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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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Figure 5
Photograph demonstrates an indirect technique for the
cervical spine, initially set up for either counterstrain or
facilitated positional release. This position creates an axial load down
the cervical spine to facilitate treatment.
Myofascial Release
Myofascial techniques vary greatly by practitioner and by patient. Patients
with high sensitivity to typical mobilization and exercise sometimes do better
with myofascial techniques. Myofascial release, which is frequently
performed in a direct fashion, typically focuses on the soft tissues and follows
tension lines to find positions of least tension (indirect) or most tension
(direct). In general, tissues are manipulated in craniocaudal and mediolateral
planes and augmented with rotational forces (Figure 6). These techniques are
the most highly subjective, both for identification of somatic dysfunction and
reassessment after treatment.
Figure 6
Photograph demonstrates the soft tissues of the sacral area
engaged in mediolateral and superoinferior planes,
augmented with a rotational force to initiate a myofascial release of
the tense tissues.
The Practitioner
Because the experience, capacity, proficiency, and setting of each practitioner
of manipulation can vary greatly, the considered diagnosis and treatment
selection are dependent on who performs the manipulation. Identified
potential challenges that are not likely to improve with manipulation may
require other attention or workup, and they can be worsened with the
application of substantial manual force. Currently, subgroups of individuals
licensed for body work, from traditional osteopathic physicians and
chiropractors to most physical therapists (and more recently, licensed
massage therapists and athletic trainers) are marketing themselves as experts
in treating the same problems as orthopaedic surgeons and spine specialists.
Sharing information and fully informing all members of the treatment team
(irrespective of whether they work in the same organization) of the risks and
benefits of any treatments provided is in the best interest of the patient.
Summary
Many patients who consult with orthopaedic surgeons have specific
preferences, needs, and inherent biases, along with predetermined notions
about their symptoms, expected diagnosis, and the type of treatment they are
willing to undergo. Some patients may consider manipulation to be an
intimidating treatment option. It is helpful if the orthopaedic surgeon or spine
specialist has a general understanding of the terminology used by
practitioners of manipulation and is familiar with the focus of the individual
offering care involving manipulation. Although the literature has not
demonstrated manipulation to be superior to other nonsurgical measures,
many patients may be receptive to management of their spinal condition with
a method that is considered as effective as NSAIDs. Spinal manipulation has
been demonstrated to help in the management of symptoms of both acute and
chronic back and neck pain, and it should be considered a reasonable option
for managing appropriate spinal conditions.
Key Study Points
Osteopathic manipulative treatment is the treatment of somatic
dysfunction for removing restrictions in bodily function.
Manipulative treatments are all based on the idea that the body possesses
self-regulatory mechanisms that can be augmented or supported by
manipulation just as they are by medical treatment.
Spinal manipulative treatment has been demonstrated to be at least
moderately effective in the treatment of acute low back pain.
Injuries during manipulative treatment are rare and typically involve
transient muscle irritation.
For patients with mechanical spine pain who are hesitant to undergo
standard medical treatments, appropriately directed manipulative treatment
should be considered as a viable option.
Annotated References
1. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S: A
comparison of osteopathic spinal manipulation with standard care for patients with low
back pain. N Engl J Med 1999;341(19):1426-1431.
2. Licciardone JC, Stoll ST, Fulda KG, et al: Osteopathic manipulative treatment for
chronic low back pain: A randomized controlled trial. Spine (Phila Pa 1976)
2003;28(13):1355-1362.
3. Bronfort G, Haas M, Evans RL, Bouter LM: Efficacy of spinal manipulation and
mobilization for low back pain and neck pain: A systematic review and best evidence
synthesis. Spine J 2004;4(3):335-356.
4. Bronfort G, Haas M, Evans R, Leininger B, Triano J: Effectiveness of manual therapies:
The UK evidence report. Chiropr Osteopat 2010;18:3.
5. Standaert CJ, Friedly J, Erwin MW, et al: Comparative effectiveness of exercise,
acupuncture, and spinal manipulation for low back pain. Spine (Phila Pa 1976)
2011;36(21suppl):S120-S130.
This multistudy analysis compared several interventions for back pain. The studies
indicate that structured exercise and spinal manipulation therapy appear to have
equivalent benefits in pain and functional improvement for those with chronic low back
pain with clinical benefits evident within 8 weeks of care.
6. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW:
Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev
2011;2:CD008112.
This Cochrane review analyzed a large group of studies, eliminating those with
apparent risk of bias, and determined no difference between spinal manipulation and
other nonsurgical care.
7. Chou R, Qaseem A, Snow V, et al; Clinical Efficacy Assessment Subcommittee of the
American College of Physicians; American College of Physicians; American Pain
Society Low Back Pain Guidelines Panel: Diagnosis and treatment of low back pain: A
joint clinical practice guideline from the American College of Physicians and the
American Pain Society. Ann Intern Med 2007;147(7):478-491.
8. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG: Spinal manipulative
therapy for low back pain: A meta-analysis of effectiveness relative to other therapies.
Ann Intern Med 2003;138(11):871-881.
9. Paige NM, Miake-Lye IM, Booth MS, et al: Association of spinal manipulative therapy
with clinical benefit and harm for acute low back pain: Systematic review and metaanalysis. JAMA 2017;317(14):1451-1460.
The effectiveness of spinal manipulative therapy for acute low back pain was reviewed.
Modest improvements in pain and function were reported at up to 6 weeks.
back pain through aggressive spine rehabilitation. J Rehabil Res Dev 1997;34(4):383-
393.
manipulation methods and usual medical care for acute and subacute low back pain: A
randomized clinical trial. Spine (Phila Pa 1976) 2015;40(4):209-217.
In this randomized clinical trial, acute and subacute low back pain were treated with
medical care, muscle energy techniques, or thrust techniques. All treatments resulted in
some improvement, and the thrust techniques provided the best self-reported
improvement in the short term. Level of evidence: II.
nonspecific low back pain result in better long-term outcome? Spine (Phila Pa 1976)
2011;36(18):1427-1437.
This small, single-blinded, placebo-controlled study examined baseline manipulation
versus long-term maintenance treatment. The longer-term treatment was demonstrated
to maintain improvements achieved during initial treatment phase.
patients with chronic mechanical neck pain: A randomized controlled trial. Man Ther
2011;16(2):141-147.
This randomized controlled trial reported on thoracic manipulation in patients with
chronic neck pain with an initial treatment phase and follow-up at 8 weeks and 3 and 6
months. The patients with manipulation had substantially better self-reported
improvement directly after treatment and at follow-up.
systematic review and risk assessment. J Manipulative Physiol Ther 2004;27(3):197-
210.
Williams & Wilkins, 2011.
This text provides a comprehensive description of most aspects of osteopathy.
Wolters Kluwer, 2017.
This text provides a practical hands-on application of the principles of manual medicine
for use in the clinical setting.
Chapter 13
Alternative Medicine and
Spine Care
Chi-Tsai Tang, MD Craig Ziegler, MD
Abstract
Alternative medicine is gaining popularity within mainstream Western
medical practice, and literature supporting various treatments is growing.
Management of low back and neck pain include acupuncture, dry needling,
cupping, chiropractic care, massage therapy, herbal medicines and
supplements, yoga, and tai chi. Acupuncture involves inserting small
needles in specific locations in the body, and dry needling can be viewed as
a westernized form of acupuncture with a limited indication of managing
myofascial pain. Acupuncture has the most evidence supporting it, and can
provide improvements in pain and function immediately postintervention
and potentially for several months in patients with chronic low back pain
and neck disorders. Cupping provides suction to the skin to help increase
blood circulation. Chiropractic care typically involves performing spinal
manipulations using high-velocity, low-amplitude thrusts. Massage therapy
involves manipulation of different layers of muscles and fascia. Several
herbal medicines and supplements may be effective for managing acute or
chronic low back pain. Yoga and tai chi are movement-based treatments
that involve a meditative and breathing component, respectively.
Keywords: acupuncture; chiropractic care; complementary and
alternative medicine; cupping; dry needling; herbal medicine;
supplements; massage therapy; tai chi; yoga
Neither of the following authors nor any immediate family member has received
anything of value from or has stock or stock options held in a commercial company
or institution related directly or indirectly to the subject of this chapter: Dr. Tang
and Dr. Ziegler.
Introduction
Complementary and alternative medicine (CAM) is a therapy that is not fully
accepted in mainstream Western medical practice. Reasons include a lack of
medical literature to support its use and an accepted mechanism of action.
Many treatments that have been historically considered alternative in the
United States are gaining popularity and acceptance. Professional athletes’
use of alternative treatments, the desire for more natural treatments, and a
lack of efficacy from standard mainstream treatments often are reasons for
the use of CAM therapy. The medical literature supporting many alternative
treatments is growing. A recent study showed that patients with lumbar disk
herniations and radiating pain who received CAM therapy had significant
improvements in pain and function. Eighty-seven percent of patients were
highly satisfied or satisfied, and fewer than 10% went on to have surgery at
5-year follow-up.
1
Alternative treatments of the spine can be categorized as (1) bioenergetic
therapies, such as acupuncture or cupping; (2) biomechanical treatments,
such as chiropractic care or massage therapy; (3) supplements and herbal
products; and (4) mind-body therapies, such as yoga, tai chi, or hypnosis.
Although a comprehensive review of alternative treatments is beyond the
scope of this chapter, common treatments with supporting evidence are
reviewed.
Acupuncture
Acupuncture is probably one of the most well-known alternative treatments
in spine care. Treatment involves placing small (typically 30- to 36-gauge)
solid filiform needles in several specific locations on the body. Acupuncture
has its origins in traditional Chinese medicine, in which the ancient Chinese
believed pain was a result of blockages in the flow of qi (life energy) and
stagnation in the flow of blood. The Chinese believed that qi circulated along
meridians, and that qi can be influenced by needling specific acupuncture
points along the body.
Figure 1
Anterior (A) and posterior (B) illustrations depict the major
meridians.
There are 361 different acupuncture points along the body that are
distributed along 12 principal meridians and 8 extraordinary meridians
(Figure 1). The 12 principal meridians are named after traditional Chinese
medicine organs and include the Gallbladder, Heart, Kidney, Large Intestine,
Liver, Lung, Pericardium, Small Intestine, Spleen, Stomach, Urinary Bladder,
and Triple Heater or San Jiao. The San Jiao does not have an analogous organ
in Western medicine, but functions in metabolism and is located in the
thoracic and abdominopelvic cavities. Specific acupuncture points are
designated by the meridian on which they are located and a particular
number. Many of the acupuncture points correlate with motor points of
muscles, are over focal meeting points of superficial nerves, or are located
along intermuscular connective tissue planes.
2,3
Studies of acupuncture points
have found that many of the points have decreased resistance compared with
surrounding tissue and there is less resistance when current is passed between
points on the same meridian compared with control points.
4,5
Studies also
have shown that certain acupuncture points may have a distinct effect distant
from their site. For example, a study showed that electroacupuncture at
Urinary Bladder 67 (an acupuncture point located at the distal tip of the fifth
toe for which one of its classic functions is related to the eyes) caused
increased signal in Brodmann Areas 18 and 19 (areas in the brain empirically
related to ophthalmic disorders) on functional MRI.6 Meridians have not been
found to correlate with any known nervous, vascular, or lymphatic channels;
however, research has linked acupuncture meridians to myofascial pathways.
For example, the Urinary Bladder meridian correlates well with the
myofascial meridian of the posterior line and the myofascial sequence of
retromotion.
7,8
Some of the techniques used in acupuncture, such as needle rotation9 and
leaving the needles in place for a short period of time,10 have been shown to
have significant effects on the fibroblasts in the loose connective tissue,
which can cause the tissues to change shape and expand. In addition to local
tissue effects, acupuncture has been shown to have systemic effects,
including the release of endogenous opioids, which are the body’s own paininhibiting substances. For example, a study showed that needling the Large
Intestine 4 acupuncture point can inhibit tooth pain, but this effect was
nullified when naloxone, an opioid antagonist, was given.11 This result
indicates that acupuncture works in part because of endogenous opioid
mechanisms.
A course of acupuncture will typically consist of a series of treatments
performed once to twice per week for several weeks; more chronic conditions
usually require more treatments. In modern medical acupuncture practice,
there are numerous acupuncture practices and treatment paradigms. Some
practices, such as Baldry and the Japanese style, involve superficial needling
only, and this method is thought to be sufficient in alleviating pain and
deactivating trigger points.12 Other practices, such as Gunn Intramuscular
Stimulation, involve needling into the deep paraspinal muscles and motor
points of muscles. Gunn Intramuscular Stimulation proposes a
radiculoneuropathic myofascial pain model in which silent myofascial lesions
in the deep paraspinal muscles cause compression and dysfunction of the
nerve root, which causes denervation supersensitivity down the myotomal
chain.13 Some treatments involve needling at the site of pain, whereas other
treatments such as auricular acupuncture rely on supposed reflex mechanisms
of action.14 Other acupuncture treatments involve attaching electrical leads to
the acupuncture needles and passing current between the needles; a
commonly used method is called percutaneous electrical nerve stimulation.
15
Patient safety is of the utmost concern when recommending a particular
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