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Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain

By |May 23, 2018|Low Back Pain, Veterans|

Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone
on Pain and Disability Among US Service Members With Low Back Pain.
A Comparative Effectiveness Clinical Trial

The Chiro.Org Blog

SOURCE:   JAMA Network Open. 2018 (May 18); 1 (1): e180105

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,
Davenport, Iowa

(2) Parker University Research Institute,
Dallas, Texas

(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.

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Manipulation and Mobilization for Treating Chronic Low Back Pain

By |May 17, 2018|Low Back Pain|

Manipulation and Mobilization for Treating Chronic Low Back Pain: A Systematic Review and Meta-analysis

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SOURCE:   Spine J. 2018 (May);   18 (5):   866–879

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

RAND Corporation,
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.

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Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain

By |April 12, 2018|Guidelines, Low Back Pain|

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain:

A Guideline From the Canadian Chiropractic Guideline Initiative

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SOURCE:   J Manipulative Physiol Ther. 2018 (Mar 29) [Epub]

André E. Bussières, DC, FCCS(C), PhD, Gregory Stewart, DC, Fadi Al-Zoubi, PT, MSc, Philip Decina, DC, Martin Descarreaux, DC, PhD, Danielle Haskett, BSc, Cesar Hincapié, DC, PhD, Isabelle Pagé, DC, MSc, Steven Passmore, DC, PhD, John Srbely, DC, PhD, Maja Stupar, DC, PhD, Joel Weisberg, DC, Joseph Ornelas, DC, PhD

School of Physical and Occupational Therapy,
Faculty of Medicine, McGill University,
Montreal, Québec, Canada

OBJECTIVE: &nbsp The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

METHODS: &nbsp The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

RESULTS: &nbsp For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

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Prognostic Implications of the Quebec Task Force Classification of Back-related Leg Pain

By |April 9, 2018|Low Back Pain, Sciatica|

Prognostic Implications of the Quebec Task Force Classification of Back-related Leg Pain:
An Analysis of Longitudinal Routine Clinical Data

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SOURCE:   BMC Musculoskelet Disord. 2013 (May 24); 14: 171

Alice Kongsted, Peter Kent, Tue Secher Jensen, Hanne Albert and Claus Manniche

Research Department,
The Spine Centre of Southern Denmark,
Middelfart, Hospital Lillebaelt,
Institute of Regional Health Services Research,
University of Southern Denmark,
Middelfart, Denmark

BACKGROUND:   Low back pain (LBP) patients with related leg pain have a more severe profile than those with local LBP and a worse prognosis. Pain location above or below the knee and the presence of neurological signs differentiate patients with different profiles, but knowledge about the prognostic value of these subgroups is sparse. The objectives of this study were (1) to investigate whether subgroups consisting of patients with Local LBP only, LBP + leg pain above the knee, LBP + leg pain below the knee, and LBP + leg pain and neurological signs had different prognoses, and (2) to determine if this was explained by measured baseline factors.

METHODS:   Routine clinical data were collected during the first visit to an outpatient department and follow-ups were performed after 3 and 12 months. Patients were divided into the four subgroups and associations between subgroups and the outcomes of activity limitation, global perceived effect (GPE) after 3 months, and sick leave after 3 months were tested by means of generalised estimating equations. Models were univariate (I), adjusted for duration (II), and adjusted for all baseline differences (III).

RESULTS:   A total of 1,752 patients were included, with a 76% 3-month and 70% 12-month follow-up. Subgroups were associated with activity limitation in all models (p < 0.001). Local LBP had the least and LBP + neurological signs the most severe limitations at all time-points, although patients with neurological signs improved the most. Associations with GPE after 3 months were only significant in Model I. Subgroups were associated with sick leave after 3 months in model I and II, with sick leave being most frequent in the subgroup with neurological signs. No significant differences were found in any pairwise comparisons of patients with leg pain above or below the knee.

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What Low Back Pain Is and Why We Need to Pay Attention

By |April 7, 2018|Low Back Pain|

What Low Back Pain Is and Why We Need to Pay Attention

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SOURCE:   Lancet. 2018 (Mar 20) [Epub]

Prof Jan Hartvigsen, PhD, Mark J Hancock, PhD, Alice Kongsted, PhD, Prof Quinette Louw, PhD, Manuela L Ferreira, PhD, Stéphane Genevay, MD, Damian Hoy, PhD, Prof Jaro Karppinen, PhD, Glenn Pransky, MD, Prof Joachim Sieper, MD, Prof Rob J Smeets, PhD, Prof Martin Underwood, MD

Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark,
Odense, Denmark;
Nordic Institute of Chiropractic and Clinical Biomechanics,
Odense, Denmark.

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide.

For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause – eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling.

Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect.

Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

From the FULL TEXT Article:


Low back pain is an extremely common symptom experienced by people of all ages. [1–3] In 2015, the global point prevalence of activity-limiting low back pain was 7.3%, implying that 540 million people were affected at any one time. Low back pain is now the number one cause of disability globally. [4] The largest increases in disability caused by low back pain in the past few decades have occurred in low-income and middle-income countries, including in Asia, Africa, and the Middle East, [5] where health and social systems are poorly equipped to deal with this growing burden in addition to other priorities such as infectious diseases.

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Prevention and Treatment of Low Back Pain

By |April 6, 2018|Low Back Pain|

Prevention and Treatment of Low Back Pain:
Evidence, Challenges, and Promising Directions

The Chiro.Org Blog

SOURCE:   Lancet. 2018 (Mar 20) [Epub]

Nadine E Foster, Johannes R Anema, Dan Cherkin, Roger Chou, Steven P Cohen, Douglas P Gross, Paulo H Ferreira, Julie M Fritz, Bart W Koes, Wilco Peul, Judith A Turner, Chris G Maher, on behalf of the Lancet Low Back Pain Series Working Group

Arthritis Research UK Primary Care Centre,
Research Institute for Primary Care and Health Sciences,
Keele University,
Staffordshire, UK.

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences.

The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation.

These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

From the FULL TEXT Article:


Despite the plethora of treatments and health-care resources devoted to low back pain, back-related disability and population burden have increased. [1, 2] The first paper [3] in this Series describes the global burden and effect of low back pain and provides an overview of the causes and course of low back pain. In this Series paper, we summarise the evidence for effectiveness of interventions for the prevention and treatment of low back pain and the recommendations from best practice guidelines. Despite generally consistent guideline recommendations around the world, clear evidence exists of substantial gaps between evidence and practice that are pervasive in low-income, middle-income, and high-income countries. Different response strategies are needed that prevent and minimise disability and promote participation in physical and social activities. Here we highlight examples of effective, promising, or emerging solutions from around the world and make recommendations to strengthen the vidence base for them.


Table 1

By contrast with the large number of trials that assess treatments for low back pain, evidence about prevention, particularly primary prevention, is inadequate (table 1). Most of the widely promoted interventions to prevent low back pain (eg, work-place education, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices) do not have a firm evidence base. A 2016 systematic review [4] identified only 21 trials with 30,850 adults (one in a low-middle-income country [Thailand]), and a 2014 systematic review [5] analysed only 11 randomised controlled trials with 2,700 children (one in a low-middle income country [Brazil]).

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