Chiropractic Health Club     Dr Jay Kang, DC
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Research Articles

 1.  Considering Back Surgery or Want to Avoid Surgery?

Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study.  McMorland G, DC, Suter E, PhD, Casha S, MD, PhD, FRCSC, du Plessis SJ, MD, Hurlbert RJ, MD, PhD, FRCSC, FACSc.  JMPT 2010; 33(8): 576-84.


This just published study compares the clinical efficacy of spinal manipulation (SM) versus surgical microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH).


Methods: 120 patients presenting through elective referral by primary care physicians to 3 neurosurgical spine surgeons (the 3 MDs who are authors of this study) were screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3-4, L4-5, or L5-S1. All subjects had MRI confirmation of a herniated disk via MRI.  40 consenting Pts who met inclusion criteria: Pts must have failed =/> 3 months of non-operative management: analgesics, lifestyle modification, physical therapy, massage, &/or acupuncture. Qualifying patients were randomized to either surgical microdiskectomy or standardized chiropractic SM (side posture HVLA SM: 2-3 tx/wk for 4 wks, 1-2 tx for next 3-4 wks. Total average visits: 21). Patients were permitted to crossover to the alternate treatment if after 3 months of care they had no response to their primary treatment.


Outcomes: SF-36, McGill Pain Questionnaire, Aberdeen Back Pain Scale, & Roland-Morris Disability Index. Patients were followed-up at 3, 6, 12, 24, & 52 weeks.


Results: Significant improvement in both treatment groups compared to baseline scores over time was seen in all outcome measures. After 1 year, follow-up did not reveal any difference in outcome based on the original treatment received for subjects who responded to there assigned treatment. However, 8 of 20 patients failed to improve with chiropractic manipulation and crossed over from SM to surgery. These patients improved to the same degree as the primary surgical patients. Three surgical patients failed to improve and crossed over from surgery to SM. These 3 patients did not receive benefit from chiropractic care.


Conclusions: 60% of sciatica patients who had failed other medical management benefited from Spinal Manipulation to the same degree as if they underwent surgical intervention. Of the 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic Lumbar Disk Herniation failing medical management should consider a trial of spinal manipulation followed by surgery if warranted.


Commentary from Malik Slosburg, DC, MS:

This brand new study is very exciting for the chiropractic profession because it provides good evidence that side posture HVLA manipulation is effective for 60% of patients in the study with MRI documented symptomatic herniated lumbar disk who have failed to improve with traditional conservative medical care and physical therapy.


The benefits of SM for the 60% who responded to spinal manipulation were just as good as for those who had the microdisckectomy. In addition, the discussion section of the study notes that there were no ill effects or complications for those who tried chiropractic care first but failed to respond, delaying the time of their surgery. Their surgical outcome was just as good as that of the patients who received surgery initially.


Furthermore, it is encouraging that the 3 neurosurgeons that operated in the surgical arm of the study were all authors and clearly agreed with and co-wrote the conclusion that patients with symptomatic LDH failing medical management should consider a trial of spinal manipulation followed by surgery if warranted.


Dr Kang, DC Says:

This study shows that chiropractic treatment should be considered first before surgery, especially for lower back disc problems.


“We have Traction Tables designed to stretch out your lower back discs, Exercise Equipment to strengthen your back, and Chiropractic Adjustments to take the pressure off the nerves.”


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 2.  Looking For Effective Ways to Strengthen Your Spine, Like Never Before?


Effects of Swiss-ball core strength training on strength, endurance, flexibility, and balance in sedentary women.  Sekendiz, B, Cuge, M, Korkusuz, F.  Journal of Strength and Conditioning Research 2010. 24(11): 3032–3040.


Sedentary work involving prolonged non-varying seated postures results in a high risk of developing LBP. This study investigates the effects of Swiss-ball core strength training on trunk extensor (lower back)/ flexor (abdominals) & lower limb extensor (quadriceps)/flexor (hamstring) muscular strength, as well as, abdominal, lower back & leg endurance, flexibility & dynamic balance in sedentary women (n = 21; age = 34) trained for 45 min, 3x/wk for 12 wks.


Methods: Dynamic exercises were used to recruit global (outer (superficial) muscles: rectus abdominis, obliques, latisimus dorsi, & erector spinae and local (deeper) muscles (transverse abdominis, multifidus, & pelvic floor) in order to generate higher levels of force than static isolation exercises which specifically recruit only a few deep muscles: transverse abdominis & multifidus. The recruitment of both superficial and deep muscles helps to develop strength & endurance of all the muscle groups that provide spinal stability. Both types of muscle groups (deep & superficial) have similar activity patterns and simultaneous neuromuscular function during dynamic tasks, especially when performed on an unstable platform. Both deep & superficial muscle groups are important for dynamic spinal stability.


Results: There significant differences between pre & post measures of 60 & 90 seconds of trunk flexion/extension, 60 & 240 seconds of lower limb flexion/extension, abdominal endurance, lower back muscular endurance, lower limb endurance, lower back flexibility, & dynamic balance were found.  Swiss-ball core strength training exercises can improve strength, endurance, flexibility, & dynamic balance in sedentary women.


Conclusion: The results of this study indicate that Swiss-ball core strength training exercises can improve strength, endurance, flexibility, & balance in sedentary women. Previous studies suggest that exercises (curl-ups, double leg lowering, push-ups) performed on a Swiss-ball increase the core muscular activity more than when performed on a stable surface. This is, at least in part, because coactivation of the global & local muscles is necessary in order to stabilize the spine and maintain balance & prevent the threat of falling off the Swiss ball. This Swiss-ball core strength training protocol can be implemented as a preventative training against falls and subsequent injuries in sedentary women related to poor balance, lower limb and core strength.


Commentary from Malik Slosburg, DC, MS:

This new study adds further credibility to previous research that the use of unstable platforms such as a Swiss or gym ball can substantially improve strength, endurance, flexibility and dynamic balance in sedentary patients.


In addition, the study emphasizes that exercise training should not be limited to focusing only on the deep stabilizing muscles such as the transverse abdominis and multifidus. It specifically includes and discusses the role of recruiting and coordinating both the deep/stabilizing muscles as well as the superficial/global muscles because they all work together as parts of a larger, full kinetic chain functional unit to provide dynamic stability. These dynamic exercises which recruit and coactivate both deep and global muscles will have considerably more carry-over effect to the real world activities and improve safety and function of the dynamic activities patients engage in the real world. The more static exercises which focus primarily only on the transverse abdominis and multifidus are, essentially, muscle isolationist exercises which are really only appropriate in the initial phase of rehabilitation. Clinicians want to advance their patients to more dynamic exercises which require more balance and full kinetic chain activation.


Dr Kang, DC Says:

This study shows that the use of unstable platforms, like the Gym Ball, is better at engaging the core muscles and promoting dynamic balance.


“We use the Gym Balls in our office, to retrain your small and large muscles to support your spine better and keep it place longer, during everyday real life activities.”


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 3.  Looking For A Chiropractor That Does More Than Just Adjustments?


Manual Therapy and Exercise for Neck Pain: A Systematic Review.  Miller J, et al. Manual Therapy 2010, online ahead of print. doi:10.1016 / j.math.2010.02.007.


This Cervical Overview Group systematic review update assesses if manual therapy, including manipulation (SM) or mobilization (MO), combined with exercise improves pain, function/disability, quality of life, global perceived effect, & patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. 17 RCTs met the criteria for this review.


Major Findings:

1. Manipulation or mobilization and exercise produce a greater long-term improvement in pain & global perceived effect when compared to No Treatment for chronic Neck Pain, subacute/chronic Neck Pain w cervicogenic headache, & chronic neck pain w/ or w/o radicular findings.

2. Manual therapy (SM or MO) + exercise produce greater short-term pain relief than exercise alone but produce no long-term difference across multiple outcomes for Neck Pain of chronic & mixed duration with or without cervicogenic headache.

3. The combination of manual therapy + exercise produces greater improvements in pain, function, quality of life, & patient satisfaction when compared to SM or MO alone for chronic neck pain.

4. SM or MO + exercise are favored over traditional care for reducing pain at short-term follow-up for acute whiplash associated disorders (WAD), but may be no different at long-term follow-up for NP of chronic or mixed duration.

5. The combination of manual therapy & exercise seems to produce greater short-term pain reduction than exercise alone & longer-term changes across multiple outcomes in comparison to manual therapy alone.


Commentary from Malik Slosburg, DC, MS:

This review reinforces the new emerging and increasingly dominant paradigm for management of neck pain (NP). The accumulation of evidence over the past decade makes it very clear that multidisciplinary care is more effective than single-modal approaches, including Spinal Manipulation, for the management of both Low Back Pain and Neck Pain.


This review concludes that Spinal Manipulation or MO + exercise produce greater improvement in pain & global perceived effect than no Treatment, for many kinds of Neck Pain.


Spinal Manipulation or MO results in greater short-term pain relief than exercise alone.


Spinal Manipulation or MO + Exercise improve long-term changes across multiple outcomes versus Spinal Manipulation or MO alone.


This review demonstrates that Spinal Manipulation or MO as a single intervention is not as effective as Spinal Manipulation or MO in combination with exercise prescription. These findings should influence how chiropractors approach and managed NP as well as LBP. If we can integrate this information into clinical practice we will improve our patients’ outcomes, satisfaction, and improve referrals of new patients.


Dr Kang, DC Says:

This study shows that doing exercise therapy along with chiropractic adjustments improves the long term outcomes versus spinal manipulation alone.


“We do more than just chiropractic Adjustments; we also do Traction Table Therapy to stretch out the spine, and Exercise Therapy to strengthen the back, for longer lasting results.”


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 4.  Did You Know Sitting Can Be Worse On Your Back Than Standing?


Lumbar spine and pelvic posture between standing and sitting: A radiologic investigation.  De Carvalho, DE, DC, MSc, et al. JMPT 2010;33(1):48-558.


Healthy males were radiographed standing and sitting in an automobile seat to measure lumbar spine and pelvic posture differences between standing and sitting.


Results: Lumbar lordosis in standing (using Cobb’s method: nl=50°-60°) average was 63° and sacral inclination average was 43°. Both decreased by 43° & 44° in sitting. Lumbar intervertebral joint angles in sitting underwent substantial flexion (L1/L2 -5°, L2/L3 -7°, L3/L4 -8°, L4/L5 -13°, & L5/S1 -4°). Measures of lumbar lordosis; intervertebral disk angles between L2/L3, L3/L4, & L4/L5; lumbosacral lordosis; lumbosacral angle and sacral tilt were all significantly decreased between standing and sitting. Intervertebral joints, which are in extension in lumbar lordosis, became flexed throughout the spine in sitting. From L1/L2 to L4/L5, intervertebral disk angles became neutral or reversed.


Discussion: In automobile sitting, the lumbar spine flattens completely except at L5/S1 and is highly suggestive of large strains at the posterior aspect of IVDs at L4/L5, one of the most common levels of lumbar disk herniation.


Conclusion: Interventions to return motion segments to a less flexed posture in sitting should be investigated because they may play a role in preventing injury and LBP. In sitting, the pelvis rotates posteriorly and the lumbar lordosis flattens increasing the strain on the posterior ligaments and other passive elements potentially contributing to injuries of the posterior passive elements. Prolonged sitting likely aggravates pre-existing LBP, instigates new LBP and may be a source of increased risk of low back injuries from disc herniations to musculoskeletal strains and sprains. Intradiscal pressure is found to be inversely proportionate to the degree of lumbar lordosis. Maintaining lumbar lordosis has a protective effect on the spine in different postures.


Commentary from Malik Slosburg, DC, MS:

This 2010 study is one of a series of recently published papers which document the loss or reversal of the normal lumbar lordotic curve when in a slump sitting posture. The contrast between the erect standing lordosis and the loss or reversal of this curve when sitting in a car seat is amply demonstrated in this study.


Maintaining a neutral spine minimizes bending stresses, reducing both posterior tensile forces on back muscles and ligaments and anterior compressive forces on the lumbar intervertebral discs.


It is important, in terms of patient management, to consider how much a patient sits daily at work in an office or behind the wheel of a car or truck because prolonged slump sitting needs to be identified, addressed, and managed in order to minimize recurrences and produce successful, long-term and enduring benefits in patients’ function and pain reduction.


Dr Kang, DC Says:

This study shows that prolonged sitting with incorrect posture (slouching) can ruin your back over time.


“A sitting or desk job is not as easy on your body as most people think.  Sitting actually puts more pressure on your lower back discs than standing.  At the Chiropractic Health Club, we assess your everyday ergonomics for work, sleep, and play.”


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 5.  Have You Tried Physical Therapy or Back School, with No Results?


Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up.  Cecchi, F et al. Clinical Rehab 2010; 24(1):26-36.


Methods: This randomized controlled trial compared spinal manipulation (SM), back school (BS), & individual physical therapy (PT) in the treatment of 205 CLBP Pts (reported having LBP ‘often’ to ‘always’ for 6 mo) (140 F, 70 M) with 12 months follow-up (F-U) in Italy. Patients (Pts) were randomized to either:


Outcomes: Roland Morris Disability Questionnaire, Pain Rating Scale at baseline, discharge 3, 6, & 12 months.

Results: Spinal Manipulation Patients had better functional improvement and long-term pain relief than Back School or Physical Therapy, but received more treatments during F-U. Pain recurrences and drug use were reduced more for SM than BS or PT. SM Pts had more functional improvement than either PT or BS at discharge and across all F-Us. Pain relief at F-Us was significantly better with SM. LBP recurrences and reduction of pain-related use of drugs were also better for SM. However, Pts in SM grp received more Tx during F-Us. Additional Tx consisted of short cycles of SM. Although SM had significantly better outcomes across all F-Us, the SM group had significantly more visits over the 12 months F-U. SM was less effective than PT in promoting self-management of recurrences, but better with pain control and disability reduction than BS or PT.


Conclusions: Spinal Manipulation provided better short and long-term functional improvement, as well as, more pain relief at Follow Up than Back School or Physical Therapy. However, the SM group had significantly more visits over the 12 months of follow-up than either BS or PT groups.


Commentary from Malik Slosburg, DC, MS:

The findings of this study are exciting for chiropractors because they indicate that manipulation resulted in better long-term outcomes for patients with Chronic Low Back Patients in terms of pain reduction, disability reduction, frequency of recurrences, and Low Back Pain, than either back school or individual physical therapy even though both the back school and the individual physical therapy groups care included active exercise training.


It is also worth noting that both the BS & PT groups had 15 one hour sessions in 3 weeks, that is 5 one hour sessions a week for 3 weeks versus 4 -6 twenty minutes sessions in the SM group. Both the BS and PT groups had 15 hours of contact time versus only a maximum of 2 hours for the SM group. It is also important to note that there were many more follow-up visits in the SM group which were apparently needed to achieve/maintain these better long-term outcomes. It would be valuable to have another care group included in a subsequent study which includes both SM and the same type of exercise training as was used in either the BS or PT group.


Dr Kang, DC Says:

This study shows that Chiropractic Adjustments gets better results than Physical Therapy and Back School Alone.


“We do Both Chiropractic Adjustments and Physical Therapy Modalities/ Exercise, so why not get the best of both worlds.”


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 6.  What is Really Wrong with Your Back, Besides Aches and Pains?


CT features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain. Kalichman, L, PT, PhD, Kim, DH, MD, et al. The Spine Journal 2010; 10(3):200–208.


Background: This community-based study of 187 subjects (Ss) (150 Ss without Low Back Pain in the past 12 months & 37 Ss with LBP in the past 12 months) evaluated the prevalence of lumbar spine degeneration features on CT and the association between lumbar spine degeneration features and LBP.


Methods: The study calculated the prevalence of spinal degeneration features: disc narrowing, facet joint osteoarthritis (OA), spondylolysis, spondylolisthesis, spinal stenosis and the density of multifidus (MF) & erector spinae (ES) on CT in Ss with and without LBP to evaluate the association of spinal degeneration with age. The prevalence of degeneration features was calculated in four age grps (<40, 40–50, 50–60, & 60+ yrs).
Results: The average age of Ss was 52.7 years. There is a high prevalence of disc narrowing (63.9%), facet joint OA (64.5%), & spondylolysis (11.5%). Only spinal stenosis showed statistically significant association with self-reported LBP.


Conclusions: Degenerative features of the lumbar spine were extremely prevalent. The only degenerative feature associated with self-reported Low Back Pain was spinal stenosis. Other degenerative features appear to be unassociated with Low Back Pain in the past 12 months.


Paraspinal muscles and LBP: A growing body of studies has demonstrated an association between changes in paraspinal muscles and LBP. Facet joint OA showed significant association with low density of MF & ES, and degenerative spondylolisthesis showed a close to significant association with low density of multifidus. Our results are in accord with a previous study which found that specific training of paraspinal muscles significantly reduces pain and disability in Ss with spondylolysis & spondylolisthesis. It would be interesting to explore if strengthening exercise for paraspinal muscles will prevent the development of facet joint OA and degenerative spondylolisthesis.


Commentary from Malik Slosburg, DC, MS:

This new study, like many before it, found that radiographic features of spinal degeneration are extremely prevalent in people greater than 40 years of age whether or not they have a history of significant Low Back Pain or not.


However, this study is one of the first to evaluate whether there is a correlation between radiographic signs of degeneration and signs of atrophy (in this case low density) of the multifidus (MF) and erector spinae (ES) muscles. The fact that there was a significant association between indicators of MF & ES atrophy and facet joint osteoarthritis and near significant association with degenerative spondylolisthesis is thought provoking, particularly in light of earlier studies which demonstrated that exercise training of these back muscles resulted in long-term (30 month follow-up) reduction of both pain and disability in people with spondylolysis and spondylolisthesis.


This evidence is just one more confirmation of the importance of both evaluating these muscles for atrophy and the likelihood that exercise training focused on enhancing endurance, strength, and motor control of these muscles may contribute to not only improved function, reduced pain, but, perhaps, a reduction facet joint osteoarthritis.


Dr Kang, DC Says:

This study shows that spinal degeneration can be present, even without a history of back pain.


“We have an X-ray Machine to see exactly what is causing your back pain and find what other doctors have missed.”


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 7.  Why Does My Back Keep Getting Re-injured?

Why do Some Patients Keep Hurting Their Back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain.  McDonald D, Moseley GL, Hodges PW. Pain 2009; 142: 183-188.


Methods: This study evaluates the control of short (deep) & long (superficial) fibers of the multifidi (MF) to determine if there is difference in 15 subjects (Ss) with a History of recurrent unilateral LBP but currently pain free at the time of the evaluation vs 19 healthy controls (ctls). Intramuscular electrodes were inserted in deep & superficial MF and surface electrodes were placed over the deltoids to record EMG activity during rapid arm flexion & extension to compare the onset of short & long MF fibers relative to the deltoids. THE contraction of the MF w rapid arm flexion & extension is an unconscious feed forward activation of core stabilizers to provide active stabilization of the spine when motion of the upper extremity results in shifts of load and reactive torques in the spine.


Results: 1. Deep MF fibers were active earlier than superficial fibers on both sides of the spine in healthy ctls & on the non-painful side in recurrent LBP Ss (feed-forward activation of unconscious stabilizing muscles), but were delayed on the previously painful side of the spine. 2. Activity of deep back MF muscles is different & delayed in Ss w recurrent unilateral LBP, despite resolution of Sx. 3. Changes in back muscles in Ss with a History of recurrent LBP are more profound in the deep fibers & on the side of Sx.  These deep MF contribute up to 2/3 of the control of lumbar intersegmental motion. 4. Impaired control of these muscles is likely to compromise spinal function. 5. THE persistence of these changes during remission implies persistent altered loading on spinal structures during remission, which may be a cause of recurrent episodes. 6. Spinal injury specifically reduces the excitability of corticomotor inputs to the short fibers of the lumbar MF (L-MF). 7. An alternate motor strategy & subsequent changes in control of the deep MF can remain after an initial bout of LBP despite the resolution of Sx. 8. Such a change in strategy may indicate ongoing problems as alterations in control of back muscles lead to changes in joint loading & kinematics of the spine. 9. Resolution of BP doesn't imply a return to normal control of the deep back muscles. Studies demonstrate that reduced CSA of deep back muscles remains in some Pts following an ALBP despite resolution of Sx.


Conclusion: This study presents evidence that even though they are pain-free & between episodes of LBP, recurrent unilateral Low Back Patient Subjects don't control their back muscles in the same way as healthy controls. The findings raise the possibility that this abnormal pattern of muscle control, in the absence of pain, may leave the spine vulnerable to re-injury & predispose to recurrent episodes.


Commentary from Malik Slosburg, DC, MS:

This 2009 study's findings confirm the recent trend in motor control change research and does an excellent job in summarizing the conclusions based on the accumulation of this evidence over the past decade. Disturbances in motor control can be persistent and leave the area vulnerable to re-injury & recurrence.


The findings suggest that the addition of exercise training to normalize & restore motor control patterns may have significant long-term benefits. In addition, the discussion about spinal injury specifically reducing the excitability of corticomotor inputs to the short fibers of the lumbar MF indicates the complexity of the reorganization of motor control changes with low back injury.


Dr Kang Says:

This study shows that patients with a history of back pain have an altered motor control of their muscles, which predisposes them to re-injury, unless there is exercise retraining of those muscles during the recovery phase.


“We incorporate exercise training to retrain your muscle control and get them stronger, for longer lasting results.”


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 8.  Prescription Medications Not Working?


A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain.  Hondras MA, DC, MPH, et al. JMPT 2009;32(5):330-43.


This study compares 2 biomechanically distinct forms of spinal manipulation (SM) & minimal conservative medical care (MCMC) for subjects (Ss) =/>55 yrs (mean 63.1) with subacute or chronic nonradicular LBP w/o significant co-morbidities. 240 Ss randomized to 6 wks of care into 3 grps: 12 visits of either diversified side-posture (HVLA-SM) (n=96) or Cox technique: flexion-distraction (low-velocity, variable-amplitude (LVVA)-SM, or 3 visits of MCMC (minimum of 3 visits/6 wks w goal of pain management using acetaminophen, NSAIDs, &/or muscle relaxants to improve pain & ADLs). Ss in all grps were given 30 min of instructions for home exercise tailored to each Ss’ abilities including 7 exercises & an aerobic program.


Primary Outcome: Roland Morris Disability questionnaire (RMD) at baseline, 3, 6, 12, & 24 wks. Also fear avoidance belief questionnaire (FABQ), VAS, physical subscale of SF-36.


Results: Mean RMD change scores from baseline to the end of care: 2.9 Cox & 2.7 diversified SM groups & 1.6 in MCMC group (grp). The Cox group had significant improvements in mean functional status ranging from 1.3 to 2.2 points over the MCMC group. There were no serious adverse events assoc with any of the Txs.


Conclusions: Subjects who received either form of Spinal Manipulation were 30% - 40% better in functional status than those in Minimal Conservative Medical Care group. There were no differences between Spinal Manipulation groups at any end point on any outcome. Findings suggest that the choice of diversified (HVLA) or Cox (LVVA) SM made little difference in health benefits. From an evidence-based perspective, Patient preference & clinical experience should drive how chiropractors & Patients make decisions concerning what Spinal Manipulation procedure to use.


Commentary from Malik Slosburg, DC, MS:

This study demonstrates that in older individuals either high velocity Spinal Manipulation (diversified) or low velocity (Cox) resulted in significantly better outcomes than a minimum of 3 visits to an MD for medications with the goal of pain management. The key statement in the conclusion is: subjects who received either form of Spinal Manipulation were 30% - 40% better in functional status than those in Minimal Conservative Medical Care group.


In addition, there were no significant differences in any outcomes between the two 2 biomechanically distinct forms of spinal manipulation. Both techniques had a significant advantage over the medical/medication group in terms of functional status. Spinal Manipulation contributes significantly to improving functional status.


Dr Kang, DC Says:

This study shows patients get better results with Chiropractic Adjustments than minimal conservative medical care (pain management with prescription medications).


“We focus on adjusting your spine back to proper alignment to allow it to heal naturally, instead of trying to cover up your symptoms with pain medication.”


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 9.  Why Is Exercise So Important To Do After Your Spine has Started To Heal?


Multifidus morphology in persons scheduled for single-level lumbar microdiscectomy.  Kulig K, Scheid AR, Beauregard R, et al. Am J Phys Med Rehab 2009; 88:355-61.


In this study bilateral multifidus (MF) cross-sectional area (CSA) were measured on MRIs of 20 Patients scheduled for L4-5 microdiscectomy to analyze the degree & location of lumbar MF asymmetry.


Results: Mean differences in MF CSA were 15.8% & were statistically significant. The radiologist could visually recognize MF asymmetry when the difference was at least 12.6%. Atrophy of the lumbar MF includes a decrease in muscle fiber size & is associated with replacement of muscle with fat & fibrous tissues. In 17 of 20 cases the smaller side of the MF was either on the side of disc protrusion or the disc protrusion was deemed to be central.


Discussion: Previous studies report a mean percent difference between left and right sides of MF CSA of <10% in asymptomatic Ss w/o Hx of LBP. Most radiologists don’t comment on paraspinal muscle asymmetry on MRI. However, because lumbar muscle morphology has been associated with a History of BP & surgery and may be predictive of outcome, reporting paraspinal muscle asymmetry on MRI is strongly recommended. Evidence indicates that MF recovery doesn't occur spontaneously once pain has resolved. Exercises for the MF are, therefore, necessary to recover muscle size after the first episode of LBP. The inclusion of paraspinal muscle findings by radiologists on MRI reports will greatly assist in the education of health care providers and patients.


Commentary from Malik Slosburg, DC, MS:

This new article demonstrates that asymmetry of the MF is grossly visible to radiologists on MRI and the study strongly recommends that this finding be reported because it may be predictive of outcomes for LBP. In addition, the study reinforces the previous finding that MF recovery doesn't occur on its own after a first episode of LBP has resolved. Therefore, exercises for the MF are necessary to recover its original size so that it can help stabilize and protect the spine. This is a valuable article to send to radiologists to get them to report on MF asymmetry on MRIs.


Dr Kang, DC Says:

This study shows that your lower back muscles don’t automatically recover on its own after the first episode of Low Back Pain, without exercises to retrain them.


“When your back is hurting, it is best to start exercise after your back starts to heal with chiropractic adjustments, otherwise you are just aggravating and prolonging the problem.”

Adjustment First...                               Then Therapy...                                      Then Exercise...      

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 10.  Do I Have A Short Leg Causing My Lower Back Pain?


Preoperative leg-length inequality and hip osteoarthrosis: a radiographic study of 100 consecutive arthroplasty patients. K. Tallroth, M. Ylikoski, H. Lamminen, K. Ruohonen.  Skeletal Radiology (2005) 34:136–139, DOI 10.1007/s00256-004-0831-5


Abstract Objective: To assess the leg-length inequality in patients with hip osteoarthrosis (OA) and to evaluate a possible association between the length disparity and side of OA. Design and patients: Weight-bearing radiographs of 100 consecutive patients undergoing arthroplasty for primary OA were examined and measured for inequality of leg length, pelvic tilt and severity of OA.


Results: The radiographic results showed that preoperatively OA occurred more frequently in the hip of the longer (84%) than the shorter (16%) leg. However, the development of OA did not show a linear relationship with the magnitude of leg-length inequality.


Conclusion: As hip OA occurred more frequently in the longer leg the authors speculate whether leg-length inequality might predispose to OA in the hip of the longer leg.


Dr Kang, DC Says:

This study shows that a short leg can cause hip arthritis on the longer side.


“A significantly short leg can also cause chronic lower back problems.  We measure any leg length discrepancy accurately within millimeters, show you how to fix the problem, and show you if it has been affecting your spine.”


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