Chiropractic vs. Oral Steroids vs. Muscle Relaxants: Outcomes for Low Back Pain and Sciatica

 

A report on the scientific literature 


By Mark Studin DC, FASBE(C), DAAPM, DAAMLP

 

Reference: Studin M. (2015) Chiropractic vs. Oral Steroids vs. Muscle Relaxants: Outcomes for Low Back Pain and Sciatica,The American Chiropractor, 37(7) 42-47

 

Choices. Every health care practitioner is caring for his/her patients having multiple treatment options and often those choices are influenced by pieces of information. That information can be what was learned in formal training, colleagues sharing anecdotal experience, patients giving direct feedback or well-scripted “representatives” of the pharmaceutical industry who only have one agenda…sales.As a result of doctors managing their patients’ conditions, there are two major parameters that are utilized, best medical practice, also known as “experience,” and evidence-based practice or that which has only been concluded in the medical literature. Both have a strong place in a healthcare delivery system with the best possible outcomes as the ultimate goals.

 

“A best practiceis a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a "best" practice can evolve to become better as improvements are discovered. (“Best Practice,” http://en.wikipedia.org/ wiki/Best practice).”

 

“Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992. It started inmedicineasevidence-based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology, education, library and information science…” (“Evidence-Based Practice,” http://en.wikipedia.org/wiki/Evidence-based_practice) and other fields. Its basic principles are that all practical decisions made should 1) be based on research studies and 2) that these research studies are selected and interpreted according to some specific norms characteristic for EBP. Typically such norms disregardtheoretical studiesandqualitative studiesand considerquantitative studiesaccording to a narrow set of criteria of what counts asevidence.

 

 

“’Evidence-based behavioral practice’(EBBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses" (“Evidence-Based Practice, http://en.wikipedia.org/wiki/Evidence-based_practice).

 

This highly-debated topic of best practice vs. evidence-based practice has valid issues on each side, but putting together the two concepts as a hybrid would allow them to thrive in any healthcare delivery system as all options would be considered. This would allow advances in healthcare to save more lives, increased quality of life and at the same time, enough safeguards to prevent abuse of those with one-sided agendas to profit. It would also take the blinders off those who have dogmatic prejudice against that which has been verified to be successful in both the best practice and evidenced-based models (experience and literature).   

For years, too many non-chiropractic practitioners have ignored the “best practice” model or the results reported by both the patients and the practicing chiropractors with treatments regarding low back and leg pain (often associated with herniated discs). These non-chiropractic practitioners refuse to consider chiropractic as a first referral option. The main reason cited over the past few decades as this author’s personal experience has been that there is no literature that proves these claims in spite of patients corroborating their positive experiences with the chiropractors’ claims. As a result of ignorance, blinders and possibly a deep rooted prejudice, too many patients have been and are currently being treated with poor alternatives based upon outcomes that are now being clearly reported. Treatment with both oral steroids and muscle relaxers are two often used, but inferior choices and now the literature verifies why chiropractic is the best possible first-line of referral for diagnosis that are the subject for this paper.

 

ORAL STEROIDS

Goldberg et al. (2015) reported: Despite conflicting evidence, [epidural steroid injections] are frequently offered under the assumption that radicular symptoms are caused by inflammation of the affected lumbar nerve root.Epidural steroid injections are invasive, generally require a pre-procedure magnetic resonance imaging (MRI) study, and expose patients to fluoroscopic radiation. In addition, the US Food and Drug Administration recently warned of rare but serious neurologic sequella from [epidural steroid injections].Oral administration of steroid medication may provide similar anti-inflammatory activity, does not require an MRI or radiation exposure, can be delivered quickly by primary care physicians, carries less risk, and would be much less expensive than an [epidural steroid injection]. Oral steroids are used by many community physicians, have been included in some clinical guidelines,and are noted as a treatment option by some authors.However, no appropriately powered clinical trials of oral steroids for radiculopathy have been conducted to date. To address this issue, we performed a parallel-group, double-blind randomized clinical trial of a 15-day tapering course of oral prednisone vs placebo for patients with an acute lumbar radiculopathy associated with a herniated lumbar disk... (p. 1916).

 

Results showed that “participants in both blinded treatment groups showed an improvement in symptoms over the initial 6 weeks, with more gradual reductions until the 24-week visit, after which changes were more variable. Baseline ODI [Oswestry Disability Index] scores were 51.2 and 51.1 in the prednisone and placebo groups, respectively; corresponding ODI scores at 3 weeks were 32.2 and 37.5” (Goldberg, 2015, p. 1919-1920). This indicates that both at 3 and 6 weeks there was no difference in the placebo vs. oral steroid groups. Among patients with acute radiculopathy due to a herniated lumbar disk, a short course of oral steroids, compared with placebo, resulted in modest improvement in function and no significant improvement in pain” (Goldberg, 2015, p.1922).

 

MUSCLE RELAXANTS

 

Hoiriis et al. (2004) reported, “Reviews of low back pain studies often fail to distinguish between manipulative interventions. Manipulation and spinal manipulative therapy (SMT) are vague terms describing procedures used by chiropractors, physiotherapists, massage therapists, and osteopaths. These maneuvers may decrease ligamentous adhesions and myospastn, increase disk nutrition, or alter the function of the nervous system. The manipulative procedures used in this study, referred to as chiropractic adjustments, involve specific application of force thought to restore mechanical and neurological function to the spine…This study was a randomized clinical trial (RCT) in which subjects and assessors were blinded to the interventions, chiropractic providers were blinded to medical/sham assignment and an independent consultant provided the statistical analysis. Visit lengths and provider-subject interactions were monitored to preserve patient blinding” (p. 389).

 

At the 2 week period, the study revealed that the chiropractic group had statistically slightly better outcomes, but statistically insignificant, than the muscle relaxants and at the 4 week period had a significantly reduced visual analog pain scale of 24% from the muscle relaxant group and 23% from the placebo group. Although the authors reported this as statistically insignificant, I don’t, and one cannot lose sight of the fact that chiropractic outperformed muscle relaxant therapy with the absence of any possibility of side effects from medications, making the utilization of the drugs clinically unnecessary based upon the outcomes of a safer and statistically better alternative.  

 

CHIROPRACTIC TREATMENT

 

It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 2010 that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study. 

 

The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.

 

Although the previous report concluded that a chiropractic spinal adjustment is an effective treatment modality for a herniated disc, a more recent study by Leemann et al. (2014), further clarifies the improvement with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients.

 

In this study, the acute onset patient (the pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.

 

Chiropractic Care and Herniated Discs with Leg Pain

 

2 Week Improvement

1 Month Improvement

3 Month Improvement

80.6%

84.6%

94.5%

 

The caveat is that there are patients who could need drugs or surgery and an accurate diagnosis is paramount. It is incumbent upon the doctor of chiropractic to be fully trained in both the diagnostic and treatment facets of care. It is also important that the chiropractor be well-versed in MRI protocols and interpretation as well as disc pathology in order to be able to triage the patient accordingly based upon the clinical presentation inclusive of the MRI results.

 

Chiropractic is one of the safest treatments currently available in healthcare and when there is a treatment where the potential for benefits far outweighs any risk, it deserves serious consideration.  Whedon, Mackenzie, Phillips, and Lurie (2015) based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study and accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified (Whedon et al., 2015, p. 5) 

 

CONCLUSION

 

Contemporary research is clearly defining the most effective and safest treatment options for low back pain sufferers with associated leg pain (sciatica). In too many offices today, chiropractic treatment is not being considered the first option for care and the responsibility to change that habit falls to the chiropractic profession. Our profession is no different than the pharmaceutical companies who have an “army” of drug representatives. Pharmaceutical sales representative (formerly detailmen) are sales people employed bypharmaceutical companiesto persuade doctors to prescribe their drugs to patients. Drug companies in theUnited Statesspend ~$5 billion annually sending representatives to doctors,to provide product information, answer questions on product use, and deliver product samples. Companies maintain this provides an educational service by keeping doctors updated on the latest changes in medical science. Critics point to a systematic use of gifts and personal information to befriend doctors to influence their drug prescriptions.”  (http://en.wikipedia.org/ wiki/Pharmaceutical_sales_representative)

 

What makes the chiropractic profession different from the “real world” of business? The answer is absolutely nothing and it is incumbent upon every entity of the profession from individual practitioners to organizations to start educating the public and every referral source because we now have the evidence. Oral steroids offer no relief and modest return to function. Muscle relaxants offer some help, but render worse results than chiropractic care with clearly defined side effects that can be avoided. It has been clearly concluded that chiropractic care is an extremely safe environment regarding side effects. That is verifiable with close to 7 million subjects studied. By considering chiropractic as the first-line for referral, the scientific evidence verifies solutions to low back pain and leg pain inclusive of herniated discs. The results indicate that at 2 weeks, 80.6% and at 3 months 94.5% of those with herniated dics show significant improvement with chiropractic care.

 

References:

1. Best Practice. (2015). Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Best_practice

2. Evidence-Based Practice. (2015). Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Evidence-based_practice

3. Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L., Hamilton, L.,…Avins, A. L. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: A randomized clinical trial. Journal of the American Medical Association (JAMA), 313(19), 1915-1923.

4. Hoiriis, K. T., Pfleger, B., McDuffie, F. C., Cotsonis, G., Elsangak, O., Hinson, R., & Verzosa, G. T. (2004). A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for sub-acute low back pain. Journal of Manipulative and Physiological Therapeutics, 27(6), 388-398.

5. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. .Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.

6. Leeman S., Peterson C., Schmid C., Anklin B., Humphrys K. (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging Confirmed Symptomatic Lumbar Disc Herniations Receiving High Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One Year Follow Up, .Journal of Manipulative and Physiological Therapeutics, 37(3), 155-163.

7. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.

8. Pharmaceutical Sales Representative. (2015). Wikipedia. Retrieved from http://en.wikipedia.org/wiki/ Pharmaceutical_sales_representative

 

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University Of Bridgeport College Of Chiropractic, an Adjunct Professor, Division of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the legal community (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at or at 631-786-4253 or DrMark@AcademyOfChiropractic.com 

 

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Published in Low Back Problems

Disc Surgery (Discectomy,) Sciatica (Leg Pain) & Lumbar Disc Herniation

Surgery vs. Chiropractic Care

 

A report on the scientific literature 


by

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

 

60% of Surgical Candidates Avoid Surgery with Chiropractic

 

According to a group at MayoClinic.com (2010), "Sciatica refers to pain that radiates along the path of the sciatic nerve and its branches — from your back down your buttock and leg. The sciatic nerve is the longest nerve in your body. It runs from your spinal cord to your buttock and hip area and down the back of each leg. Sciatica is a symptom, not a disorder. The radiating pain of sciatica signals another problem involving the nerve, such as a herniated disk" (http://www.mayoclinic.com/health/ sciatica/DS00516).

Sciatica symptoms include: Pain "…likely to occur along a path from your low back to your buttock and the back of your thigh and calf. Numbness or muscle weakness along the nerve pathway in your leg or foot. In some cases, you may have pain in one part of your leg and numbness in another. Tingling or a pins-and-needles feeling, often in your toes or part of your foot. A loss of bladder or bowel control. This is a sign of cauda equina syndrome, a serious condition that requires emergency care" (Mayo Clinic Staff, 2010, http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=symptoms).

A prime symptom of sciatica is leg pain in conjunction with herniated discs. As reported by the US Chiropractic Directory in 2010, "Pain radiating down your leg secondary to a herniated disc is a common and often disabling occurrence. A disc in your spine is comprised of 2 basic components, the inner nucleus pulposis that is gelatinous in composition and the outer annulus fibrosis that is fibro-cartilaginous and very strong. When a person experiences trauma and the forces are directed at the spine and disc. The pressure on the inside of the disc is increased (like stepping on a balloon) and the internal nucleus pulposis creates pressure from the inside out. It tears the outer annulus fibrosis causing the internal material to go beyond the outer boundaries of the disc. This has often been misnamed a ‘slipped disc’ because the disc doesn’t slip or slide, it is torn from the trauma allowing the internal material to escape.
 
Conversely, a bulging disc, which gets confused with a herniated disc, is a degenerative "wear and tear scenario" that occurs over time with the annulus fibrosis degenerating. This can also be a "risk factor" allowing the disc to herniate with less trauma due to the degeneration or thinning of the disc walls. This, however, is a conversation for another article.
 
Lifetime prevalence of a herniated disc has been estimated to be 35% in men and 45% in woman and it has been estimated that 90% of all leg pain secondary to herniated discs occurs at either the L4-5 or L5-S1 levels. It has also been reported that average duration of symptoms is 55.9 weeks, underscoring the critical necessity for finding a viable solution for these patients" (
http://www.uschirodirectory.com/index.php/patient-information/item/235-herniated-discs-radiating-pain-and-chiropractic).

It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 2010 that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.

This study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates.

Both the surgical and chiropractic groups reported no new neurological problems surfaced and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. Of those patients choosing surgery as the primary means of treatment, 15% reported a failed surgical outcome and then chose chiropractic as a secondary choice. Of those 15% with failed surgeries, all were reported to have performed worse in clinical outcomes.

While it is clear that an accurate diagnosis could dictate that many patients require immediate surgery, many also do not. The above study indicates that a conservative non-operative approach of chiropractic care prevented 60% from needless surgery. While a larger study would give us more information, based upon the outcomes, cost factors and potential increased risks of surgery, it was concluded that chiropractic is a viable, first line treatment option.

These studies along with many others conclude that a drug-free approach of chiropractic care is one of the best solutions for patients with surgical lumbar discs and sciatic pain. To find a qualified doctor of chiropractic near you go to the US Chiropractic Directory at www.USChiroDirectory.com and search your state.

References:

1. Mayo Clinic Staff. (2010, April 22). Sciatica, Definition. MayoClinic.com, Retrieved from, http://www.mayoclinic.com/health/sciatica/DS00516

2. Mayo Clinic Staff. (2010, April 22). Sciatica, Symptoms. MayoClinic.com, Retrieved from http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=symptoms

3. Studin, M. (2010). Herniated discs, radiating pain and chiropractic. US Chiropractic Directory. Retrieved from http://www.uschirodirectory.com/index.php/patient-information/item/235-herniated-discs-radiating-pain-and-chiropractic

4. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33 (8), 576-584

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Published in Leg-Feet Problems

Disc Herniations, Bulges, Sciatic Pain and Chiropractic

A report on the scientific literature 



By
William J. Owens DC, DAAMLP
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
 

The authors of a recent study state, “Acute back pain and sciatica are major causes of disability, with impairment of daily living activities” (Santilli, Beghi & Finucci, 2006, ). Pain that starts in the lower back and shoots down the leg is called sciatica.  This is a very common and painful condition. The most common reason for pain down the leg is a bulge or a herniation of the soft disc between the bones of the spine.  These are called intervertebral discs, sometimes referred to as a “slipped disc.”

This research paper reported on 102 cases of patients and stated, “Patients receiving active manipulations [chiropractic adjustment] enjoyed significantly greater relief of local and radiating [shooting] acute lower back pain, spent fewer days with moderate-to-severe and consumed fewer drugs for the control of pain” (Santilli, Beghi & Finucci, 2006, ). 
If you are suffering from lower back and leg pain, a doctor of chiropractic has the training and experience to determine whether the chiropractic adjustment can help you.  Determining the exact CAUSE of your pain is the first step, treating it is the second.  Chiropractic care has been shown to be effective in helping people with lower back and leg pain. 



Refernces:

1.  Santilli, V., Beghi, E., & Finucci, S. (2006). Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: A randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal 6(2), 131-137. 

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Published in Herniations
Sciatica, Low Back Pain and Chiropractic

A report on the scientific literature 


By
William J. Owens DC, DAAMLP
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
 
 
Many people have heard the term, Sciatica. Sciatica literally means inflammation of the Sciatic nerve. The Sciatic nerve is a large nerve that runs from the lower back, through the buttocks and then down the leg. It is a combination of all the spinal nerves in the lower back. Injury or swelling in any one single nerve can cause “Sciatica” and pain down the path of the nerve. Some people feel it in their toes, some in the knee and some just in the buttocks like something is jabbing them. The pain can come from many different sources, most commonly from the lower back.   Treatment is generally targeted to the parts of the body that are creating the “pain down the leg”. These parts include the bones of the spine, the intervertebral discs or the muscles that lie over the top of the Sciatic Nerve. 
 
A recent study in 2008 reviewed all the scientific research related to Chiropractic and lower back pain along with leg complaints, some of which went back to the 1980’s!  The research related to lower back pain and leg pain is growing and showing the effectiveness of Chiropractic care and Sciatica.  The authors reported “The purpose of this work is to provide a balanced interpretation of the literature to identify safe and effective treatment options in the care of patients with low back pain and related disorders.”1 The paper revealed the following information:
 
1.      Acute Back Pain – there is evidence that the chiropractic adjustment has better short term efficacy than mobilization or diathermy (a physical therapy treatment that heats up the tissues).
 
2.      Chronic Back Pain – the chiropractic adjustment combined with strengthening exercises was as effective at pain relief as Non-steroidal anti-inflammatory drugs (Ibuprofen) with exercise. They also stated there was fair evidence that the chiropractic adjustment was better than physical therapy and home exercise for reducing disability. There was evidence that the chiropractic adjustment improved outcomes more than general medical care or placebo in the short term and to physical therapy in the long-term.
 
“Patients overall were more satisfied and felt they were provided better explanations about their pain from practitioners who used manual therapy {chiropractic adjustments.}”1 There were many research studies that were reviewed in this paper but here are some of the highlights.
 
“The group receiving manipulation [chiropractic adjustment] had a shorter treatment time and a more marked improvement. At 6 month follow-up, the manipulation [chiropractic adjustment] group showed better neuromotor system function and a better ability to continue employment. Disability was lower in the manipulation [chiropractic adjustment] group.” 4
 
“Outcomes from manipulation [chiropractic adjustment] were better for neurologic and motor function as well as disability”4
 
 
 
For the Sciatica patients…….
 
“For patients with LBP [low back pain] and restricted straight leg raise test [laying on your back, legs straight then having someone lift your straight leg in the air] manipulation [chiropractic adjustment] conferred highly significant relief, more than alternate interventions.” 2
 
“Coxhead et al included among their subjects patients who had at radiating pain at least to the buttocks. Interventions included traction, manipulation, exercise, and corset, using a factorial design. After 4 weeks of care, manipulation [chiropractic adjustment] showed a significant degree of benefit on one of the scales used to assess progress.” 3
 
“Manipulation [chiropractic adjustment] was reported to be superior to conventional therapy.”
 
Doctors of Chiropractic have been treating lower back pain with and without leg pain for a very long time. It is an extremely safe and effective approach to Sciatica. Pain down your leg should never be ignored and a Doctor of Chiropractic is trained to determine the cause. 
 
 
 
 
1.      Dana Lawrence DC MMedEd, William Meeker, DC, MPH, Richard Branson, DC, Gert Bronfort, DC, PhD, Jeff R. Cates DC, MS, Mitch Hass, DC, MA, Michael Haneline, DC, MPH, Marc Micozzi, MD PhD, William Updyke, DC, Robert Mootz, DC, John Triano, DC, PhD and Cheryl Hawk, DC, PhD. Chiropractic Management of Low Back Pain and Low Back Related Leg Complaints: A literature synthesis. J Manipulative Physiol Ther 2008;31:659-674.
2.      Mathews JA, Mills SB, Jenkins VM, Grimes SM, Morkel MJ, Mathews W, Scott SM, Sittampalam Y. Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. Br J Rheumatolo 1987:26416-23.
3.      Coxhead CE, Inskip H, Meade TW, North WR, Troup JD. Multicenter trial of physiotherapy in the management of sciatic symptoms. Lancet 1981;1:1065-8.
4.      Arkuszewski Z. The efficacy of manual treatment in low back pain: a clinical trial. Man Med 1986;2:68-71.
5.      Nwuga VCB. Relative therapeutic efficacy of vertebral manipulation and conventional treatment in back pain management. Am J Phys Med 1982;61:273-8. 

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Published in Sciatic Problem

More Research