
Hello,
Hello,
If you suffer from tension headaches the most effective course of treatment is taking an over-the counter pain reliever like Acetaminophen (Tylenol), Ibuprofen (Advil or Motrin) and Naproxen sodium (Aleve). Be cautious not to create routine, however, since these medicines aren’t meant for continuous, regular use. Furthermore to ginger tea, peppermint oil are both natural solutions to treat headaches.
If you’re prone headaches, there are a few lifestyle changes you can implement to avoid tension headaches. The prevention of triggers will be your first move. Other than stress, the most the most common triggers are sleepiness and eye strain in the words of Cleveland Clinic. If you’re working on your computer for long periods throughout the day, take brief breaks from the screen multiple times during the day.
As with everything else it is important to be in moderation and balancing everything in your life, including eating, moving and sleeping , is among the most beneficial ways to live your life. Simple things such as cutting down on certain foods can alleviate headaches. Consuming healthy food and snacks in a timely manner and staying hydrated, performing at least one type of activity each day and getting a good night’s sleep is recommended to help with tension headaches. Yoga, meditation and massage therapy may aid in keeping headaches at bay. Cleveland Clinic noted.
While it can be a source of frustration however, they’re not usually associated with grave health implications. It is important to speak with your physician if the pain persists.
What Is
For a long period, the aim was to look nice! Nowadays, we are aware that sports can be a great prevention measure and contributes to a healthy lifestyle. Neck pain can be uncomfortable and it can also impact the mood. Sports can prevent and helps maintain your mood in a healthy way.
Anyone suffering from neck tension or pain and neck pain – and in Germany this is a lot of millions of people, at a minimum temporarily – naturally tends to avoid any movements that are painful due to the tension. Although this may be understandable however, it’s not a good idea. While it alleviates symptoms, it can also increase the pain in the neck.
The most convenient and less painful method to treat neck pain is to treat it with prophylaxis. Simple gymnastic exercises can guarantee the best results when performed often, and you break the rigid position at work or in the car.
Set your fingers on the back of your head , with your fingers interlaced , and then push your head toward your chest. This causes a mild pulling pain that is felt throughout your neck and below the shoulder blades. Maintain this posture for a few minutes before slowly raising your head again. Repeat five to eight times for the workout.
“Soft” or “soft” sports such as endurance running, permit the muscles of the neck and back region to relax and relax. In the same way the muscles are filled with blood and heated up, which helps relieve tension.
Running music can aid in reducing internal stress and, consequently, reduce tension and the possibility of neck pain.
Your run must be comfortable with no effort, and with the “clear mind”. If you experience headaches during the run, it should stop and have a medical professional or fitness trainer consulted. If you are overweight, be aware of how heavy the burden is prior to beginning running regularly.
Aquatic sports activities offer many benefits, not just in the case of neck pain prevention. Due to the increased intensity (compared against air) our muscles are in a sense more strained however at the same time, they are protected. The reason for this is the automatic damping of movements, as fast actions are not possible in water. Furthermore, buoyancy forces ease the joints.
Particularly with the most popular form of swimming the breaststroke, care must be taken to not overextend the cervical vertebrae. This can be achieved by submerging the head in a small amount in the swim. The head is tilted towards the side. People who are able and enjoy crawling or backstroke must be able to prioritize these styles.
Canoeing is the ideal sport to use as a balance sport to working at the PC The rigid chair posture can become one of the causes for neck pain even though you’re in this position.
However, the constant strong, steady movement of the paddle results in muscles of the upper region that include the shoulders, arms back, chest and shoulders and back – being activated equally. While at the same time the calm ride across the water can have a tranquil and soothing result. To improve endurance and fitness it is an absolute godsend.
There aren’t many sports where posture is as vital as it is in dancing. Your body will be stretched, and continuously is held tight.
“You look at your partner while holding your head up high. Carelessness should not be accepted. This kind of body tension is needed, for instance during many strength training exercises or when riding horses, however dancing alone guarantees that you follow the rules.
Also, the neck-friendly strengthening of back and chest muscles is supported by the psychological impact that dancing is enjoyable. To counter this neck pain, it doesn’t stand any chance.
Regular exercise and sports can help in the fight against neck discomfort. Prevention is the most important factor. Being active is generally beneficial however you will only see a change in your lifestyle by being active frequently. This will help eliminate issues that result from neck pain, and help keep you active all over.
We address frequently asked questions regarding neck discomfort below.
Gymnastics, strength training and canoeing are some of the best methods to aid you. Dancing and jogging can help to ease neck pain.
Avoid drafts and get warm to the area affected. The following stretching exercise can aid in reducing pain: stretch your right arm and lower your head down to your left for 10 seconds. Then do the same exercise with your left arm, and lower your head towards on the left side.
Regularly strengthening your muscles is the most effective way to aid you. Include a neck workout in your back workout to help you keep your back from pain and strengthen your muscles.
The
Objective To assess whether percutaneous transforaminal endoscopic discectomy (PTED) is non-inferior to conventional open microdiscectomy in reduction of leg pain caused by lumbar disc herniation.
Design Multicentre randomised controlled trial with non-inferiority design.
Setting Four hospitals in the Netherlands.
Participants 613 patients aged 18-70 years with at least six weeks of radiating leg pain caused by lumbar disc herniation. The trial included a predetermined set of 125 patients receiving PTED who were the learning curve cases performed by surgeons who did not do PTED before the trial.
Interventions PTED (n=179) compared with open microdiscectomy (n=309).
Main outcome measures The primary outcome was self-reported leg pain measured by a 0-100 visual analogue scale at 12 months, assuming a non-inferiority margin of 5.0. Secondary outcomes included complications, reoperations, self-reported functional status as measured with the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery. Outcomes were measured until one year after surgery and were longitudinally analysed according to the intention-to-treat principle. Patients belonging to the PTED learning curve were omitted from the primary analyses.
Results At 12 months, patients who were randomised to PTED had a statistically significantly lower visual analogue scale score for leg pain (median 7.0, interquartile range 1.0-30.0) compared with patients randomised to open microdiscectomy (16.0, 2.0-53.5) (between group difference of 7.1, 95% confidence interval 2.8 to 11.3). Blood loss was less, length of hospital admission was shorter, and timing of postoperative mobilisation was earlier in the PTED group than in the open microdiscectomy group. Secondary patient reported outcomes such as the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery, were similarly in favour of PTED. Within one year, nine (5%) in the PTED group compared with 14 (6%) in the open microdiscectomy group had repeated surgery. Per protocol analysis and sensitivity analyses including the patients of the learning curve resulted in similar outcomes to the primary analysis.
Conclusions PTED was non-inferior to open microdiscectomy in reduction of leg pain. PTED resulted in more favourable results for self-reported leg pain, back pain, functional status, quality of life, and recovery. These differences, however, were small and may not reach clinical relevance. PTED can be considered as an effective alternative to open microdiscectomy in treating sciatica.
Trial registration NCT02602093ClinicalTrials.gov NCT02602093.
With a lifetime prevalence of up to 43%, sciatica is a common health problem in the general population.1 Sciatica is typically characterised by radiating leg pain starting from the low back, at times accompanied by sensory or motor deficits, and most frequently caused by lumbar disc herniation.23 Sciatica has a favourable natural course in most people; however, surgery may be indicated when conservative treatment fails or progressive neurological deficits develop.4 Previous studies have shown the short term benefits of surgery for pain relief, function, and perceived recovery, with similar long term outcomes to prolonged conservative management for people with sciatica lasting from six to 12 weeks. Recent studies showed that surgery led to a greater reduction in leg pain on long term follow-up compared with conservative management for sciatica lasting from four to 12 months.56
Following publication of initial reports on surgery for lumbar disc herniation in 1934, attempts were made to reduce the surgical invasiveness of this procedure.78 These modifications have led to conventional transflaval open microdiscectomy becoming the standard procedure for treating lumbar disc herniation.910 Owing to the development of surgical endoscopes and their application to the lateral transforaminal “safe” entry zone as described by Kambin and Brager, other surgical techniques were developed with the intention to be less invasive.1112 Percutaneous transforaminal endoscopic discectomy (PTED) is one of these proposed less invasive techniques. PTED is expected to lead to less postoperative back pain, shorter hospital admission, and a faster recovery because paraspinal muscles are not detached from their insertion, bony anatomy is not changed, and general anaesthesia is not used.13 Some concerns exist, however, in the scientific literature about the effectiveness for leg pain and recovery of function after PTED compared with open microdiscectomy, and previously published studies may have been influenced by commercial enterprises.14151617 Furthermore, as PTED has a learning curve and exposes surgeons and patients to a higher radiation dose, these concerns need to be overcome with high quality evidence before PTED can be widely implemented.17181920
Previous studies that have compared PTED with open microdiscectomy found either no differences in outcomes or small differences of uncertain clinical relevance.141516172122 However, these studies were of small sample size, were not randomised, or involved only one surgeon.1415162122 Therefore, a randomised controlled trial with adequate sample size and low risk of bias is warranted. Advantages adherent to minimally invasive surgery are claimed for PTED, such as less postoperative back pain and shorter hospital admission, so we hypothesised that PTED should not be worse than open microdiscectomy in treating leg pain to be offered as a treatment alternative. Therefore, the aim of the PTED-study was to investigate whether the effect of PTED was non-inferior to conventional open microdiscectomy in terms of reduction in leg pain in patients having surgery for sciatica caused by lumbar disc herniation.
This multicentre, non-inferiority randomised controlled trial was conducted at four general hospitals in the Netherlands in patients with sciatica caused by lumbar disc herniation. Details of the protocol and study design have been published previously.23 The study was funded by ZonMw, the Netherlands Organisation for Health Research and Development, without involvement of the medical technology industry. The research protocol was approved by the research ethics board of all participating hospitals and registered at ClinicalTrials.gov (NCT02602093). All patients provided written informed consent before enrolment.
From February 2016 to April 2019, neurosurgeons and orthopaedic surgeons screened and enrolled patients with sciatica during outpatient clinic visits. Patients were eligible for the PTED-study if they had an indication for surgery according to Dutch consensus, which means that patients should have at least six weeks of excessive radiating leg pain with no tendency for any clinical improvement despite conservative therapy. Aside from leg pain, patients could be included with or without motor or sensory loss, as is part of daily practice. Furthermore, patients should be between 18 and 70 years of age; have a nerve root compression by a lumbar disc herniation proven by magnetic resonance imaging, corresponding to the clinical dermatomal area; and have sufficient knowledge of the Dutch language to complete forms and follow instructions independently. Exclusion criteria were previous surgery at the same or adjacent disc level; cauda equina syndrome; isthmic or degenerative spondylolisthesis; pregnancy; severe comorbid medical or psychiatric disorder (American Society of Anesthesiologists’ classification >2); severe caudal or cranial sequestration of disc fragments, defined as sequestration towards more than half of the adjacent vertebra; contraindication for surgery, and moving abroad on short notice.
We randomised patients in a one to one ratio to PTED or open microdiscectomy by using computer generated variable block sizes (four, six, or eight), stratified by enrolling centre. Blinding of patients was not feasible because of the substantial differences between the two procedures (for example, PTED being performed under conscious sedation and having an 8 mm incision 8-12 cm lateral of the spine midline and open microdiscectomy being performed under general anaesthesia with a 2-4 cm dorsal incision in the spine midline). Both surgical techniques were presented to patients as equal in effectiveness during enrolment.
All surgeons were spine dedicated with eight to 11 years of experience in degenerative lumbar spine surgery. One of the primary reasons for conducting this study was the opinion that PTED did not meet scientific criteria inherent in reimbursement within the Dutch public healthcare system.24 Therefore, PTED was temporarily reimbursed by insurance companies on the condition that patients were enrolled in the PTED-study. Furthermore, only one of the participating surgeons was proficient in doing PTED in the Netherlands; therefore, three surgeons (one per hospital) were trained to do PTED. Each surgeon attended an accredited postgraduate hands-on workshop and did 10-15 procedures under the supervision of a senior surgeon with ample experience in PTED. After these supervised procedures, the surgeons did PTED independently. Their first 50 cases (including the supervised cases) would be deemed learning curve cases.
The full procedure has been described previously.13 Local anaesthesia was administered, and surgery was performed under conscious sedation. The site was verified by fluoroscopy, after which a line was drawn from the centre of the herniation. The needle was placed, and the position was checked. After the needle had reached the correct position, a guidewire was inserted. After that, a series of conical rods were introduced, and subsequently a drill was introduced through the cannula. By drilling, the neuroforamen was enlarged. Hereafter, the instruments were removed with the guidewire remaining in place. Then, the endoscope with the working channels was introduced via the cannula. Following removal of the loose disc fragments, the cannula and endoscope were removed. Patients were treated on an outpatient basis.
Open microdiscectomy was conducted under general anaesthesia.9 The disc level was verified using fluoroscopy, and a paramedian incision was made. The use of loupes or a microscope was optional. After identification of the lamina, the yellow ligament was removed to identify the nerve root and disc herniation. The amount of degenerative disc material removed was at the discretion of the surgeon. Laminotomy, as well as foraminotomy, was done if necessary. A partial medial facetectomy was used for the foraminal herniated disc, and an approach alongside the facet joints was used for the extraforaminal herniated disc. The patient was discharged as soon as medically responsible, which is usually one day after surgery.
Patients in both groups were discharged as soon as medically responsible. Pain medication was offered to all patients if necessary and included paracetamol and optionally non-steroidal anti-inflammatory drugs, short acting opioids, or both. We used questionnaires to monitor the use of pain medication and of co-interventions.
The primary outcome was the improvement in leg pain at one year, as measured with a visual analogue scale ranging from 0 to 100 with higher scores indicating more leg pain.2526 We chose the visual analogue scale for leg pain as the primary outcome because the goal of surgery is to reduce leg pain, so PTED should be non-inferior in reduction of leg pain to be considered as a treatment alternative to open microdiscectomy. The visual analogue scale for leg pain was measured at baseline; one day; two, four, and six weeks; and three, six, nine, and 12 months postoperatively. Secondary outcomes were functional status as measured with the Oswestry Disability Index (ranging from 0 to 100, with higher scores indicating more disability)27; visual analogue scale for back pain (ranging from 0 to 100, with higher scores indicating more back pain)26; visual analogue scale for quality of life (ranging from 0 to 100, with higher scores indicating a higher quality of life)28; the physical component summary and mental component summary of the short form 36 (SF-36),2930 with higher scores indicating better perceived health; and seven point Likert-type scales measuring self-perceived recovery from symptoms, recovery from leg pain, satisfaction with treatment, and change in symptoms.2829313233 We defined recovery and satisfaction by combining “complete” and “nearly complete” recovery or satisfaction. We added an 11 point numerical rating scale for leg pain, back pain, and quality of life for internal validation of the study results in a protocol amendment.34 All secondary outcome measures were assessed at the same time points as the primary outcome except for one day postoperatively, when only functional disability, quality of life, back pain, self-perceived recovery, and satisfaction were measured. Questionnaires were sent to patients by email or regular mail. At six weeks, three months, and 12 months after surgery, patients visited the clinic for a neurological examination by a research nurse who was aware of the treatment allocation. In addition to the patient reported outcome measures, data on the surgical procedure, complications, discharge, and reoperations were collected. Supplementary table A gives an overview of all outcomes measured in the PTED-study.
The expected mean difference between the groups in visual analogue scale for leg pain was 5 with a standard deviation of 14.9.35 With a margin of non-inferiority set at 5.0 (expected difference), a one sided α of 0.05, and a β of 0.10, we estimated that a sample size of 306 patients would show non-inferiority with 90% power. Considering an attrition rate of 20%, we set the sample size at 382. We planned to recruit an additional 150 patients (50 per surgeon) for the learning curve in the PTED arm. We based this decision to include 50 learning curve cases per surgeon on the literature and consensus of the research group.1836 We excluded these learning curve cases from the primary analyses. In total, we included an additional 300 patients (150 randomised to PTED as learning curve cases and 150 randomised to open microdiscectomy) above the sample size calculation because reimbursement of PTED was dependent on participation in the trial. Thus, the goal was to recruit 682 participants.
We did the primary analyses according to the intention-to-treat principle. We did per protocol analyses as sensitivity analyses, including only patients who received the intervention to which they were randomised. Furthermore, we did sensitivity analyses including the learning curve patients and sensitivity analyses using the numerical rating scale to test the robustness and validity of the results. We presented baseline characteristics by using percentages for categorical variables and means and standard deviations or medians and interquartile ranges, when appropriate, for continuous variables. We used mixed model analyses with random intercepts on the patient level to account for dependency of measurements over time within patients. We used linear mixed models to analyse leg pain, functional disability, back pain, quality of life, physical component summary, and mental component summary. We used logistic mixed models to analyse the dichotomised Likert-type scales. In addition to the adjusted models in which we corrected for the baseline score and centre, fully adjusted models for the primary analyses are shown in the supplementary material. Fully adjusted models included adjustment for factors such as the baseline score, centre, age, sex, duration of complaints, smoking status, body mass index, employment status, site of disc protrusion, treatment preference of the patient, and psychopathology as measured on the four dimensional symptom questionnaire.3738 Finally, we added a linear and logistic regression analysis adjusting for baseline and hospital for the outcomes at 12 months as an alternative analysis. Mean differences and odds ratios are presented with their 95% confidence intervals. We estimated confidence intervals from linear mixed model analyses by using 1000 bootstrap samples according to the bias accelerated procedure to take into account skewness of residuals. We used SPSS version 27.0 for all analyses.
As follow-up data were collected using electronic questionnaires, all patients who had data available had complete data available at that follow-up point. We handled data missing owing to missed visits or patients’ withdrawal from the study at follow-up time points by mixed model analysis using the maximum likelihood estimation.
Some amendments were made to the study protocol after enrolment started but before the study was completed. One was the inclusion of an 11 point numerical rating scale for the outcomes that were measured by a visual analogue scale—leg pain, back pain, and quality of life. The reason for this was that some concerns were raised about the validity of the visual analogue scale, as its length may differ while using different electronic devices (for example, smartphone, tablet, or laptop) and we had not standardised the use of one of these devices. We therefore added the numerical rating scale for leg pain as the primary outcome. However, because we expected results of the visual analogue scale and numerical rating scale to be similar, we reinstated the visual analogue scale as the primary outcome. For reasons of transparency, we also report the results for the numerical rating scale on the primary outcome, leg pain, as a sensitivity analysis. Secondly, we increased the enrolment period of the trial by one year. Before the trial started, we had planned to recruit patients during a two year period. Because the enrolment was slower than anticipated, we increased the enrolment period to three years. Finally, we increased the follow-up period of the included patients to also include 24 month and 60 month measurements.
Before the start of the PTED-study, members of the patients’ organisation “de Wervelkolom” (“the Spine”) were involved in the study design. Furthermore, this organisation was also part of the half yearly board meetings during which recruitment, implementation, and results of the study were discussed. The general public was not involved with the study.
In the period between February 2016 and April 2019, 711 patients were assessed for eligibility, of whom 613 patients were enrolled into the PTED-study (fig 1). The baseline characteristics of the patients were similar in both groups (table 1). The trial was finalised before the estimated sample size of 682 participants was reached, because the end of the enrolment period of the study was reached. Of the 304 patients randomised to PTED, 286 (94%) received the intervention; of the 309 patients randomised to open microdiscectomy, 244 (79%) had microdiscectomy as assigned; 10 of these were tube assisted. At 12 months of follow-up, the primary outcome was available for 532 (87%) of the randomised patients.
Flowchart of study eligibility, enrolment, procedures, and outcomes. LHD=lumbar disc herniation;PTED=percutaneous transforaminal endoscopic discectomy
Characteristics of participants. Values are numbers (percentages) unless stated otherwise
The estimated learning curve of 150 learning curve cases was not reached. Of the 304 patients randomised to the PTED group, 125 were learning curve cases (supplementary table B). During the learning curve, the PTED procedure was converted to open microdiscectomy in four patients (supplementary table C). Four complications occurred, and 14 (11%) patients had repeated surgery within one year because of recurrent disc herniation. All patient reported outcome measures showed significant improvement after 12 months (supplementary table C) compared with baseline.
The median visual analogue scale for leg pain showed a similar improvement in leg pain in both groups following surgery (fig 2). In the first three months, mean differences in reduction of leg pain between the groups were small (table 2; supplementary table D). At six, nine, and 12 months, mean differences in favour of PTED increased. At 12 months’ follow-up, the mean between group difference in leg pain was 7.1 (95% confidence interval 2.8 to 11.3) in favour of PTED. This between group difference indicates that PTED was non-inferior, because the between group difference in leg pain was not worse than 5.0 at 12 months for PTED compared with open microdiscectomy.
Median scores on visual analogue scale for leg pain, Oswestry Disability Index, visual analogue scale for back pain, visual analogue scale for quality of life, SF-36 physical component summary, and SF-36 mental component summary. PTED=percutaneous transforaminal endoscopic discectomy
Primary and secondary outcomes according to treatment and timing of treatment after surgery
In general, mean differences in secondary outcomes between both groups were small in the first three months and increased in favour of PTED at six, nine, and 12 months (fig 2; table 2). At 12 months, the median score on the Oswestry Disability Index was 10.0 (interquartile range 2.0-17.8) in the PTED group and 12.7 (2.2-28.4) in the open microdiscectomy group (mean difference of 5.3, 3.0 to 7.7). At 12 months, back pain intensity was 16.0 (interquartile range 3.0-38.8) in the PTED group compared with 21.0 (5.0-55.0) in the open microdiscectomy group (mean difference 6.0, 2.0 to 10.0). Furthermore, at 12 months the median visual analogue scale score for quality of life was 76.5 (interquartile range 61.8-86.8) in the PTED group compared with 70.5 (54.3-83.0) in the open microdiscectomy group (mean difference of −6.2, −9.2 to −3.2). The mean differences for the SF-36 physical component summary and mental component summary at 12 months were in the same direction as the other secondary outcomes: −2.8 (−4.1 to −1.6) and −2.1 (−3.4 to −0.9), respectively. At 12 months, the odds ratio for recovery of symptoms was 2.7 (95% confidence interval 1.4 to 5.2), and the odds ratio for recovery of leg pain was 2.0 (1.0 to 3.7). Furthermore, the odds ratio for satisfaction with change in symptoms and satisfaction with the result of treatment were 2.6 (1.4 to 4.8) and 2.6 (1.3 to 5.0), respectively.
Both procedures were of similar duration, but less perioperative blood loss occurred in the PTED group (table 3). Eight (3%) dural tears and three (1%) wound infections were reported in the open microdiscectomy group compared with none in the PTED group. One (0.4%) nerve root injury and one (0.4%) deep vein thrombosis occurred in the open microdiscectomy group. Of the patients in the PTED group, 94% could be discharged on the day of surgery compared with 6% in the open microdiscectomy group. Measured at six weeks, the mean length of the scar was 11.7 (SD 9.2) mm in the PTED group and 38.4 (15.0) mm in the open microdiscectomy group. The rate of repeated surgery within one year was 5.3% in the PTED group compared with 5.6% in the open microdiscectomy group. At two weeks and six months of follow-up, the use of non-opioid analgesics seemed to be similar between both groups, whereas patients in the PTED group seemed to use fewer non-opioid analgesics at 12 months than did patients in the open microdiscectomy group. Furthermore, patients from the PTED group used fewer opioid analgesics than did patients from the open microdiscectomy group at two weeks, six months, and 12 months of follow-up.
Surgical outcomes and complications of patients who had surgery, according to intention-to-treat analysis. Values are numbers (percentages) unless stated otherwise
Figure 3 gives an overview of all analyses conducted for the primary outcome. In general, all alternative analyses did not significantly affect the main results. The results of the alternative analyses using linear regression shows a between group difference of 7.9 (1.8 to 13.4) in favour of PTED on the visual analogue scale for leg pain at 12 months (supplementary table E). The per protocol analysis included 168 patients who had PTED and 244 patients who had open microdiscectomy (supplementary tables F and G). At 12 months, the mean between group difference in improvement of leg pain for PTED compared with open microdiscectomy was 8.3 (4.1 to 12.8). Secondary outcomes were also comparable to the results according to the intention-to-treat analysis. In addition, we did sensitivity analyses including the 125 learning curve cases of all three surgeons who did not do PTED before the study. These analyses resulted in comparable outcomes to the primary analysis (supplementary table H). Finally, when we re-ran the analyses using the numerical rating scale instead of the visual analogue scale for leg pain, back pain, and quality of life (supplementary table I), we found similar results to those with the visual analogue scale. The numerical rating scale for leg pain showed a mean between group difference of 0.6 (0.2 to 1.1) at 12 months in favour of PTED.
Results of primary outcome for main and alternative analyses. Mean difference between groups is shown on visual analogue scale (VAS) for leg pain at 12 months, together with 95% confidence interval (CI). Modified intention-to-treat population included all patients randomised to percutaneous transforaminal endoscopic discectomy (PTED) or open microdiscectomy (OM) without learning curve cases. Per protocol population included all patients randomised to PTED or OM who received allocated treatment. Learning curve cases were also omitted for these analyses. Results of modified intention-to-treat population are also presented including learning curve cases. Crude analyses were adjusted for baseline and centre. Fully adjusted analysis included adjustment for baseline score, centre, age, sex, duration of complaints, smoking status, body mass index, employment status, site of disc protrusion, treatment preference of patient, and psychopathology as measured on four dimensional symptom questionnaire
In this multicentre trial among patients with sciatica caused by lumbar disc herniation, we found PTED to be non-inferior to open microdiscectomy in reduction of leg pain at 12 months. Mean differences in leg pain reduction between the groups were small in the first three months, but they increased in favour of PTED at six, nine, and 12 months. Different hypotheses can be formulated to explain this difference. An explanation may be that three months after surgery the formation of scar tissue may limit the patients in the open microdiscectomy group more than those in the PTED group, as a less invasive surgical route was used to access the disc herniation. Eventually at 12 months, patients in the PTED group experienced a larger reduction in leg pain than did patients in the open microdiscectomy group, which is a larger difference than expected and clearly within the non-inferiority margin. One can argue as to whether this difference of 7.1 on a 0-100 visual analogue scale would be clinically relevant, as it is below commonly recognised minimally clinically important difference thresholds.3940 Similarly, the secondary patient reported outcomes showed more favourable results for the patients in PTED group—namely, in functional disability, back pain, quality of life, and self-perceived recovery. These effect sizes, however, were small and may also not reach clinical relevance.40 Further results show that the rate of repeated surgery within one year due to sciatica was similar. Analysis of the learning curve cases showed that PTED can safely be adopted by surgeons in different centres under initial supervision of a surgeon proficient in PTED.
A recently published meta-analysis compared PTED with open microdiscectomy in the treatment of sciatica.17 This meta-analysis included 14 prospective studies, of which nine were (quasi)randomised, and eventually concluded that moderate quality evidence existed for no difference in leg pain reduction or functional status at long term follow-up. The results of our study are in line with these findings. Most of the studies in the meta-analysis did not have an adequate randomisation procedure. Three of the identified studies in the meta-analysis had a low risk of selection bias but had some form of attrition or reporting bias.162241 These studies, however, were either underpowered to detect small differences between groups or were conducted by a single surgeon or in single centre. Furthermore, these studies did not show the feasibility of implementing PTED among surgeons naïve to the procedure.
Some limitations have to be acknowledged. Firstly, participation bias cannot be ruled out because a proportion of patients with a strong preference for PTED who were randomised to open microdiscectomy dropped out of the study immediately. Secondly, blinding of patients was not possible owing to the substantial differences between PTED and open microdiscectomy. Thirdly, the pre-estimated sample size of 682 patients was not reached. Of the 382 patients calculated as being necessary in the final sample size of the trial (that is, excluding learning curve cases), we were able to include 179 instead of 191 of the patients who would have PTED. However, the sensitivity analysis including the learning curve patients (n=613) confirms the robustness of our findings. Another concern that was raised during the trial related to the validity of the visual analogue scale when used on different electronic devices, as its length may vary. Therefore, during the trial, we added the numerical rating scale as an updated primary outcome instead of the visual analogue scale. However, after looking at the visual analogue scale on different devices, we found that the visual analogue scale always remained as a scale from 0 to 100, no matter the length of the scale on the device. Therefore, we decided, during the trial, to keep the visual analogue scale as the primary outcome and to analyse the numerical rating scale as a sensitivity analysis. Our main analysis shows a between group difference of 7.1 on the 0-100 visual analogue scale for leg pain, which is comparable to the between group difference of 0.6 on the 0-10 numerical rating scale for leg pain. Another point of discussion could be the use of mixed models for our primary analysis. Mixed model analyses adjust the primary outcome at 12 months for leg pain measured at earlier time points and may lead to a subtly different outcome than our defined primary outcome of improvement in leg pain at 12 months. Both methods of analysing the data (linear regression and mixed model) suggest similar outcomes (fig 3; supplementary table E) and support the conclusion that PTED is non-inferior to open microdiscectomy in leg pain reduction.
Strengths of this study include the multicentre, randomised design and the inclusion of learning curve cases in the sample size. An additional strength is the generalisability. We chose the study’s inclusion and exclusion criteria to reflect current neurosurgical practice for sciatica. This is also underlined by the proportion of patients that were enrolled after screening. Another strength is the signed agreement on the non-inferiority margin by the research group, patients’ organisation, professional organisations and the Dutch Health Care Institute, before the trial started. Furthermore, clinical outcomes, complications, and adverse events were structurally documented between short time intervals.
Before this study, PTED was not reimbursed by various insurance companies because of the lack of evidence on the benefits of PTED compared with open microdiscectomy in the treatment of sciatica. The results of the study show that PTED is non-inferior to open microdiscectomy in the treatment of leg pain but also that no meaningful clinical differences in patient reported outcomes exist between the procedures. Therefore, future decisions on doing lumbar discectomy should consider patients’ preferences for a treatment, the burden of the treatment to the patient, and the costs of the treatment. Aside from the lack of clinically relevant differences between the procedures, PTED comes with advantages of facilitating outpatient surgery, less estimated blood loss, a low complication rate, lower use of opioids, and a smaller scar, as well as a comparable rate of repeated surgery within one year. Furthermore, 81% of the patients included preferred PTED, indicating the popularity of this procedure among patients. PTED, however, has a learning curve with a higher rate of repeated surgery within one year, more exposure to perioperative radiation, and possibly greater costs.171920 Whether the small differences in clinical outcomes and the advantages of PTED will outweigh the potential higher costs of the procedure remains open for debate. To answer these remaining questions, an economic evaluation has been conducted alongside the PTED study and is being published separately.42 As a result of this study, the Dutch government now reimburses PTED and patients are able to have PTED outside of the experimental setting. This reimbursement also comes with the need for an implementation plan to ensure that the PTED technique is performed by surgeons who have received proper training.
PTED was non-inferior to open microdiscectomy in reduction of leg pain. PTED resulted in more favourable results for patients’ self-reported leg pain, back pain, functional status, quality of life, and recovery. These differences, however, were small and may not reach clinical relevance. PTED can be considered as an effective alternative to open microdiscectomy in treating sciatica.
We gratefully acknowledge the support of the Dutch Health Insurance Board; ZonMw, the Netherlands Organisation for Health Research and Development; the participating patients; the patients’ organisation de Wervelkolom (nvvr); Pieter J Schutte (Alrijne Hospital) and Arnold Vreeling (Rijnstate Hospital) as study surgeons; and the research nurses Esther Willemsen, Steffi van Beek, Chantal Ritskes, Monique Stuit (Park MC), Paula van Limpt (Elisabeth-TweeSteden Hospital), Moniek Vroemen, Annemiek Hol (Rijnstate Hospital), and Marjon Nuijten (LUMC, Alrijne Hospital).
BATON ROUGE, La. (WAFB) The following Thursday, March 10 , the task force of the Comite River Diversion Canal was hoping to hear about an agreement had been made by Florida Gas and our federal partners to speed up the process.
“We were hoping for today, but I’m extremely disappointed and angry because they’ve been saying for at least six weeks that on the date of their taskforce, they’re going to be able to give us good news, and they’ll be able to provide positive news, but the next day they have no news…that’s absurd,” said Rep. Valarie Hodges (R).
As the chairperson of the taskforce and also a victim of the floods of 2016 Hodges is a victim of the 2016 flood herself. Hodges has reached her exhausted by the slowness with which the process has been.
“We were told in December the project would be completed and now we’re considering the possibility of extending it to a whole year. It’s a real shock,” Rep. Hodges continued.
The idea of a diversion channel in the Comite River have been around since the 80’s , after Baton Rouge was dealt a severe blow. Discussions were revived after the 2016 flood. Many are concerned is that one more catastrophic weather event could render regions along the river in a position of being unable to rebuild. The contract has not been signed, but the parties haven’t even begun negotiations. There is no start or deadline for finishing has been decided.
“We do not know which is the issue. Negotiations that the state is currently in progress via DOTD together with Florida Gas, those negotiations will give us the rigor that we require to truly control our construction timeline,” said Col. Stephen Murphy with the U.S. Army Corps of Engineers.
Rep. Hodges tells WAFB that from now until the next task force’s meeting she will press on the Army Corps, DOTD, and other agencies to move the ball forward. No date has been established for the next task force meeting at this time.
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A longer life is a goal that spans all ages. Mankind has always had a desire to attain longer life span. People are willing to spend money on items and services which promise a improvement in their lives on this planet.
Researchers have long studied potential ways to extend life. There have been books written. Seminars have been held. Conferences have been held. Everyone wants to know how to live living longer.
Are you also seeking to add additional years of health into your daily routine? Let me share some exciting information for you! The information isn’t actually a secret but it’s more like an affirmation of something that’s been widely known for some time.
The truth is that Exercises that strengthen your body are linked with a lower chance of dying due to any cause. In addition, to give you an additional benefit that the benefits are more effective when exercises to build strength are paired with aerobic exercise.
I’ve noticed that every time I write about or discuss longevity, one audience who squeaks their ears most quickly is those who are over 50. Most people over 50 have accepted the reality that they are in fact mortal and is bound to be an end to their lives. As we enter our 40s, many people still cling to the notion of eternal immortality. When we reach 50, we’ve started to recognize that the second part of our lives is beginning.
It is also when the majority of people start paying attention to stories like this one. Themes like the topic of the idea of living longer catch our attention.
In the end, the research studies that resulted in the conclusion that exercises to strengthen your body reduce the chance of dying from any reasons have proven that this is the case for people who are old. Also it’s probably no longer too early for the majority of people to benefit by engaging in exercises to strengthen their muscles.
One of the first thoughts that came to mind when I was researching this topic to write this column, “How much exercise do individuals really require to experience benefits.” The answer to this question is yet to be found, but recent studies have shown benefits by having only two sessions per week that last between 15 and 30 minutes. If you invest of 30-60 minutes a week of exercises to strengthen your body, you could expect to see a significant increase in your chance of long-term health.
The following issue was “How intense does the exercise require?” In general terms all exercises that work the muscles with a sufficient amount of resistance is beneficial. Certain studies have concentrated on specific kinds of resistance exercises, and others have utilized free weights and body weight exercises like lunges, push-ups, and squats. Others have utilized elastic resistance exercise bands.
If you’re not very active, but want to begin an exercise routine that includes strengthening exercises as beneficial to consult an instructor. A coach who is familiar with this kind of exercise, and who is trained to assist and educate others is extremely beneficial. This will help you get started safely and help you save time trying to master the fundamentals. This can also help prevent the development of bad habits and decrease your chance of getting injured.
Studies also revealed that the long-term benefit of exercising is increased by adding aerobic exercises. Aerobics is any type of exercise which could cause you to breath a bit more difficult than normal. It could involve running, walking or jogging at a fast pace and swimming, or dancing.
It is crucial to be cautious and shrewd in the beginning of something similar to this. If one feels tired due to the recliner, an appointment with the primary health care professional is recommended prior to commencing any exercise program.
It is also recommended to avoid any urge to be overly enthusiastic regarding the beginning of your activities. Ideally, you must be able to keep up with any activity you begin. Concentrate on forming the habit, planning your time, and creating the routine, rather than trying to do too much in the beginning. Making a habit of progressively doing the same thing without resistance can be useful. It is possible to increase the more intensity later on.
Research has also proven that these types of exercises may not just result in a longer lifespan but also improve overall health and happiness in the years to come. Being physically active helps keep you in control and improve your abilities.
Dr. Mark Kestner is a licensed chiropractor and acupuncturist with more than 30 years of experience focusing mostly on treating complicated and chronic spine, neurological and joint conditions in Murfreesboro. His office is located at 1435 NW Broad St. Contact him at [email protected].
The Sciatic nerve , that is often reduced to a medical condition known as Sciatica and is associated with leg pain and numbness that is not as strong or noticeable that starts from the back of the lower part region and gradually moves to the buttock area and then toward the rear in the leg. The majority of the time, sciatica is believed to affect just one part of the lower part of the body, with pain that extends through the back of your lower thigh to the rear of the thigh, and then down to the rear to the back of your leg. The pain may continue to extend into the foot or toes based on the location the location where the sciatic nerve has been affected, and thus differ between one person and the next.
It is characterized by multiple symptoms Some patients complain of extreme and uncontrollable pain, others share their experiences of it as irritating and infrequent. The pains, however, are believed to get worse in the future . Therefore, we advise caution and exercise accordingly.
In the same way as the effects of the discomfort on different people and their symptoms, specific symptoms of sciatica differ in their type as well as their location and intensity, according to the condition causing the sciatica. Patients can also experience pins and needles that feel within the same area. While the permanent damage to sciatic nerves (tissue injury) is a uncommon condition however, when it does happen, it’s usually irreparable.
So, if you experience weakening in the lower part of the body and numbness or pain within the upper legs and/or loss of control over the bowel or bladder It is suggested to seek medical attention immediately before the condition gets worse becomes worse.
The symptoms of sciatica
The most frequent symptoms of Sciaticaare
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There may be a constant discomfort on one side of your howevertocks or the leg (rarely will it occur in all legs).
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The pain tends to get worse when standing or while coughing/sneezing.
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There may be numbness, weakness, or even difficulty in getting the foot or leg.
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Experience burning or tingling sensations in the lower leg.
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It is also possible to feel the sharp pain which causes it to be difficult to stand or walk.
The causes of Sciatica
Sciatica is usually caused by irritation to it’s root(s) in the lower lumbar spine and the lumbosacral spinal. The most common cause for this is a herniated or prolapsed disc within the vertebrae (often known as”sipped disc). Other causes of sciatica include :
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Lumbar spinal Stenosis.
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The degenerative disc condition.
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Spondylolisthesis.
If you are expecting or obese, or wear high heels or rest on a soft mattress, you’re more likely to experience sciatica-related pain.
Treatment for Sciatica
If you’ve got an injured disk, it doesn’t mean that you’ll require surgery. There are several instances in which the symptoms have improved over time. In fact 90% of people suffering from sciatica don’t require surgery.
Most often, it’s the combination of preventive measures along with medicines and controlled exercises that aid in treating the discomfort. Find our how to cure sciatica for good
Precautions
Patients should avoid abrupt or extreme motions in the lower back in order to avoid further aggravation of pain. For example, kneeling, squatting, stretching to the waist or hips, and lifting large weights (or even lifting light weights improperly) must be avoided.
Physical therapy and exercise
Doctors typically prescribe a precise, controlled, and gradual exercise regimen. This is because, regardless of how absurd it might sound, exercise works quite well for people suffering from sciatica as opposed against bed rest. You may also be able to rest for a week or two after your pain is getting worse and then after some time inactivity, the pain will go away and it’s in the opposite direction. These exercises serve two functions:
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They ease discomfort of sciatica in the short long
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They aid in conditioning and can help prevent future recurrences the discomfort.
Without a routine of exercise the back muscles and spinal structures get weaker and are less in a position to support the back. This may cause back injuries and strain that can cause more discomfort. The body’s movements aid in the transfer of fluids and nutrients within the discs , and help maintain their health and prevent any stress to the nerve that runs through sciatica.
Many patients have experienced relief using an endoscopic or endoportal decompression that is a 30-minute procedure which requires less than 24 hrs hospitalization.
The procedure involves a smaller than one centimetre long cut where the surgeon took out the portion that puts tension on nerves in cases of a slipped disc and spinal stenosis.
Surgery could be the last option for people suffering from sciatica pain, however, your doctor will make sure that he’s tried and tried every option before deciding to go for surgery. In light of the irreparable nature of the damage to nerves caused by inexperienced handling of the issue or self-medication. It is recommended that you consult an orthopedic surgeon, a neurosurgeon or a spine surgeon when you are in the earliest stage of pain.
(Dr Ayush Sharma is Founder Director and Co-Founder of Laser Spine Clinic)
Sciatica
When things get tough, Betty Moore keeps going. The bubbly 76-year-old Boyertown resident isn’t planning to slow her pace.
Despite having to undergo another back surgery in November to fix damaged nerves and a bulging disc, she’s active.
Moore is active three times per each week. She’s part of a group known as”the “Foxy Ladies and Gentlemen,” that is held in Chestnut Knoll, a personal health and memory care community located in Boyertown.
Exercise classes for free are available via Chestnut Knoll and its partnership with FOX Rehabilitation, which provides therapy services on site as well as the exclusive FOX The Optimal Living Program to residents.
The program was initially conceived as a pilot program as a means to ensure seniors had access to therapy regardless of insurance restrictions.
“The FOX Optimal Living Program has exceeded our expectations , both for our residents as well as the local community,”” stated Chestnut Knoll’s executive director Shawn Barndt. “Since its inception the program has proven to be an industry-changing event and is the reason that makes Chestnut Knoll stand out within the senior living market.”
Director of Physiology, and Exercise Physiologist Eric Sartor facilitates the classes with different workouts which focus on strengthening mobility, balance, and mobility. The exercises are designed for older people and are adapted to suit different abilities which means that anyone can take part.
“We would like to welcome everyone to the fitness course,” Moore said. “Eric is an absolute pleasure; he shows interest in your life. And is also willing to tolerate our antics.”
Her aim is to improve her strength following the recent treatment. With a consistent exercise program, Moore noted she now is standing more often during classes.
“Betty is such a distinctive and positive aspect to our team,” Sartor said. “She is a pro to engage with fellow staff and members, laughing and inspiring on a regular basis. She is always positive and fresh, making smiles appear on many faces. I also loved getting to meet Betty in a way in her short stay on Chestnut Knoll. Betty is an extremely valued member of our group , and I’m grateful that she is able to attend frequently.”
Moore took these classes prior to the outbreak. She came across Chestnut Knoll through chance when she was at the appointment she had with her sibling. She had a chat with a lady in the waiting room who informed her of Chestnut Knoll’s class in exercise.
“I tried it and, since then, I’ve even enlisted friends to go,” Moore said, smiling.
She soon realized that the classes offered were not just the basics of fitness. The lively group that comprises Chestnut Knoll resident is a unique mix of fun, friendship and encouragement that is full of laughter and letting good times go on.
“It’s an amazing group of students; we have fun whenever we’re all together and appreciate each other’s company” Moore said. “We keep track of each other both inside and outside of class. On the first Wednesday of each month, we celebrate by having a night out for lunch.”
The group formed bonds with staff and residents It was not a surprise that Moore was referred to Chestnut Knoll after she required an emergency care after her operation.
“If I was forced to move to Chestnut Knoll for a long time I would do it,” Moore said. “The staff are friendly and helpful, and the food was delicious and delicious. I can say this. Chestnut Knoll is an excellent location to stay!”
Are you interested in joining an workout class or in need of emergency care? Contact us at 610-473-8066 to learn more.
Chestnut Knoll is a prestigious senior residence that offers the best in personal Care as well as Memory Care homes for rent on a month-to-month lease that does not include purchase fees. The services include 24/7 personal assistance for medical assistance and meals, as well as household chores, social gatherings and transportation. Residents have access to FOX Optimal Living, which is an scientifically-supported continuum of wellness and rehabilitation services. Chestnut Knoll also provides At Home Services, available for seniors who reside in the. The service provides help with medication monitoring and personal care, as well as assistance with companion care, light housekeeping and laundry, as well as transportation. The winner of the An A Place for Mom’s Best of Senior Living Award. For more information on personal care, memory care and home-care services, call Julie Krasley, director of marketing, at 610-473-8066 or visit www.chestnutknoll.com.
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It’s not a secret that high cholesterol can be a trigger for a variety of serious health issues. It includes coronary artery disease which can cause serious issues , such as heart attacks and other heart problems that cause pain.
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“The consequences of high cholesterol accumulate over time,” says cardiologist Luke Laffin, MD. “We must be aggressive in attempting to reduce the level. In long-term periods high cholesterol raises the risk of heart attacks, strokes, and the hardening of your arteries, also known as atherosclerosis. These are the most important things we are concerned about.”
If you suffer from high cholesterol and you also notice you suffer from frequent headaches or periods that cause dizziness or headaches, it could be tempting to believe there’s a direct correlation between both. But Dr. Laffin explains why that’s not the scenario.
Many people who have high cholesterol don’t show any signs until they suffer heart attacks or a stroke, or have angina, a heart-related pain condition.
In this light, can excessive cholesterol cause headaches? “There’s no evidence conclusive to suggest that it causes headaches,” Dr. Laffin says.
When your levels of cholesterol are very high, your physical symptoms differ. “We may see deposits of cholesterol in unusual areas, such as your elbows or Achilles tendon” Dr. Laffin notes. “Particularly in young people, it is possible to notice cholesterol buildup and deposits within the eye area if levels are high.”
There is a lot of confusion about problems that are frequently related to high cholesterol — and not high cholesterol in and of itself may cause headaches.
“I observe many people asking, “Is my blood pressure high creating headaches?’ It’s quite common,” says Dr. Laffin. It’s the “vast majority of times” there isn’t a need to worry about it Dr. Laffin says. “Your brain has an amazing capability to adjust to elevated blood pressure levels in brief periods of time. However, if the levels are extremely high then you may experience headaches.”
Blood pressure that is high and cholesterol are both the risk factors that can lead to atherosclerosis. “How it can cause headaches is uncertain,” says Dr. Laffin. However, plaque buildup within your arteries may create high blood pressure which could cause stroke.
The Dr. Laffin notes that there’s no research to prove that the presence of cholesterol in migraines causes headaches. “We typically consider migraine headaches to be possibly a vasodilation-related phenomenon,” he says, or something that happens when blood vessels expand or dilate. “That’s distinct in comparison to atherosclerosis.”
Over the last few years, however numerous studies have revealed intriguing connections between cholesterol levels and migraine headaches.
A study in 2015 revealed that people who suffered from frequent intense migraines had greater total cholesterol levels as well as greater levels of LDL (or the bad) cholesterol. In the case of those who participated in the study, they received treatment for three months which reduced migraines, their levels dropped.
But, the study involved only 52 participants who participated, which is not enough of a sample to draw any major, broad conclusions. It’s not clear that the high cholesterol level is responsible for these migraines. “The most common conclusion is that there’s a connection when talking about migraine headaches” Dr. Laffin says. However, that doesn’t refer to cause and effect.
A different study from 2011 found that migraine sufferers with aura, a particular type of migraine that manifests with speech or vision changes (see figure 1) were more likely to have higher total cholesterol levels and triglycerides levels contrasted with those who did not have headaches. But, this is an instance of associationthat is, you can’t claim that the increased cholesterol levels led migraines with aura.
Furthermore, the study was only conducted by participants in the Epidemiology of Vascular Aging Study that were classified as being elderly. That is there’s no scientific proof that this applies to individuals of all ages.
If you’re experiencing dizzy, it could be experiencing a physical sign of a bigger problem.
“Dizziness is a general word that people often employ to describe a variety of things,” notes Dr. Laffin. “Room spinning, as well as the vertigo-like feeling is very unlike lightheadedness.”
The doctor. Laffin says feeling like that the room is spinning could typically be due to vertigo, or an inner-ear issue that is not necessarily related to heart illness. However, lightheadedness can surely be a sign of a heart-related problem.
“Say you have cholesterol or plaque in your carotid arteries , and lack of blood flow or if you’ve got narrowing of the valves in your heart or arrhythmias” Dr. Laffin says, “these could cause what people call dizziness but it’s probably better known as lightheadedness.”
working at home could cause a lot of damage to your posture. Even though you can work in your pajamas on your laptop at night is a great alternative to getting to work but it’s not doing your neck or shoulders any good. If you’re one of the WFH employees suffering from the dreaded neck and shoulder pains and pains, temporary relief is within reach with the Neck Pain Pro Complete 6-Piece Set. This featured item is currently on sale for 56% off, and can be purchased for $129.99.
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Although it was designed specifically for neck pain the Neck Pain Pro is not just for the neck. Neck Pain Pro includes additional body pads you can place to other areas of the body to ease tension and pain, or to improve circulation.
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