MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

No 10-year follow-up study of so-called alternative medicine (SCAM) for lumbar intervertebral disc herniation (LDH) has so far been published. Therefore, the authors of this paper performed a prospective 10-year follow-up study on the integrated treatment of LDH in Korea.

One hundred and fifty patients from the baseline study, who initially met the LDH diagnostic criteria with a chief complaint of radiating pain and received integrated treatment, were recruited for this follow-up study. The 10-year follow-up was conducted from February 2018 to March 2018 on pain, disability, satisfaction, quality of life, and changes in a herniated disc, muscles, and fat through magnetic resonance imaging.

Sixty-five patients were included in this follow-up study. Visual analogue scale score for lower back pain and radiating leg pain were maintained at a significantly lower level than the baseline level. Significant improvements in Oswestry disability index and quality of life were consistently present. MRI confirmed that disc herniation size was reduced over the 10-year follow-up. In total, 95.38% of the patients were either “satisfied” or “extremely satisfied” with the treatment outcomes and 89.23% of the patients claimed their condition “improved” or “highly improved” at the 10-year follow-up.

The authors concluded that the reduced pain and improved disability was maintained over 10 years in patients with LDH who were treated with nonsurgical Korean medical treatment 10 years ago. Nonsurgical traditional Korean medical treatment for LDH produced beneficial long-term effects, but future large-scale randomized controlled trials for LDH are needed.

This study and its conclusion beg several questions:

WHAT DID THE SCAM CONSIST OF?

The answer is not  provided in the paper; instead, the authors refer to 3 previous articles where they claim to have published the treatment schedule:

12. Park JJ, Shin J, Choi Y, Youn Y, Lee S, Kwon SR, et al. Integrative package for low back pain with leg pain in Korea: a prospective cohort study. Complement Ther Med. 2010;18(2):78–86. [PubMed[]
13. Shin JS, Lee J, Kim MR, Shin BC, Lee MS, Ha IH. The long-term course of patients undergoing alternative and integrative therapy for lumbar disc herniation: 3-year results of a prospective observational study. BMJ open. 2014;4(9) []
14. Shin JS, Lee J, Lee YJ, Kim MR, Ahn YJ, Park KB, et al. Long-term course of alternative and integrative therapy for lumbar disc herniation and risk factors for surgery: a prospective observational 5-year follow-up study. Spine. 2016;41(16):E955–EE63. [PubMed[]
I could only access the BMJ Open article, and it tells is this:

The treatment package included herbal medicine, acupuncture, bee venom pharmacopuncture and Chuna therapy (Korean spinal manipulation). Treatment was conducted once a week for 24 weeks, except herbal medication which was taken twice daily for 24 weeks; (1) Acupuncture: frequently used acupoints (BL23, BL24, BL25, BL31, BL32, BL33, BL34, BL40, BL60, GB30, GV3 and GV4)10 ,11 and the site of pain were selected and the needles were left in situ for 20 min. Sterilised disposable needles (stainless steel, 0.30×40 mm, Dong Bang Acupuncture Co., Korea) were used; (2) Chuna therapy12 ,13: Chuna is a Korean spinal manipulation that includes high-velocity, low-amplitude thrusts to spinal joints slightly beyond the passive range of motion for spinal mobilisation, and manual force to joints within the passive range; (3) Bee venom pharmacopuncture14: 0.5–1 cc of diluted bee venom solution (saline: bee venom ratio, 1000:1) was injected into 4–5 acupoints around the lumbar spine area to a total amount of 1 cc using disposable injection needles (CPL, 1 cc, 26G×1.5 syringe, Shinchang medical Co., Korea); (4) Herbal medicine was taken twice a day in dry powder (2 g) and water extracted decoction form (120 mL) (Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Peucedanum japonicum, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis and Atractylodes japonica). These herbs were selected from herbs frequently prescribed for LBP (or nerve root pain) treatment in Korean medicine and traditional Chinese medicine,15 and the prescription was further developed through clinical practice at Jaseng Hospital of Korean Medicine.9 In addition, recent investigations report that compounds of C. barometz inhibit osteoclast formation in vitro16 and A. japonica extracts protect osteoblast cells from oxidative stress.17 E. ulmoides has been reported to have osteoclast inhibitive,18 osteoblast-like cell proliferative and bone mineral density enhancing effects.19 Patients were given instructions by their physician at treatment sessions to remain active and continue with daily activities while not aggravating pre-existing symptoms. Also, ample information about the favourable prognosis and encouragement for non-surgical treatment was given.

The traditional Korean spinal manipulations used (‘Chuna therapy’ – the references provided for it do NOT refer to this specific way of manipulation) seemed interesting, I thought. Here is an explanation from an unrelated paper: Image result for chuna therapy

Chuna, which is a traditional manual therapy practiced by Korean medicine doctors, has been applied to various diseases in Korea. Chuna manual therapy (CMT) is a technique that uses the hand, other parts of the doctor’s body or other supplementary devices such as a table to restore the normal function and structure of pathological somatic tissues by mobilization and manipulation. CMT includes various techniques such as thrust, mobilization, distraction of the spine and joints, and soft tissue release. These techniques were developed by combining aspects of Chinese Tuina, chiropratic, and osteopathic medicine.[] It has been actively growing in Korea, academically and clinically, since the establishment of the Chuna Society (the Korean Society of Chuna Manual Medicine for Spine and Nerves, KSCMM) in 1991.[] Recently, Chuna has had its effects nationally recognized and was included in the Korean national health insurance in March 2019.[]

This almost answers the other questions I had. Almost, but not quite. Here are two more:

  • The authors conclude that the SCAM produced beneficial long-term effects. But isn’t it much more likely that the outcomes their uncontrolled observations describe are purely or at least mostly a reflection of the natural history of lumbar disc herniation?
  • If I remember correctly, I learned a long time ago in medical school that spinal manipulation is contraindicated in lumbar disc herniation. If that is so, the results might have been better, if the patients of this study had not received any SCAM at all. In other words, are the results perhaps due to firstly the natural history of the condition and secondly to the detrimental effects of the SCAM the investigators applied?

If I am correct, this would then be the 4th article reporting the findings of a SCAM intervention that aggravated lumbar disc herniation.

 

 

PS

I know that this is a mere hypothesis but it is at least as plausible as the conclusion drawn by the authors.

 

31 Responses to Lumbar disc herniation treated with SCAM: 10-year results of an observational study

  • EE: I learned a long time ago in medical school that spinal manipulation is contraindicated in lumbar disc herniation.

    “Spinal manipulation is an option for symptomatic relief in patients with lumbar disc herniation with radiculopathy.”

    https://www.guidelinecentral.com/guideline/9905/

    See some of the references for papers published since your attendance in medical school. You’re welcome.

    https://usir.salford.ac.uk/id/eprint/56596/1/mejrh-7-1-98983.pdf

    • the opinions on this issue differ very much (https://pubmed.ncbi.nlm.nih.gov/28924697/):
      Purpose: Chiropractic spinal manipulation treatment (SMT) is common for back pain and has been reported to increase the risk for lumbar disc herniation (LDH), but there is no high quality evidence about this. In the absence of good evidence, clinicians can have knowledge and beliefs about the risk. Our purpose was to determine clinicians’ beliefs regarding the risk for acute LDH associated with chiropractic SMT.

      Methods: Using a belief elicitation design, 47 clinicians (16 chiropractors, 15 family physicians and 16 spine surgeons) that treat patients with back pain from primary and tertiary care practices were interviewed. Participants’ elicited incidence estimates of acute LDH among a hypothetical group of patients with acute low back pain treated with and without chiropractic SMT, were used to derive the probability distribution for the relative risk (RR) for acute LDH associated with chiropractic SMT.

      Results: Chiropractors expressed the most optimistic belief (median RR 0.56; IQR 0.39-1.03); family physicians expressed a neutral belief (median RR 0.97; IQR 0.64-1.21); and spine surgeons expressed a slightly more pessimistic belief (median RR 1.07; IQR 0.95-1.29). Clinicians with the most optimistic views believed that chiropractic SMT reduces the incidence of acute LDH by about 60% (median RR 0.42; IQR 0.29-0.53). Those with the most pessimistic views believed that chiropractic SMT increases the incidence of acute LDH by about 30% (median RR 1.29; IQR 1.11-1.59).

      Conclusions: Clinicians’ beliefs about the risk for acute LDH associated with chiropractic SMT varied systematically across professions, in spite of a lack of scientific evidence to inform these beliefs. These probability distributions can serve as prior probabilities in future Bayesian analyses of this relationship.

      • there are numerous documented cases where SMT has CAUSED disc herniation!

        • And there is research that indicates SMT may have helped LDH.

          • I don’t doubt it!
            when there is such a contradiction, it seems wise to me to think of the precautionary principle.

          • “There is little evidence to suggest that drug treatments are effective in treating herniated disc.

            With regard to non-drug treatments, spinal manipulation seems to be more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates.

            We found insufficient evidence judging the effectiveness of automated percutaneous discectomy, laser discectomy, or percutaneous disc decompression.”

            BMJ Clin Evid. 2009; 2009: 1118.

          • do you know the difference between protrusion and herniation?
            obviously not!

          • From the paper:

            “Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space.”

            Also:

            “Disc protrusions are a type of disc herniation characterized by protrusion of disc content beyond the normal confines of the intervertebral disc, over a segment less than 25% of the circumference of the disc.”

            https://radiopaedia.org/articles/disc-protrusion?lang=us

            Maybe you need to go study.

          • after you!
            A herniated disc is one that has ruptured through the annulus, while a protrusion hasn’t.

          • there are three basic types of disc herniation

            contained herniation
            non-contained herniation
            sequestered herniation

            Some add a forth which are:

            disc protrusion
            prolapsed disc
            disc extrusion
            sequestered disc

            where the first two are considered incomplete (contained) and the last two are called complete (non-contained) but they are all classified as a disc herniation.

            You’re welcome

          • ‘DC’ is tediously wrong, as usual.

            Edzard wrote “A herniated disc is one that has ruptured through the annulus, while a protrusion hasn’t.”, which is clearly explained and illustrated by
            HERNIATED DISC The Difference Between Bulging Disc and Herniated Disc, Miami Neuroscience Center at Larkin:
            https://miamineurosciencecenter.com/en/conditions/herniated-disc/

            See also
            Bulging disk vs. herniated disk: What’s the difference?, Randy A. Shelerud, MD, Mayo Clinic:
            https://www.mayoclinic.org/diseases-conditions/herniated-disk/expert-answers/bulging-disk/faq-20058428

            “Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”
            — Björn Geir Leifsson, MD

          • it’s difficult to discuss with a chiro
            it’s impossible to discuss with one who ‘knows’ that he is NEVER wrong.
            DC is no exception; DD was even worse!

          • no response? Maybe some references?

            “Disc herniation is pathologically divided into 4 stages of herniated nucleus pulposus: 1) bulging, 2) protrusion, 3) extrusion, 4) sequestration.” Reumatologia. 2015; 53(4): 186–191.

            “Herniated discs may take the form of protrusion or extrusion, based on the shape of the displaced material.” SPINE Volume 26, Number 5, pp E93–E113

            Gotta run, class is over.

          • wow Pete. I am sharing information from research papers and you are linking to websites geared towards laypeople.

            Another one?

            “…protrusion of the intervertebral disc is collectively referred to as disc herniation…” Orthop Surg. 2015 Feb; 7(1): 1–12.

            perhaps this will help clarify it for you?

            “Herniation is broadly defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space. The disc material may be nucleus, cartilage, fragmented apophyseal bone, annular tissue, or any combination thereof.

            Herniated discs may be classified as protrusion or extrusion, based on the shape of the displaced material.

            Protrusion is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space.” The Spine Journal 14 (2014) 2525–2545.

          • hernias exist in various parts of the body and are defined as follows: “A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.” https://www.nhs.uk/conditions/hernia/

            hernia (n.)
            late 14c., hirnia, from Latin hernia “a rupture,” related to hira “intestine,” from PIE root *ghere- “gut, entrail.” The re-Latinized spelling of the English word is from 17c. Related: Herniated (1819).
            Latin hernia “rupture;”
            https://www.etymonline.com/word/hernia

          • I suppose using the correct name for each spine problem is totally irrelevant when a layperson visits a chiropractic clinic: a quack uses the same theatrics, and same ‘adjustment tools’, whatever the problem.

            Either that, or on Mondays all their marks are treated with to the ‘electric massager’; on Tuesdays to the clickety stick; on Friday to the sharp intake of breath followed by “These herniated discs will require,” (the quack flicks through the mark’s records to assess financial worth) “perhaps, 12 weeks of treatment. Followed by maintenance treatment, to keep your spine healthy.”

            Quack obtains ‘informed consent’ with: “How do you feel about this. Do you have insurance?”

            If you have a health problem, the last person you should consult is a chiropractor
            https://edzardernst.com/2020/04/if-you-have-a-health-problem-the-last-person-you-should-consult-is-a-chiropractor/

          • the NHS “definition” is specific to this:

            “A hernia usually develops between your chest and hips. In many cases, it causes no or very few symptoms, although you may notice a swelling or lump in your tummy (abdomen) or groin.”

            You failed to support your position. I did not. Moving on.

          • SPECIFIC???
            “usually” is the opposite of it!

          • Same old Pete. He can’t stay on topic.

          • Did you even bother to read the NHS page? Or did you just stop at their “definition”? Geesh.

            “The lump can often be pushed back in or disappears when you lie down. Coughing or straining may make the lump appear.”

          • of course, the NHS site deals with the specific type of hernia that people know about.
            what has this to do with the general definition of the term?
            nothing!

          • “Lumbar disc herniation (LDH), defined as displacement of the central nucleus beyond the margins of the annulus fibrosis”
            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176838/

          • Yes based upon their classification system. They listed three types but were only concerned with type 2 and 3 as their focus was on trying to predict surgical success. Type 1, which didn’t meet their measurement requirements as a usual surgical candidate, is what others would consider a contained or a protruded herniation.

            Again:

            “Herniated discs may be classified as protrusion or extrusion, based on the shape of the displaced material.”

            The Spine Journal. REVIEW ARTICLE| VOLUME 14, ISSUE 11, P2525-2545, NOVEMBER 01, 2014

            Lumbar disc nomenclature: version 2.0

            Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology

            You disagree? Take it up with them.

          • @ ‘DC’, You are off-topic, and wrong.

            Is a chiropractor qualified and licenced, to diagnose and treat an actual medical condition, such as a herniated disc?

            No, doing so would be (depending on jurisdiction):
            • practising medicine without a medical licence
            • health fraud
            • medical fraud
            • quackery

            A note for the readers:

            If you are in doubt who to trust, the promoter or the critic of chiropractic, I suggest you ask yourself a simple question: who is more likely to provide impartial information, the chiropractor who makes a living by his trade, or the academic who has researched the subject for the last 30 years?”
            — Chiropractic: Not All That It’s Cracked Up to Be, by Edzard Ernst

          • Interesting

            “Many patients with symptomatic LDH, particularly those with mild or moderate symptoms, will improve with nonsurgical management, which may include manual spinal manipulation, physical therapy, nonsteroidal anti-inflammatory drugs, analgesics, and/or corticosteroid injections.”

            ISASS Policy Guideline – Surgical Treatment of Lumbar Disc Herniation with Radiculopathy December 23, 2019

          • An interesting study:

            Nonsurgical treatment outcomes for surgical candidates with lumbar disc herniation: a comprehensive cohort study

            If these noninvasive treatments were not effective, other nonsurgical treatments, such as manual manipulation, therapeutic massage, and injection-based treatments, were performed for another several weeks1,2

            Although surgery provided faster and better improvement of back and leg pain than nonsurgical treatment at 1 month, the effect of both treatments became the same thereafter for 24 months.

            https://www.nature.com/articles/s41598-021-83471-y

          • Another interesting study

            Results: No significant differences for self-reported pain or improvement were found between the 2 groups. “Improvement” was reported in 76.5% of SMT patients and in 62.7% of the NRI group. Both groups reported significantly reduced NRS scores at 1 month (P = .0001).

            Cynthia K Peterson et al. J Manipulative Physiol Ther. 2013 May

      • Interesting. Same journal, same year.

        “ We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.”

  • “If I remember correctly, I learned a long time ago in medical school” Thats the story of your life. Stopped progressing in the late 20s and a real lot self confidence.

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