Christine M. Goertz, DC, PhD 1; Cynthia R. Long, PhD 1; Robert D. Vining, DC 1; Katherine A. Pohlman, DC, MS 2; Joan Walter, JD, PA 3; Ian Coulter, PhD 4
(1) Palmer College of Chiropractic,
Palmer Center for Chiropractic Research,
(2) Parker University Research Institute,
(3) Samueli Institute for Information Biology,
Silver Spring, Maryland
(4) RAND Corporation,
Santa Monica, California
Importance It is critically important to evaluate the effect of nonpharmacological treatments on low back pain and associated disability.
Objective To determine whether the addition of chiropractic care to usual medical care results in better pain relief and pain-related function when compared with usual medical care alone.
Design, Setting, and Participants A 3–site pragmatic comparative effectiveness clinical trial using adaptive allocation was conducted from September 28, 2012, to February 13, 2016, at 2 large military medical centers in major metropolitan areas and 1 smaller hospital at a military training site. Eligible participants were active-duty US service members aged 18 to 50 years with low back pain from a musculoskeletal source.
Interventions The intervention period was 6 weeks. Usual medical care included self-care, medications, physical therapy, and pain clinic referral. Chiropractic care included spinal manipulative therapy in the low back and adjacent regions and additional therapeutic procedures such as rehabilitative exercise, cryotherapy, superficial heat, and other manual therapies.
Main Outcomes and Measures Coprimary outcomes were low back pain intensity (Numerical Rating Scale; scores ranging from 0 [no low back pain] to 10 [worst possible low back pain]) and disability (Roland Morris Disability Questionnaire; scores ranging from 0–24, with higher scores indicating greater disability) at 6 weeks. Secondary outcomes included perceived improvement, satisfaction (Numerical Rating Scale; scores ranging from 0 [not at all satisfied] to 10 [extremely satisfied]), and medication use. The coprimary outcomes were modeled with linear mixed-effects regression over baseline and weeks 2, 4, 6, and 12.
Results Of the 806 screened patients who were recruited through either clinician referrals or self-referrals, 750 were enrolled (250 at each site). The mean (SD) participant age was 30.9 (8.7) years, 175 participants (23.3%) were female, and 243 participants (32.4%) were nonwhite. Statistically significant site × time × group interactions were found in all models. Adjusted mean differences in scores at week 6 were statistically significant in favor of usual medical care plus chiropractic care compared with usual medical care alone overall for low back pain intensity (mean difference, –1.1; 95% CI, –1.4 to –0.7), disability (mean difference, –2.2; 95% CI, –3.1 to –1.2), and satisfaction (mean difference, 2.5; 95% CI, 2.1 to 2.8) as well as at each site. Adjusted odd ratios at week 6 were also statistically significant in favor of usual medical care plus chiropractic care overall for perceived improvement (odds ratio = 0.18; 95% CI, 0.13–0.25) and self-reported pain medication use (odds ratio = 0.73; 95% CI, 0.54–0.97). No serious related adverse events were reported.
Adding chiropractic care to standard medical management of low back pain (LBP) in a military population reduced patient-reported pain and disability and improved satisfaction scores compared with standard treatment alone, new data show.
The findings, reported by Christine M. Goertz, DC, PhD, from Palmer College of Chiropractic, Davenport, Iowa, and colleagues in an article published online May 18 in JAMA Network Open, confirm results from the team’s pilot study.
In addition, the new data align with recent guidelines from the American College of Physicians that recommend inclusion of spinal manipulation, among other nondrug treatments, as first-line therapy for acute and chronic low-back pain.
For the current study, Goertz and colleagues enrolled 750 active-duty US service members aged 18 to 50 years with LBP from three military facilities in a pragmatic comparative effectiveness trial.
Patients were screened between September 28, 2012, and November 20, 2015, and 250 patients from each of the study sites were allocated to receive usual medical care with chiropractic care (375 participants) or usual medical care alone (375 participants). Usual medical care was defined as any care recommended or prescribed by nonchiropractic military clinicians to treat LBP, including self-management advice, drug treatment, physical therapy, or referral to a pain clinic.
Department of Public Health Sciences,
John A. Burns School of Medicine,
University of Hawaii,
M?noa, Honolulu, HI 96822, USA.
The objectives of this article are to
(1) describe spinal manipulation use by time, place, and person, and
(2) identify predictors of the use of spinal manipulation.
We conducted a systematic review of the English-language literature published from January 1, 1980 through June 30, 2011. Of 822 citations identified, 213 were deemed potentially relevant; 75 were included after further consideration. Twenty-one additional articles were identified from reference lists. The literature is heavily weighted toward North America, Europe, and Australia and thus largely precludes inferences about spinal manipulation use in other parts of the world. In the regions covered by the literature, chiropractors, osteopaths, and physical therapists are most likely to deliver spinal manipulation, often in conjunction with other conservative therapies.
Back and neck pain are the most frequent indications for receiving spinal manipulation; non-musculoskeletal conditions comprise a very small percentage of indications. Although spinal manipulation is more commonly used in adults than children, evidence suggests that spinal manipulation may be more likely used for non-musculoskeletal ailments in children than in adults. Patient satisfaction with spinal manipulation is very high.
From the Full-Text Article:
Although spinal manipulation has been practiced for thousands of years in several cultures spanning the globe, it is most commonly associated with chiropractic and osteopathy, which originated in the late 1800s in the United States (Pettman, 2007). The purpose of this article is to review the literature on the use of spinal manipulation. Specifically, our objectives are twofold: (1) To describe spinal manipulation use by time (temporal trends), place (geographic distribution), and person (practitioner and patient), and (2) to identify predictors of the use of spinal manipulation.
Julie C. Kendall, Simon D. French, Jan Hartvigsen, and Michael F. Azari
School of Health and Biomedical Sciences,
PO Box 71 Bundoora,
Melbourne, VIC 3083 Australia.
BACKGROUND: Dizziness in older people is a risk factor for falls. Neck pain is associated with dizziness and responds favourably to neck manipulation. However, it is unknown if chiropractic intervention including instrument-assisted manipulation of the neck in older people with neck pain can also improve dizziness.
METHODS: This parallel two-arm pilot trial was conducted in Melbourne, Australia over nine months (October 2015 to June 2016). Participants aged 65–85 years, with self-reported chronic neck pain and dizziness, were recruited from the general public through advertisements in local community newspapers and via Facebook. Participants were randomised using a permuted block method to one of two groups: 1) Activator II™-instrument-assisted cervical and thoracic spine manipulation plus a combination of: light massage; mobilisation; range of motion exercises; and home advice about the application of heat, or 2) Sham-Activator II™-instrument-assisted manipulation (set to zero impulse) plus gentle touch of cervical and thoracic spinal regions. Participants were blinded to group allocation. The interventions were delivered weekly for four weeks. Assessments were conducted one week pre- and post-intervention. Clinical outcomes were assessed blindly and included: dizziness (dizziness handicap inventory [DHI]); neck pain (neck disability index [NDI]); self-reported concerns of falling; mood; physical function; and treatment satisfaction. Feasibility outcomes included recruitment rates, compliance with intervention and outcome assessment, study location, success of blinding, costs and harms.
RESULTS: Out of 162 enquiries, 24 participants were screened as eligible and randomised to either the chiropractic (n = 13) or sham (n = 11) intervention group. Compliance was satisfactory with only two participants lost to follow up; thus, post-intervention data for 12 chiropractic intervention and 10 sham intervention participants were analysed. Blinding was similar between groups. Mild harms of increased spinal pain or headaches were reported by 6 participants. Costs amounted to AUD$2635 per participant. The data showed a trend favouring the chiropractic group in terms of clinically-significant improvements in both NDI and DHI scores. Sample sizes of n = 150 or n = 222 for dizziness or neck pain disability as the primary outcome measure, respectively, would be needed for a fully powered trial.
Robert D Vining, Stacie A Salsbury, W Carl Cooley, Donna Gosselin, Lance Corber, and Christine M Goertz
Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
Davenport, IA, USA.
OBJECTIVES: Individuals rehabilitating from complex neurological injury require a multidisciplinary approach, which typically does not include chiropractic care. This study describes inpatients receiving multidisciplinary rehabilitation including chiropractic care for brain injury, spinal cord injury (SCI), stroke, and other complex neurological conditions.
DESIGN: Chiropractic services were integrated into Crotched Mountain Specialty Hospital (CMSH) through this project. Patient characteristics and chiropractic care data were collected to describe those receiving care and the interventions during the first 15 months when chiropractic services were available.
SETTING: CMSH, a 62–bed subacute multidisciplinary rehabilitation, skilled nursing facility located in Greenfield, New Hampshire, USA.
RESULTS: Patient mean (SD) age (n=27) was 42.8 (13) years, ranging from 20 to 64 years. Males (n=18, 67%) and those of white race/ethnicity (n=23, 85%) comprised the majority. Brain injury (n=20) was the most common admitting condition caused by trauma (n=9), hemorrhage (n=7), infarction (n=2), and general anoxia (n=2). Three patients were admitted for cervical SCI, 1 for ankylosing spondylitis, 1 for traumatic polyarthropathy, and 2 for respiratory failure with encephalopathy. Other common comorbid diagnoses potentially complicating the treatment and recovery process included myospasm (n=13), depression (n=11), anxiety (n=10), dysphagia (n=8), substance abuse (n=8), and candidiasis (n=7). Chiropractic procedures employed, by visit (n=641), included manual myofascial therapies (93%), mechanical percussion (83%), manual muscle stretching (75%), and thrust manipulation (65%) to address patients with spinal-related pain (n=15, 54%), joint or regional stiffness (n= 14, 50%), and extremity pain (n=13, 46%). Care often required adapting to participant limitations or conditions. Such adaptations not commonly encountered in outpatient settings where chiropractic care is usually delivered included the need for lift assistance, wheelchair dependence, contractures, impaired speech, quadriplegia/paraplegia, and the presence of feeding tubes and urinary catheters.
Ian D. Coulter, PhD, Cindy Crawford, BA, Eric L. Hurwitz, DC, PhD, Howard Vernon, DC, PhD, Raheleh Khorsan, PhD, Marika Suttorp Booth, MS, Patricia M. Herman, ND, PhD
1776 Main St,
Santa Monica, CA 90407-2138, USA
BACKGROUND CONTEXT: Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies.
PURPOSE: The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain.
STUDY DESIGN/SETTING: This is a systematic literature review and meta-analysis.
OUTCOME MEASURES: The present study measures self-reported pain, function, health-related quality of life, and adverse events.
METHODS: We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912.
RESULTS: Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=–0.28, 95% confidence interval (CI) –0.47 to –0.09, p=.004; I2=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=–0.33, 95% CI –0.63 to –0.03, p=.03; I2=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=–0.43, 95% CI –0.86 to 0.00; p=.05, I2=79%; SMD=–0.86, 95% CI –1.27 to –0.45; p< .0001, I2=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=–0.20, 95% CI –0.35 to –0.04; p=.01; I2=0%) but not disability (SMD=–0.10, 95% CI –0.28 to 0.07; p=.25; I2=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described.