January 2010 Newsletter from Malik Slosberg, DC, MS

Study #1: Hondras MA, DC, MPH, et al. 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. JMPT 2009;32(5):330-43.

Study #2: Kulig K, Scheid AR, Beauregard R, et al. Multifidus morphology in persons scheduled for single-level lumbar microdiscectomy. Am J Phys Med Rehabil 2009;88:355-61.


Study #1: Hondras MA, DC, MPH, et al. 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. 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 signif comorbidities. 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 grp had signif improv’ts in mean functional status ranging from 1.3 to 2.2 points over the MCMC group. There were no serious adverse events assoc w any of the Txs.

Conclusions: Ss who received either form of SM were 30% - 40% better in functional status than those in MCMC grp. There were no differences between SM grps 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, Pt preference & clinical experience should drive how DCs & Pts make decisions concerning what SM procedure to use.

Comment: This study demonstrates that in older individuals either high velocity SM (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 SM were 30% - 40% better in functional status than those in MCMC grp. 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. SM contributes significantly to improving functional status.


Study #2: Kulig K, Scheid AR, Beauregard R, et al. Multifidus morphology in persons scheduled for single-level lumbar microdiscectomy. Am J Phys Med Rehabil 2009;88:355-61.

In this study bilateral multifidus (MF) cross-sectional area (CSA) were measured on MRIs of 20 Pts 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 Hx 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.

Comment: 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.