Chiro.org - Chiropractic Resource Organization.     Support Chiropractic Research!

Monthly Archives: October 2016

Home/2016/October

Mechanisms of Low Back Pain:
A Guide for Diagnosis and Therapy

By |October 30, 2016|Diagnosis, Low Back Pain|

Mechanisms of Low Back Pain:
A Guide for Diagnosis and Therapy

The Chiro.Org Blog


SOURCE:   F1000Res. 2016 (Oct 11); 5. pii: F1000

Massimo Allegri, Silvana Montella, Fabiana Salici,
Adriana Valente, Maurizio Marchesini, Christian Compagnone,
Marco Baciarello, Maria Elena Manferdini, and Guido Fanelli

Department of Surgical Sciences,
University of Parma,
Parma, Italy


Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making.

Answering the question “what is the pain generatoramong the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.

There are more articles like this @ our:

Low Back Pain and Chiropractic Page

(more…)

An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

By |October 28, 2016|Guidelines, Low Back Pain|

An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

The Chiro.Org Blog


SOURCE:   Eur Spine J. 2010 (Dec); 19 (12): 2075–2094

Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C.

Department of General Practice,
Erasmus MC, P.O. Box 2040, 3000 CA,
Rotterdam, The Netherlands


This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain.

Another review of guidelines published in June 2010 also noted a great degree of similarity between guidelines and that

“Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy.”

Although there is always a need for more evidence, the evidence over the last few years is providing much stronger support for SMT and that evidence is slowly finding its way into major clinical guidelines both in the United States and internationally.

The Abstract

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000.

Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity.

There are more articles like this @ our:

Practice Guidelines Page

and the:

Low Back Pain and Chiropractic Page

(more…)

Estimating the Risk of Chronic Pain: Development and Validation of a Prognostic Model (PICKUP) for Patients with Acute Low Back Pain

By |October 27, 2016|Low Back Pain|

Estimating the Risk of Chronic Pain: Development and Validation of a Prognostic Model (PICKUP) for Patients with Acute Low Back Pain

The Chiro.Org Blog


SOURCE:   PLoS Med. 2016 (May 17); 13 (5): e1002019

Adrian C. Traeger, Nicholas Henschke, Markus Hübscher,
Christopher M. Williams, Steven J. Kamper,
Christopher G. Maher, G. Lorimer Moseley,
James H. McAuley

Prince of Wales Clinical School,
University of New South Wales,
Sydney, New South Wales, Australia


BACKGROUND:   Low back pain (LBP) is a major health problem. Globally it is responsible for the most years lived with disability. The most problematic type of LBP is chronic LBP (pain lasting longer than 3 mo); it has a poor prognosis and is costly, and interventions are only moderately effective. Targeting interventions according to risk profile is a promising approach to prevent the onset of chronic LBP. Developing accurate prognostic models is the first step. No validated prognostic models are available to accurately predict the onset of chronic LBP. The primary aim of this study was to develop and validate a prognostic model to estimate the risk of chronic LBP.

METHODS AND FINDINGS:   We used the PROGRESS framework to specify a priori methods, which we published in a study protocol. Data from 2,758 patients with acute LBP attending primary care in Australia between 5 November 2003 and 15 July 2005 (development sample, n = 1,230) and between 10 November 2009 and 5 February 2013 (external validation sample, n = 1,528) were used to develop and externally validate the model. The primary outcome was chronic LBP (ongoing pain at 3 mo). In all, 30% of the development sample and 19% of the external validation sample developed chronic LBP. In the external validation sample, the primary model (PICKUP) discriminated between those who did and did not develop chronic LBP with acceptable performance (area under the receiver operating characteristic curve 0.66 [95% CI 0.63 to 0.69]). Although model calibration was also acceptable in the external validation sample (intercept = -0.55, slope = 0.89), some miscalibration was observed for high-risk groups. The decision curve analysis estimated that, if decisions to recommend further intervention were based on risk scores, screening could lead to a net reduction of 40 unnecessary interventions for every 100 patients presenting to primary care compared to a “treat all” approach. Limitations of the method include the model being restricted to using prognostic factors measured in existing studies and using stepwise methods to specify the model. Limitations of the model include modest discrimination performance. The model also requires recalibration for local settings.

There are more articles like this @ our:

Low Back Pain and Chiropractic Page

(more…)

Cost-Effectiveness Of General Practice Care For Low Back Pain: A Systematic Review

By |October 25, 2016|Cost-Effectiveness|

Cost-Effectiveness Of General Practice Care For Low Back Pain: A Systematic Review

The Chiro.Org Blog


SOURCE:   Eur Spine J. 2011 (Jul); 20 (7): 1012–1023

Chung-Wei Christine Lin, Marion Haas, Chris G. Maher,
Luciana A. C. Machado, Maurits W. van Tulder

The George Institute for Global Health and
Sydney Medical School,
The University of Sydney,
PO Box M201, Missenden Rd,
Sydney, NSW 2050, Australia.


Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data.

Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone.

There are more articles like this @ our:

Cost-Effectiveness of Chiropractic Page

(more…)

Imperfect Placebos Are Common In Low Back Pain Trials:

By |October 20, 2016|Placebo|

Imperfect Placebos Are Common In Low Back Pain Trials: A Systematic Review Of The Literature

The Chiro.Org Blog


SOURCE:   Eur Spine J. 2008 (Jul); 17 (7): 889–904

L. A. C. Machado, S. J. Kamper, R. D. Herbert,
G. Maher, and J. H. McAuley

Back Pain Research Group,
Musculoskeletal Division,
The George Institute for International Health,
Missenden Rd, P.O. Box M201,
Camperdown, NSW, 2050, Australia.


The placebo is an important tool to blind patients to treatment allocation and therefore minimise some sources of bias in clinical trials. However, placebos that are improperly designed or implemented may introduce bias into trials. The purpose of this systematic review was to evaluate the adequacy of placebo interventions used in low back pain trials. Electronic databases were searched systematically for randomised placebo-controlled trials of conservative interventions for low back pain. Trial selection and data extraction were performed by two reviewers independently. A total of 126 trials using over 25 different placebo interventions were included. The strategy most commonly used to enhance blinding was the provision of structurally equivalent placebos. Adequacy of blinding was assessed in only 13% of trials. In 20% of trials the placebo intervention was a potentially genuine treatment. Most trials that assessed patients’ expectations showed that the placebo generated lower expectations than the experimental intervention.

There are more articles like this @ our:

The Problem with Placebos/Shams Page

(more…)

Placebo Effects In Trials Evaluating 12 Selected Minimally Invasive Interventions

By |October 19, 2016|Placebo|

Placebo Effects In Trials Evaluating 12 Selected Minimally Invasive Interventions: A Systematic Review And Meta-Analysis

The Chiro.Org Blog


SOURCE:   BMJ Open. 2015 (Jan 30); 5 (1): e007331

Robin Holtedahl, Jens Ivar Brox, Ole Tjomsland

Department of Physical Medicine and Rehabilitation,
Oslo University Hospital,
Oslo, Norway.


OBJECTIVES:   To analyse the impact of placebo effects on outcome in trials of selected minimally invasive procedures and to assess reported adverse events in both trial arms.

DESIGN:   A systematic review and meta-analysis.

DATA SOURCES AND STUDY SELECTION:   We searched MEDLINE and Cochrane library to identify systematic reviews of musculoskeletal, neurological and cardiac conditions published between January 2009 and January 2014 comparing selected minimally invasive with placebo (sham) procedures. We searched MEDLINE for additional randomised controlled trials published between January 2000 and January 2014.

DATA SYNTHESIS:   Effect sizes (ES) in the active and placebo arms in the trials’ primary and pooled secondary end points were calculated. Linear regression was used to analyse the association between end points in the active and sham groups. Reported adverse events in both trial arms were registered.

RESULTS:   We included 21 trials involving 2,519 adult participants. For primary end points, there was a large clinical effect (ES≥0.8) after active treatment in 12 trials and after sham procedures in 11 trials. For secondary end points, 7 and 5 trials showed a large clinical effect. Three trials showed a moderate difference in ES between active treatment and sham on primary end points (ES ≥0.5) but no trials reported a large difference. No trials showed large or moderate differences in ES on pooled secondary end points. Regression analysis of end points in active treatment and sham arms estimated an R(2) of 0.78 for primary and 0.84 for secondary end points. Adverse events after sham were in most cases minor and of short duration.

There are more articles like this @ our:

The Problem with Placebos/Shams Page

(more…)