Review of Prospective Study:
Kohlbeck FJ, Haldeman S, Hurwitz E, Dagenais S. Supplemental Care with Medicine-Assisted Manipulation Versus Spinal Manipulation With Chronic Low Back Pain. J Manipulative Physiol Ther 2005: 245-52.
By Dr. Chris Kemper, Chief clinician, Northern California Group
Introduction
This prospective cohort was conducted in 2000-2002 by Kohlbeck & Haldeman et al. under the clinical direction of Jim Wooley, D.C. and Chris Kemper, D.C. who provided clinical services for 68 patients from two separate geographic areas with chronic low back and/or pelvic pain. The study compared outcomes of two groups, a control and an experimental.
Measures and Intervention
Both groups were diagnosed with chronic lumbopelvic pain, compromised axial alignment, impaired trunk flexion per Wooley & Kemper’s hypothesis, and tested positive for serious loss of thigh rotator motor strength.
Both groups received MRIs before and after treatment. MRIs looked at several factors including: Canal diameter; disc bulging and protrusion in mms; level of inferior tip of the conus medullaris; centrality of the conus.
Both groups first received manual therapy aimed at improving spinal alignment measured on Cartesian coordinates. Assessments were made with X-ray1 and instrumentation2, both while weight bearing. Both groups received 12 sessions of deep tissue massage, myofascial stretching, and supervised therapeutic exercises.
All experimental group participants volunteered for the protocol of 3 medicine-assisted coccyx treatments at 1-week intervals. None of the control group participants received medicine-assisted coccygeal treatment of any kind.
Methods
Only participants with persistent pain and impairment in the key clinical measures were eligible for the experimental group. Care was taken to insure that improvement in spinal flexibility and strength, induced by alignment or therapy, had leveled off prior to providing the experimental group with medicine-assisted coccygeal treatment.
Every patient in the experimental group (medicine-assisted manipulation) received coccygeal manipulation. The goal, in providing sedation and analgesia, was to be able to apply a standard degree of traction and manipulation for the hypomobile coccyges and surrounding long axis myofascial tissue, regardless of patient pain tolerance.
Outcomes
The group receiving the coccygeal manipulation overall experienced greater improvement in pain and lumbopelvic range of motion. The following categories of improvement were assessed: Lumbar flexion; Straight Leg Raise; Motor deficit; Disc bulging and protrusion; and vertical and frontal plane change in position of conus medullaris.
Problems with the study
The study was not randomized nor was it blinded as coccygeal manipulation did not lend itself well to blinding. MRIs were read by two separate board certified radiologists rather than one; one for the Northern California study group and one for the Southern California study group. Only one radiologist documented all the data for their respective group. However, when looking at the data from the group that was accumulated, these data did reveal a change in conus position in the post-treatment MRIs. The change was upward and toward the middle of the canal, suggesting a possible relaxation of the cord resulting from treatment. While the change was measurable it did not occur in every case.
A change in disc bulging and protrusion was also measured. While not every subject with measurable bulging or protrusion exhibited a reduction after treatment, most did. In the 21 participants nearly 100 millimeters of pre-treatment disc bulging and or protrusion decreased to nearly 75 millimeters in the post-treatment group. Since bulging and protrusions decreased, further research is indicated to more thoroughly compare each of the pre-treatment clinical measures such as trunk flexion, straight leg raise, thigh weakness, pelvic tilt and or rotation as well as conus position and canal diameter so that disc bulging and protrusion may be better assessed in relation to what this, first of its kind, study intended to observe.
Craniocervical and lumbopelvic X-ray studies and alignment services generally followed a methodology described by Pettibon, Sweat and Harrison. Pelvic coordinates were closely monitored, before and after treatment with the Anatometer®, a precision device developed by the National Upper Cervical Research Association.
Questions evolving from the study
Does coccyx displacement and hypomobility cause or lead to abnormal spinal cord tension? If so, what are the most sensitive indicators of sacrococcygeal hypomobility-induced cord tension?
If coccyx mobilization, according to Wooley and Kemper, does affect cord tension, what is the minimum normal coccygeal range of motion?
Is impaired trunk flexion related to impaired thigh strength?
Is impaired straight leg raise an indicator of disc compression or a predictor of disc bulging or protrusion?