November 2010 Newsletter from Malik Slosberg, DC, MS

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

Sekendiz, B, Cug˘ , M, Korkusuz, F. Effects of Swiss-ball core strength training on strength, endurance, flexibility, and balance in sedentary women. Journal of Strength and Conditioning Research 2010. 24(11): 3032–3040.
Today is November 23 and here are two new studies. They cover two different topics. The first is an exciting interdisciplinary study by a chiropractor, a PhD, and three neurosurgeons. This paper evaluates the efficacy of spinal manipulation versus microdisckectomy for patients who have failed traditional conservative care for an MRI documented symptomatic lumbar disc herniation with radiculopathy. Its findings and conclusions are very positive for side posture manipulation for such patients. The second study looks at an exercise protocol for sedentary women utilizing a Swiss ball. I have included photos from the study of the specific exercises in the right hand column of this update. This paper addresses the issue of dynamic versus static exercise, as well as, isolating activation of the deep stabilizing muscles, the transverse abdominis and multifidus versus activation of both the deep stabilizing muscles and the more global muscles of the core. The study demonstrates the benefits of the coactivation both muscle groups in an exercise training protocol to improve strength, endurance, flexibility, and balance.

McMorland G, DC, Suter E, PhD, Casha S, MD, PhD, FRCSC, du Plessis SJ, MD, Hurlbert RJ, MD, PhD, FRCSC, FACSc. Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study. 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 nonoperative management: analgesics, lifestyle modification, physical therapy, massage, &/or acupuncture. Qualifying patinets 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 patient did not receive benefit from chiropractic care.
Conclusions: 60% of sciatica patients who had failed other medical management benefited from SM to the same degree as if they underwent surgical intervention. Of the 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider a trial of spinal manipulation followed by surgery if warranted.

Commentary: 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. Also of interest is the finding that the 3 patients in the surgical group who failed to respond to surgery did not respond to subsequent chiropractic SM. The one limitation of the study is the small sample size of the study, with only 20 patients in each of the treatment groups. Furthermore, it is encouraging that the 3 neurosurgeons who 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.

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