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National Clinical Guidelines for Non-surgical Treatment of Patients with Recent Onset Low Back Pain or Lumbar Radiculopathy

By |July 27, 2017|Guidelines, Low Back Pain|

National Clinical Guidelines for Non-surgical Treatment of Patients with Recent Onset Low Back Pain or Lumbar Radiculopathy

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SOURCE:   Eur Spine J. 2017 (Apr 20) [Epub] 1451–1460

Mette Jensen Stochkendahl, Per Kjaer,
Jan Hartvigsen, Alice Kongsted1,
Jens Aaboe, Margrethe Andersen, et al.

Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark,
Campusvej 55, 5230, Odense M, Denmark.


PURPOSE:   To summarise recommendations about 20 non-surgical interventions for recent onset (<12 weeks) non-specific low back pain (LBP) and lumbar radiculopathy (LR) based on two guidelines from the Danish Health Authority.

METHODS:   Two multidisciplinary working groups formulated recommendations based on the GRADE approach.

RESULTS:   Sixteen recommendations were based on evidence, and four on consensus. Management of LBP and LR should include information about prognosis, warning signs, and advise to remain active. If treatment is needed, the guidelines suggest using patient education, different types of supervised exercise, and manual therapy. The guidelines recommend against acupuncture, routine use of imaging, targeted treatment, extraforaminal glucocorticoid injection, paracetamol, NSAIDs, and opioids.

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Amount of Health Care and Self-care Following a Randomized Clinical Trial Comparing Flexion-distraction with Exercise Program for Chronic Low Back Pain

By |July 25, 2017|Chiropractic Care, Low Back Pain|

Amount of Health Care and Self-care Following a Randomized Clinical Trial Comparing Flexion-distraction with Exercise Program for Chronic Low Back Pain

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SOURCE:   Chiropractic & Osteopathy 2006 (Aug 24); 14: 19

Jerrilyn A Cambron, M Ram Gudavalli,
Marion McGregor, James Jedlicka,
Michael Keenum, Alexander J Ghanayem,
Avinash G Patwardhan and Sylvia E Furner

Department of Research,
National University of Health Sciences,
Lombard, IL, USA.


BACKGROUND:   Previous clinical trials have assessed the percentage of participants who utilized further health care after a period of conservative care for low back pain, however no chiropractic clinical trial has determined the total amount of care during this time and any differences based on assigned treatment group. The objective of this clinical trial follow-up was to assess if there was a difference in the total number of office visits for low back pain over one year after a four week clinical trial of either a form of physical therapy (Exercise Program) or a form of chiropractic care (Flexion Distraction) for chronic low back pain.

METHODS:   In this randomized clinical trial follow up study, 195 participants were followed for one year after a four-week period of either a form of chiropractic care (FD) or a form of physical therapy (EP). Weekly structured telephone interview questions regarded visitation of various health care practitioners and the practice of self-care for low back pain.

RESULTS:   Participants in the physical therapy group demonstrated on average significantly more visits to any health care provider and to a general practitioner during the year after trial care (p < 0.05). No group differences were noted in the number of visits to a chiropractor or physical therapist. Self-care was initiated by nearly every participant in both groups.

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Cortical Changes in Chronic Low Back Pain

By |July 3, 2017|Cortical Changes, Low Back Pain|

Cortical Changes in Chronic Low Back Pain: Current State of the Art and Implications for Clinical Practice

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SOURCE:   Man Ther. 2011 (Feb); 16 (1): 15-20

Benedict Martin Wand, Luke Parkitny,
Neil Edward O’Connell, Hannu Luomajoki,
James Henry McAuley, Michael Thacker,
G. Lorimer Moseley

School of Health Sciences,
The University of Notre Dame Australia,
Fremantle, WA, Australia


There is increasing evidence that chronic pain problems are characterised by alterations in brain structure and function. Chronic back pain is no exception. There is a growing sentiment, with accompanying theory, that these brain changes contribute to chronic back pain, although empirical support is lacking. This paper reviews the structural and functional changes of the brain that have been observed in people with chronic back pain. We cast light on the clinical implications of these changes and the possibilities for new treatments but we also advise caution against concluding their efficacy in the absence of solid evidence to this effect.


From the Full-Text Article:

Introduction

Chronic musculoskeletal pain is almost by definition a problem for which previous treatment has been unsuccessful. The clinical stories of patients with problems such as chronic low back pain (CLBP), fibromyalgia, and late whiplash associated disorder are usually ones of confusing and conflicting diagnoses and multiple treatment failures. Diagnosis and treatment has traditionally focused on what Robinson and Apkarian (2009) have called ‘end organ dysfunction’. That is, clinicians and researchers have looked to structural and functional abnormalities within the musculoskeletal system for a driver of the clinical condition and treatment has sought to normalise peripheral pathology and mechanics (stretch it, splint it, remove it, anaesthetise or denervate it). In general terms the ‘end organ dysfunction’ approach might be considered to have proven unsuccessful for these conditions (see for e.g. van Tulder et al., 2006a; van Tulder et al., 2006b). Neuroimaging studies have revealed numerous structural and functional changes within the brains of people with chronic musculoskeletal pain and there is growing opinion that these changes may contribute to the development and maintenance of the chronic pain state (Apkarian et al., 2009; Tracey and Bushnell, 2009). In this model of chronic pain the brain is seen as an explicit target for treatment and several treatment strategies have been developed and modified to fit this aim. Although there are data available on a range of chronic painful disorders, we will focus here on the cortical changes observed in patients with CLBP and the possible clinical implications for this population.


Brain changes in people with CLBP

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Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain

By |June 30, 2017|Low Back Pain|

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis

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SOURCE:   JAMA. 2017 (Apr 11); 317 (14): 1451–1460

Neil M. Paige, MD, MSHS, Isomi M. Miake-Lye, BA,
Marika Suttorp Booth, MS, Jessica M. Beroes, BS,
Aram S. Mardian, MD, Paul Dougherty, DC,
Richard Branson, DC, Baron Tang, PT, DPT,
Sally C. Morton, PhD, Paul G. Shekelle, MD, PhD

West Los Angeles Veterans Affairs Medical Center,
Los Angeles, California


Commentary from the Illinois Chiropractic Society

JAMA Endorses Spinal Manipulation

For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1]   On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.

The authors concluded:

“Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

This study comes on the heels of a February 2017 Clinical Practice Guideline from the American College of Physicians recommending spinal manipulation for acute, sub-acute, and chronic low back pain (LBP). [2]

These high-quality studies in respected medical journals add to a growing list of scientific support for spinal manipulation therapy (SMT). So why are our offices not flooded with medical referrals? An editorial accompanying the JAMA study provides perspective as to why some medical providers may be reluctant to refer to chiropractic physicians:

“Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors. Chiropractic therapy is not widely accepted by some traditional health care practitioners. This may be, at least in part, because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.

However, chiropractic care is popular today with the US public. According to a 2012 report, among patients with back or neck pain, approximately 30% sought care from a chiropractor. In a 2013 survey by Consumer Reports magazine involving 14,000 subscribers with low back pain, chiropractic care had the largest proportion of “highly satisfied” patients. Among approximately 4000 respondents who had seen a chiropractor, 59% were highly satisfied compared with 55% who saw a physical therapist and 34% who saw a primary care physician.

“Serious complications (related to SMT) are extremely rare… if spinal manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for patients with uncomplicated low back pain”. [3]

The emerging health care model dictates that all providers embrace proven clinically effective treatments, regardless of long-standing philosophical bias.   If we expect medical providers to advance their thinking to accept validated chiropractic therapies, we must first be willing to reciprocate. By working together to provide evidence-based patient-centric care, we can advance our profession to become the undeniable first choice for both patients and providers.


References:

  1. Paige NM, Miake-Lye IM, Booth MS, et al.
    Association of Spinal Manipulative Therapy With Clinical Benefit and Harm
    for Acute Low Back Pain; Systematic Review and Meta-analysis

    JAMA. 2017 (Apr 11);   317 (14):   1451–1460

  2. Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee
    of the American College of Physicians.
    Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
    A Clinical Practice Guideline From the American College of Physicians

    Ann Intern Med. 2017 (Apr 4);   166 (7):   514–530

  3. Deyo RA.
    The Role of Spinal Manipulation in the Treatment of Low Back Pain.
    JAMA. 2017;   317 (14):   1418-1419

The Abstract:

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Take the Guideline Challenge

By |May 16, 2017|Clinical Guidelines, Low Back Pain|

Take the Guideline Challenge

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SOURCE:   ACA News ~ May 15, 2017

By Christine Goertz, DC, PhD

Dr. Goertz is senior scientific advisor for the ACA. She also serves as vice chancellor for research and health policy at Palmer College of Chiropractic and is the CEO of the Spine Institute for Quality (Spine IQ)


In my last blog post, I talked about the unprecedented opportunity the chiropractic profession has to make a critical difference in areas of great public health impact, such as low back pain. I strongly believe that if we do the right thing right now, the chiropractic profession is uniquely positioned to significantly impact the quality of spine care delivery, increasing access to chiropractic care for millions of patients who desperately need conservative treatment for spine-related conditions. The flipside is that if we don’t take right action now, chiropractic risks becoming a marginalized profession that’s on the outside looking in as other health care providers take ownership of musculoskeletal conditions and spinal manipulation.

So what is right action? Recently, I asked this question of several of my colleagues who influence policy at the highest levels of research and/or health care delivery in the United States. One of those people was Francis Collins, MD, PhD, director of the National Institutes of Health. [1] Dr. Collins responded by saying:

Chiropractic’s commitment to evidence-based practice and to addressing gaps in the scientific basis of chiropractic care is vital for the progress of the field. Robust research on the safety and effectiveness of chiropractic therapies in the management of common musculoskeletal complaints must continue to be a high priority for the profession. Advancing evidence-based chiropractic care will further the integration of chiropractic into medical systems at a time when the need for effective approaches to improve outcomes for patients with chronic pain could not be more pressing.

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Elevated Production of Nociceptive CC-chemokines and sE-selectin in Patients with Low Back Pain and the Effects of Spinal Manipulation: A Non-randomized Clinical Trial

By |April 22, 2017|Low Back Pain, Spinal Joint Pain|

Elevated Production of Nociceptive CC-chemokines and sE-selectin in Patients with Low Back Pain and the Effects of Spinal Manipulation: A Non-randomized Clinical Trial

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SOURCE:   Clin J Pain. 2017 (Apr 19) [Epub]

Julita A. Teodorczyk-Injeyan, PhD,
Marion McGregor, PhD, DC,
John J. Triano, DC, PhD,
H. Stephen Injeyan, PhD, DC

Graduate Education and Research Programs,
Canadian Memorial Chiropractic College,
Toronto, Ontario, Canada


BACKGROUND:   The involvement of inflammatory components in the pathophysiology of low back pain is poorly understood. It has been suggested that spinal manipulative therapy (SMT) may exert anti-inflammatory effects.

PURPOSE:   To determine the involvement of inflammation-associated chemokines (CC series) in the pathogenesis of non-specific low back pain and to evaluate the effect of SMT on that process.

METHODS:   Patients presenting with non-radicular, non-specific low back pain (minimum pain score 3 on 10 point visual analogue scale, VAS) were recruited according to stringent inclusion criteria. They were evaluated for appropriateness to treat using a high velocity low amplitude manipulative thrust (HVLT) in the lumbar-lumbosacral region. Blood samples were obtained at baseline and following the administration of a series of 6 HVLTs on alternate days over the period of two weeks. The in vitro levels of CC chemokines (CCL2, CCL3 and CCL4) production and plasma levels of an inflammatory biomarker, soluble E-selectin, were determined at baseline and at the termination of treatments two weeks later.

RESULTS:   Compared with asymptomatic controls baseline production of all chemokines was significantly elevated in acute (P=0.004 – <0.0001), and that of CCL2 and CCL4 in chronic LBP patients (P<0.0001). Furthermore, CCL4 production was significantly higher (P<0.0001) in the acute versus chronic LBP group. sE-selectin levels were significantly higher (P=0.003) in chronic but not in acute LBP patients. Following SMT, patient reported outcomes showed significant (P<0.0001) improvements in VAS and ODI scores. This was accompanied by a significant decline in CCL 3 production (P<0.0001) in both groups of patients. Change scores for CCL4 production differed significantly (P<0.0001) only for the acute LBP cohort, and no effect on the production of CCL2 or plasma sE-selectin levels was noted in either group.

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