients undergoing LLIF surgery. Results: There was no difference between surgical times and blood loss between the groups; the number of postoperative complications was similar. Both groups showed significant improvement in clinical parameters, but there was no difference between the amount of improvement between the obese and non-obese groups. Conclusion: The present study demonstrated that LLIF is a safe and effective technique regardless of the patient's degree of obesity. Level of Evidence III; Retrospective study.

RESUMO Introdução: A obesidade é um fenômeno global que possui diversos sobre a qualidade de vida da população. Além de ser um fator que pode levar a casos de degeneração na coluna, como também pode influenciar nos desfechos clínicos das cirurgias de coluna. No entanto, com o desenvolvimento de técnicas minimamente invasivas o impacto da obesidade se tornou incerto. Métodos: Estudo de centro único, não-randomizado, comparativo, observacional, onde foram analisados os desfechos clínicos, cirúrgicos e complicações pós-operatórias entre pacientes obesos e não-obesos submetidos a cirurgia de LLIF. Resultados: Não houve diferença entre os tempos cirúrgicos e perda sanguínea entre os grupos, ademais o número de complicações pós-operatórias foi similar entre os grupos. Ambos os grupos apresentaram melhora significativa dos parâmetros clínicos, porém não houve diferença entre a quantidade de melhora entre os grupos obeso e não-obeso. Conclusão: O presente estudo demonstrou que o LLIF é uma técnica segura e eficaz independentemente do grau de obesidade do paciente. Nível de evidência III; Estudo retrospectivo.

RESUMEN Introducción: La obesidad es un fenómeno mundial que afecta la calidad de vida de la población. Además de ser un factor que puede conducir a casos de degeneración en la columna, también puede influir en los resultados clínicos de las cirugías de columna. Sin embargo, con el desarrollo de técnicas mínimamente invasivas, el impacto de la obesidad se ha vuelto incierto. Métodos: Estudio observacional, comparativo, no aleatorizado, unicéntrico, donde se analizaron los resultados clínicos, quirúrgicos y las complicaciones postoperatorias entre pacientes obesos y no obesos sometidos a cirugía LLIF. Resultados: No hubo diferencia entre los tiempos quirúrgicos y la pérdida de sangre entre los grupos, además, el número de complicaciones postoperatorias fue similar entre los grupos. Ambos grupos mostraron una mejora significativa en los parámetros clínicos, pero no hubo diferencia entre la cantidad de mejora entre los grupos obesos y no obesos. Conclusión: El presente estudio demostró que la LLIF es una técnica segura y eficaz independientemente del grado de obesidad del paciente. Nivel de Evidencia III; Estudio retrospectivo.