Welcome to the Documentation Section @ Chiro.Org! This section is devoted to a full description of what is considered “complete” patient file documentation by the Chiropractic Schools, National Associations, and Third Party payors. This section is updated frequently.
Low Back Pain
This section is compiled by Frank M. Painter, D.C. Send all comments or additions to:
Frankp@chiro.org
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Learn about chiropractic management of disc disruption.
Lower Back Trauma
R. C. Schafer Rehabilitation Monograph Series ~ Chapter 24
By Richard C. Schafer, D.C., FICC
Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet. Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.
Joint Trauma
R. C. Schafer Rehabilitation Monograph Series ~ Chapter 8
By Richard C. Schafer, D.C., FICC
The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur. The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.
A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-back Pain in a National Health Service Outpatient Clinic
J Alternative and Complementary Medicine 2008 (Jun); 14 (5): 465–473
At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group than for the pain-clinic group. Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group. This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a sub-population of patients with chronic low-back pain (CLBP).
Prospective Case Series on the Effects of Lumbosacral Manipulation on Dysmenorrhea
J Manipulative Physiol Ther 2008 (Mar); 31 (3): 237–246 ~ FULL TEXT
This prospective case series suggests the possibility that menstrual pain associated with primary dysmenorrhea may be alleviated by treating motion segment restrictions of the lumbosacral spine with a drop table technique. The research team needs to conduct a well-designed feasibility trial to further evaluate the effectiveness of this specific spinal manipulative technique for primary dysmenorrhea.
Pathophysiological Model for Chronic Low Back Pain Integrating Connective Tissue and Nervous System Mechanisms
Medical Hypotheses 2007 (Jan); 68 (1): 74-80 ~ FULL TEXT
Although chronic low back pain (cLBP) is increasingly recognized as a complex syndrome with multifactorial etiology, the pathogenic mechanisms leading to the development of chronic pain in this condition remain poorly understood. We hypothesize that pain-related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation, nervous system sensitization and further decreased mobility. In addition to providing a new, testable framework for future mechanistic studies of cLBP, the integration of connective tissue and nervous system plasticity into the model will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise). You will also enjoy Dr. Dan Murphy's Key Points.
Is Comorbidity in Adolescence a Predictor for Adult Low Back Pain? A Prospective Study of a Young Population
BMC Musculoskelet Disord 2006 (Mar 16); 7: 29 ~ FULL TEXT
Your chiropractic care may be working out “kinks” in your lower back that have been around a lot longer than you realize. This new study of 10,000 Danish residents shows a link between adolescent and adult low back pain (LBP). Researchers studied twins born between 1972 and 1982 by sending out questionnaires in 1994 and again in 2002. The outcomes showed that a high percentage of those who had LBP in 1994 still suffered from LBP in 2002. They also found that those with persistent LBP were 4.5 times more likely than the average person to have future LBP episodes!
Hormonal and Reproductive Factors Are Associated with Chronic Low Back Pain and Chronic Upper Extremity Pain in Women -- The MORGEN Study
Spine 2006 (Jun 1); 31 (13): 1496-1502
Although LBP is suggested to be linked to hormonal and reproductive factors in women, results from previous studies are inconclusive. For this reason, a cross-sectional study of 11,428 Dutch women aged 20-59 years was accomplished. Multivariate logistic regression models were used to examine associations between hormonal and reproductive factors (independent variables) and, respectively, chronic LBP, chronic UEP (upper extremity pain) and combined chronic LBP/UEP.
Past pregnancy, young maternal age at first birth, duration of oral contraceptive use, and use of estrogens during menopause were associated with chronic LBP, while young age at menarche was associated with chronic UEP. Irregular or prolonged menstruation and hysterectomy were associated both with chronic LBP and chronic UEP. No positive associations were found for current pregnancy and number of children.
• Manipulation, with or without exercise, improved symptoms more than medical care did after both 3 and 12 months
• The authors concluded:
“We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice.”
The most recent in a long line of articles showing the clear superiority of chiropractic management was
published in May of 2007 . Clinical and cost utilization based on 70,274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% less hospital days, 62.0% less outpatient surgeries and procedures, and 85% less pharmaceutical costs when compared with conventional medicine IPA performance.
That is rather significant savings, is it not?
So...what's the holdup?
Cost Effectiveness of Physical Treatments for Back Pain in Primary Care
British Medical Journal 2004 (Dec 11); 329 (7479): 1381 ~ FULL TEXT We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with "usual care" in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain. [1] Read both British Medical Journal articles about the UK BEAM Trial now.
The British Medical Research Council (MRC) Trial Finds Adding Spinal Manipulation and Exercise to GP Care Provides Relief for Back Pain
The British Medical Research Council (MRC)
A Medical Research Council (MRC) trial to assess the effectiveness of adding different treatments to “best care” in general practice for patients with lower back pain has found that spinal manipulation, in the form of chiropractic, osteopathy, or manipulative physiotherapy, followed by a programme of exercise, provides significant relief of symptoms and improvements in general health. The results of the trial are published online today, Friday 19 November, in the British Medical Journal.
Post Partum and Beyond: Managing Back Pain in Women
Dr. Diane Benizzi DiMarco ~ FULL TEXT
The post partum patient retains a higher risk for potential injury as compared to the patient who has not endured pregnancy or has not been pregnant for an extended period of time. Fertilization propels the release of estrogen, progesterone and relaxin, hormones essential to the growth and development of the embryo and fetus. These hormones that are essential to the pregnancy cause global relaxation to the ligaments and muscles in the female pregnant patient. A conglomerate of anatomical changes created by the global laxity in muscles and ligaments compromises the stability of the spine.
End Medical Mis-Management of Musculoskeletal Complaints
Q. Are medical doctors well trained to diagnose or treat musculoskeletal complaints?
A. Read the unsettling answer in this series of articles
Educational Deficiencies in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 2002 (Apr); 84–A (4): 604–608
According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate. NOTE: This is a follow-up article to the study cited below, which demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. What would the headlines would say if, after 4 years, our profession had failed to improve it's skills in musculoskeletal assessment and management? Ask your self why medicine is shown more slack than we are?
The Adequacy of Medical School Education in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 1998 (Oct); 80-A (10): 1421–1427
This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that "we therefore believe that medical school preparation in musculoskeletal medicine is inadequate" and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints.
Educating Medical Students About Musculoskeletal Problems: Are Community Needs Reflected in the Curricula of Canadian Medical Schools?
Journal of Bone and Joint Surgery 2001 (Sept); 83-A (9): 1317–1320
Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. (So they conclude:) There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.
A Comparison of Chiropractic Student Knowledge Versus Medical Residents
Proceedings of the World Federation of Chiropractic Congress 2001 Pgs. 255
A previously published knowledge questionnaire designed by chief orthopedic residents was given to a Chiropractic student group for comparison to the results of the medical resident group. Based on the marking scale determined by the chief residents, the Chiropractic group (n = 51) showed statistically significant higher average grade than the orthopedic residents. Expressed in other terms, 70% of chiropractic students passed the knowledge questionnaire, compared to an 80% failure rate for the residents.
Musculoskeletal Knowledge: How Do You Stack Up?
Physician and Sportsmedicine 2002; 30 (8) August
One of every 4 or 5 primary care visits is for a musculoskeletal problem. Yet undergraduate and graduate training for this burden of illness continues to constitute typically less than 5% of the medical curriculum. This is an area of clear concern, but also one in which sports medicine practitioners can assume leadership.
Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov); 32 (11)
It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment. This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.[ 1 ] While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.
Adequacy of Education in Musculoskeletal Medicine
J Bone Joint Surg Am 2005 (Feb);87 (2): 310–314
In this study, 334 medical students, residents and staff physicians, specializing in various fields of medicine, were asked to take a basic cognitive examination consisting of 25 short-answer questions - the same type of test administered in the original JBJS 1998 study. The average score among medical doctors, students and residents who took the exam in 2005 was 2.7 points lower than those who took the exam in 1998. Just over half of the staff physicians (52%) scored a passing grade or higher on the 2005 exam. Only 21% of the residents registered a passing grade, and only 5% of the medical students passed the exam. Overall, Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination.
More Evidence of Educational Inadequacies in Musculoskeletal Medicine
Clin Orthop Relat Res 2005 (Aug); (437): 251–259
A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.
Why is the Bone and Joint Decade Important?
Welcome to the United States Bone and Joint Decade
The Bone and Joint Decade initiative is a global campaign to improve quality of life for people with musculoskeletal conditions and to advance understanding and treatment of these conditions through research, prevention, and education. [ 1 ] The Decade aims to raise the awareness of the increasing societal impact of musculoskeletal injuries and disorders; empower patients to participate in decisions about their care; increase funding for prevention activities and research; and promote cost-effective prevention and treatment of musculoskeletal injuries and disorders.
Chiropractic Spinal Manipulation for Low Back Pain of Pregnancy: A Retrospective Case Series
J Midwifery Womens Health 2006 (Jan); 51 (1): e7-10
Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0-13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1-5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.
Cost-effectiveness of Medical and Chiropractic Care for Acute and Chronic Low Back Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 555–563
Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain. There are more articles like this in the Cost-Effectiveness Page.
Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain: A Systematic Review and Best Evidence Synthesis
Spine Journal (of the North American Spine Society) 2004 (May); 4 (3): 335–356
Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and neck pain. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.
Palmer Research Center Conducting Several Clinical Trials on Back Pain
The Palmer Center for Chiropractic Research is currently studying back pain through several groundbreaking clinical trials at its research clinic. About 500 people from throughout the Quad-City region who suffer from back pain are being recruited to participate in two separate clinical trials, expected to last up to 18 months. Both studies are funded through federal grants totaling $2.4 million.
Dose-response for Chiropractic Care of Chronic Low Back Pain
Spine J 2004 (Sep); 4 (5): 574–583
There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.
Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment
J Manipulative Physiol Ther 2004 (Mar); 27 (3): 197–210
An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million. The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.
Patient Evaluations of Low Back Pain Care From Family Physicians and Chiropractors
West J Med 1989 (Mar); 150 (3): 351–355 ~ FULL TEXT
Patients of chiropractors were three times as likely as patients of family physicians to report that they were very satisfied with the care they received for low back pain (66% versus 22%, respectively). Compared with patients of family physicians, patients of chiropractors were three times more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem.
The Not-So-Hidden Costs of Back Pain
Some "experts" - ironically, those outside the chiropractic profession - have attempted to describe back pain as a harmless, self-limiting condition that requires only rest and time for resolution, despite evidence to the contrary. If that's the case, how do these experts explain the results of a study published in the Jan. 1, 2004 issue of Spine?
Appropriate ICD-9 Diagnostic Coding in the Low Back Pain Case
The "pecking order" in which you place your diagnoses in box 21 of the CMS-1500 claim plays a role in the way insurance companies interpret the severity of a patient's condition and ultimately, how much they'll pay. The diagnoses you choose represent your patient's condition to the insurance company and must be extremely accurate. If a patient presents to your office with severe low back pain, severe leg pain, constant leg numbness and foot drop, don't automatically assume and report disc involvement without a diagnostic test to substantiate it. A table with specific codes is supplied.
You will enjoy this free online ICD-9 coding tool to help you create the most specific coding possible atFlashCode.
Low Back Pain: What Is The Long-term Course? A Review of Studies of General Patient Populations
Eur Spine J 2003 (Apr); 12 (2): 149–165
The results of the review showed that the reported proportion of patients who still experienced pain after 12 months was 62% on average (range 42-75%)...the percentage who experienced relapses of pain was 60% (range 44-78%), and the percentage who had relapses of work absence was 33% (range 26-37%)...The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.
Clinical Guidelines for the Management of Low Back Pain in Primary Care: An International Comparison
SPINE Journal 2001; 26 (22) Nov 15: 2504–2513
Clinical guidelines from 11 different countries published from 1994 until 2000 were included in this review. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. You may review more articles like this in the
LOWBACK GUIDELINES Section.
Manual Therapy and Exercise Therapy in Patients With Chronic Low Back
Pain: A Randomized, Controlled Trial With 1-Year Follow-Up
SPINE Journal 2003 (Mar 15); 28 (6): 525–531
Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the
exercise therapy group on all outcome variables throughout the entire
experimental period. Immediately after the 2-month treatment period, 67%
in the manual therapy and 27% in the exercise therapy group had returned
to work (P < 0.01), a relative difference that was maintained throughout
the follow-up period.
Low Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment
British Medical Journal 1990 (Jun 2); 300 (6737): 1431–1437
For patients with low back pain in whom manipulation is not contraindicated chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain.
Introducing chiropractic into NHS practice should be considered.
Chiropractic Care for Common Industrial Low Back Conditions
Chiropractic Technique 1993 (Aug); 5 (3): 119–125 ~ FULL TEXT
This is the first guideline I have seen which actually states the number of visits which may be appropriate for a variety of common low back conditions. I have used these "care
plans" for years, presenting them to third party's as a "working diagnosis" care plan, which need ongoing "fine tuning" during patient care. Check out this Chiropractic Technique article, and the attached care plans, which have been released exclusively to Chiro.Org by the National College of Chiropractic. Thanks, Dana! You will find other information like this in the GUIDELINES Section.
as Adobe PDF Format
They are formatted, so you can add your own letterhead and mail them out to claim adjusters tomorrow! Just use "save-as" and they are all yours!
A Prospective Study of Back Belts for Prevention of Back Pain and Injury
JAMA 2000 (Dec 6); 284 (21): 2727–2732
In the largest prospective cohort study of back belt use, adjusted for multiple individual risk factors, neither frequent back belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain.
How to Shift LBP Paradigms: The "Hinges" of Practice
Specialists in the management of spinal disorders have seen tremendous changes in the last decade. While the low back pain (LBP) problem has been acknowledged as an epidemic, a consensus has gradually emerged as to why this has happened and what can be done about it . An overemphasis on the simplistic biomedical approach of identifying and treating the structural cause of pain has led to excesses in diagnostic testing, bed rest, narcotic analgesics, and surgery (Waddell). Meanwhile, an underemphasis on illness behavior has led to an under-utilization of functional (re-activation advice, manipulation and exercise) and cognitive-behavorial approaches (Feuerstein).
Outcome of Low Back Pain in General Practice: A Prospective Study
British Medical Journal 1998 (May 2); 316 (7141): 1356–1359 ~ FULL TEXT
This FULL TEXT article investigated the generally accepted statistic that 90% of low back pain (LBP) goes away by itself. The discrepancy lies in the method of the data collection. Croft et al point out that the original study to publish the "90% recovery" results was based on patient consultation records, not follow up interviews. By comparison, this study takes into account consultation rates as well as follow-up interviews. In fact, Croft's consultation rates show a 90% drop-out rate after 3 months, not resolution of the complaint! The follow-up interviews, however, showed that most patients simply stopped consulting their doctors about low back pain, even though they still suffered pain and disability 12 months later! Clearly, the number of visits to general practitioners cannot be used as a measure of how quickly the pain and disability goes away.
MDs Employ Spinal Manipulation After a Short Training Course: Limited Benefit for Patients
The Back Letter 1998; 13 (11): 123 Results: Overall, the results do not support training primary care physicians in manipulative techniques. "The incremental effect of adding manual therapy to an approach involving enthusiastic physicians, special evaluation and patient educational skills, standard medication therapies, and exercise prescription appears to be minimal," said Carey. More intense manual therapy might hold promise, but for now the evidence for training physicians in manual therapy remains to be established, said Carey.
A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain
The New England Journal of Medicine 1998 (Oct 8); 339 (15): 1013–1029
This amusing paper found that an "educational booklet" was as effective as either chiropractic or McKenzie protocol! I still can't figure out how they managed to charge $153.00 for each and every booklet...what idiot funded this project? Maybe selling $153. books will be medicine's next big "breakthrough" in managing low back pain. Nice work, if you can get it!
Research: New Challenges for Chiropractic
Response to the Low Back Pain study in the New England Journal of Medicine listed above. Read these responses from the Research and Academic Community.
Complementary Care: When Is It Appropriate? Who Will Provide It?
Annals of Internal Medicine 1998 (Jul ); 129: 65–66 ~ FULL TEXT The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low back pain [1]. The 1994 guidelines for acute low back pain developed by AHCPR concluded that spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidial anti-inflammatory drugs [1]. At the same time, AHCPR concluded that various traditional methods, such as bed rest, traction, and other physical and pharmaceutical therapies were less effective than spinal manipulation and cautioned against lumbar surgery except in the most severe cases. Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice.
What is the Natural History for Lower Back Pain?
We have all heard the statistics that say 85% of patients are better in 6 weeks. Is this universally advertised short term outcome true? What do we mean by better? If our goal is to improve the quality of care for back pain patients then we first need to establish benchmark outcomes of recovery. If improvement is the goal then 90% of patients are improving after only 3 weeks. But, if asymptomatic is the goal then only 46% reached this goal after 7 weeks. If not having any activity limitations due to pain is the goal, as AHCPR suggests, then only 38% have achieved this goal by 7 weeks.
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