J Manipulative Physiol Ther. 2018 (Aug 15) [Epub] ~ FULL TEXT
Scott Haldeman, Claire D. Johnson, Roger Chou, Margareta Nordin, Pierre Côté, Eric L. Hurwitz, Bart N. Green, Christine Cedraschi et. al.
Santa Monica, California.
OBJECTIVES: Chronic low back pain (CLBP) and chronic neck pain (CNP) are the most common types of chronic pain, and chiropractic spinal manipulation is a common nonpharmacologic treatment. This study presents the characteristics of a large United States sample of chiropractic patients with CLBP and CNP.
METHODS: Data were collected from chiropractic patients using multistage systematic stratified sampling with 4 sampling levels: regions and states, sites (ie, metropolitan areas), providers and clinics, and patients. The sites and regions were San Diego, California; Tampa, Florida; Minneapolis, Minnesota; Seneca Falls and Upstate New York; Portland, Oregon; and Dallas, Texas. Data were collected from patients through an iPad-based prescreening questionnaire in the clinic and emailed links to full screening and baseline online questionnaires. The goal was 20 providers or clinics and 7 patients with CLBP and 7 with CNP from each clinic.
RESULTS: We had 6342 patients at 125 clinics complete the prescreening questionnaire, 3333 patients start the full screening questionnaire, and 2024 eligible patients completed the baseline questionnaire: 518 with CLBP only, 347 with CNP only, and 1159 with both. In general, most of this sample were highly-educated, non-Hispanic, white females with at least partial insurance coverage for chiropractic care who have been in pain and using chiropractic care for years. Over 90% reported high satisfaction with their care, few used narcotics, and avoiding surgery was the most important reason they chose chiropractic care.
CONCLUSIONS: Given the prevalence of Chronic low back pain (CLBP) and chronic neck pain (CNP), the need to find effective nonpharmacologic alternatives for chronic pain, and the satisfaction these patients found with their care, further study of these patients is worthwhile.
Key Indexing Terms: Manipulation, Spinal, Chronic Pain, Low Back Pain, Neck Pain, Chiropractic, Manipulation, Chiropractic
From the FULL TEXT Article:
Chronic low back pain (CLBP) and chronic neck pain (CNP) are the most common types of chronic pain. [1, 2] Their combined prevalence is estimated to be about 10% to 20% of the adult population. [1, 3–10] Although there are many treatments for chronic pain, [2, 11] because of the dangers of opioid abuse, recent efforts have focused on finding effective nonpharmacologic therapies.  Chiropractors, osteopaths, and physical therapists are the provider types most likely to deliver spinal manipulation,  which is 1 of the nonpharmacologic treatments recommended for these conditions. [14–18] In the US, about 30% of those with spinal pain have used chiropractic. 
However, what is unknown is how those with CLBP and CNP are using chiropractic. Are they using short courses of chiropractic care or are they using this care long term? What are their motivations for using chiropractic care, and are they satisfied with this care? Several studies have described the characteristics of typical chiropractic patients, [13, 20–24] and others have described the characteristics of patients with back or neck pain, [6–10, 25] including some that focus on chronic forms of these conditions. [5, 26, 27] However, no study provides a detailed look at the demographics; attitudes; motivations; pain and functioning; and the utilization of chiropractic, self-care, and other health care among those using chiropractic care for their CLBP and CNP. Given the prevalence and long-term nature of chronic pain, understanding the issues of this population are essential to developing successful policies for the treatment of CLBP and CNP.
This study describes the characteristics of a large sample of CLBP and CNP patients in the United States who use chiropractic care for their CLBP and CNP. These data were collected in support of a larger project to advance methods to determine the appropriateness of manipulation and mobilization for CLBP and CNP.
This study presents the characteristics of a large sample of chiropractic patients with CLBP or CNP. In general, most of this sample are highly-educated, non-Hispanic, white females, with at least partial insurance coverage for chiropractic and who have been in pain and using chiropractic care for years. These tendencies are generally similar across the different pain subgroups (CLBP only, CNP only, or both), with 2 exceptions. There was a higher prevalence of men in the CLBP only group than in the other 2 groups, and the group with both CLBP and CNP tended to have had their pain and used chiropractic care longer.
The best data we have on whether this sample is a true representation of all chiropractic patients at these clinics with CLBP or CNP comes from comparing those for whom we have some data (those screened in and who consented to the study but did not go on to complete the baseline survey) to those who went on to the baseline survey. We found no real statistically significant differences between these groups, even for variables indicating a strong commitment to chiropractic care. We do see a differential dropout across states in the numbers that went from the prescreening questionnaire to the baseline survey. However, the interpretation of this finding is unclear.
The study protocol requested that the front desk staff for the clinics in the study give the prescreening questionnaire (on the iPad) to all patients during the 4–week recruitment period and to tally the patients seen by the chiropractors each day. However, clinic staff were inconsistent in taking and reporting this tally, making it difficult to provide an accurate denominator across clinics for our sampling frame. Our best estimate of the average number of unique patients visiting our sample clinics was 51 patients over that 4–week period. But the fact that only 2 percent of the sample was lost for not having back pain or neck pain is an indication that some of the front desk staff may have only offered the prescreening questionnaire to those they knew to have back pain or neck pain. Other studies of chiropractic patients have shown that the majority (60%–90%) have back pain or neck pain. [20–23] Also of note, 85% of those who made it to the full screening questionnaire were determined to have CLBP or CNP. Other studies have shown lower, but still substantial, proportions of chronic pain in those with back pain and neck pain. [5, 8, 9, 25] However, there are many definitions of chronicity, [30, 31] and our higher percentage could reflect our definition of chronicity or a biased offering of the prescreening questionnaire by the front desk staff.
Our sample shows a large overlap between the prevalence of CLBP and CNP. At baseline, just over a quarter had CLBP alone, just over 17% had CNP alone, and almost 60% had both. Other studies show the higher prevalence of CLBP than CNP, but none show such a large overlap. [5, 32] Again, this could be at least partially due to our broad definition of chronicity.
The demographics of our sample are similar to what has been seen in other chiropractic, CLBP and CNP samples. Our sample is of similar age,  if not a few years older, on average than seen in other studies of chiropractic [20–23] and CLBP or CNP. [8, 10, 26, 32] Other studies have found the prevalence of women in chiropractic care [20–23] and with CLBP or CNP to be higher than for men. [5, 10, 25–27] Previous studies of chiropractic patients have also seen a high prevalence of non-Hispanic white patients, [20–22] those with high levels of income  and education, [20, 22] and those with at least partial insurance coverage for chiropractic. [20–22] Similar racial or ethnic profiles and high income and education were also found for those who used any type of complementary and alternative medicine for back and neck problems.  Other studies of CLBP and CNP have also seen long durations of pain, although none quite as long as our averages of 11.3 to 15.6 years. [26, 27, 33, 34]
Our sample is made up of individuals with CLBP or CNP who were receiving chiropractic care currently and had been receiving it for a long time. Therefore, we would expect their average pain and disability scores to better reflect those of others under chiropractic treatment. A study of manipulative treatment for CLBP had an average 0 to 10 pain score of 5.95 and an Oswestry score of 29.5 at baseline for the treatment group and a 2.57 pain score and a 13.7 Oswestry score at 12 months.  Another study of spinal manipulation for CNP had an average 0 to 10 pain score of 5.6 and a Neck Disability Index score of 27.9 at baseline for the spinal manipulation group and a 3.5 pain score and a 19.5 Neck Disability Index score at 12 months.  Our average for the CLBP only group was a pain score of 2.8 and Oswestry score of 19.1, and for the CNP only group was a pain score of 2.8 and a Neck Disability Index score of 21.4, which were all, as would be expected, closer to these studies’ posttreatment values than baseline.
Our study found that most patients had seen another type of practitioner before coming to the chiropractor, and about half saw another practitioner in the past 6 months. The most common types of practitioners seen were primary care providers, massage therapists, and physical therapists. Another study of those with neck pain and low back pain also found that for those who were seeing a chiropractor, the most common other practitioners seen were medical doctors, massage therapists, and physical therapists.  Another study of chiropractic patients reported that 3% of patients had surgery for their condition before receiving chiropractic care,20 which is lower than our average of 6%. The use of narcotics in our sample of chiropractic patients (an average of 5% reporting often or always use), however, is substantially lower than the 45% to 60% use found in a large sample of CLBP patients in North Carolina. 
Finally, our sample’s belief in, and high recommendation for, their chiropractic care aligns well with the consistent high satisfaction with chiropractic care reported elsewhere. [13, 20, 24, 35]
Because it was a study of those with CLBP or CNP under chiropractic care, and not a study of all of those with CLBP or CNP, we lack the ability to empirically place this sample within the broader CLBP and CNP populations. Second, we excluded chiropractors with instrument-assisted-only practices. We included chiropractors who used instrument-assisted therapies in their practices if they also offered manipulation or mobilization. Third, these survey data have the usual limitations related to self-reported measures. Fourth, these data are not from a random sample of all chiropractic patients with CLBP or CNP. We used a combination of systematic stratification to get a representative sample of chiropractors, clustering clinics by geographic region to allow for an in-person clinic set up, and convenience sampling of all chiropractic patients in those clinics during the 4–week recruitment window. Therefore, it is a reasonable assumption that this sample is representative of all chiropractic patients with CLBP and CNP seen in practices that are not instrument-assisted-only.
This study provides insight into the characteristics of patients who are successfully managing their CLBP and CNP. Findings of this descriptive study of a large sample of chiropractic patients with CLBP or CNP reveal this sample to be similar to those found in other studies of chiropractic patients: highly-educated, non-Hispanic, white women, with at least partial insurance coverage for chiropractic. These individuals have also been in pain and using chiropractic care for years. Most came to chiropractic after trying other types of care, and just under a third continued to receive other concurrent care for their pain. Prior to chiropractic, they saw the best results with massage therapy and acupuncture and reported high levels of belief in the success of chiropractic in reducing their pain. This group has low use of narcotics and other pain medications, and most rate avoiding surgery as the most important reason for choosing chiropractic care. Given the prevalence of CLBP and CNP, the need to find effective nonpharmacologic alternatives for chronic pain, and the long-term satisfaction these patients found with their care, further study of these patients and their providers and comparisons with other subgroups with CLBP and CNP are worthwhile. In addition, documenting the current role chiropractors are playing in the care and treatment of patients with chronic pain may help position these providers for an expanded role in the future.
Johannes, CB, Le, TK, Zhou, X, Johnston, JA, and Dworkin, RH.
The prevalence of chronic pain in United States adults: results of an internet-based survey.
J Pain. 2010; 11: 1230–1239
Institute of Medicine.
Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
The National Academies Press, Washington, DC; 2011
Meucci, RD, Fassa, AG, and Faria, NMX.
Prevalence of chronic low back pain: systematic review.
Rev Saude Publica. 2015; 49: 1–9
Freburger, JK, Holmes, GM, Agans, RP et al.
The rising prevalence of chronic low back pain.
Arch Intern Med. 2009; 169: 251–258
Webb, R, Brammah, T, Lunt, M, Urwin, M, Allison, T, and Symmons, D.
Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population.
Spine. 2003; 28: 1195–1202
Bovim, G, Schrader, H, and Sand, T.
Neck pain in the general population.
Spine. 1994; 19: 1307–1309
Guez, M, Hildingsson, C, Nilsson, M, and Toolanen, G.
The prevalence of neck pain.
Acta Orthop Scand. 2002; 73: 455–459
Cassidy, JD, Cote, P, Carroll, LJ, and Kristman, V.
Incidence and course of low back pain episodes in the general population.
Spine. 2005; 30: 2817–2823
Hestbaek, L, Leboeuf-Yde, C, and Manniche, C.
Low Back Pain: What Is The Long-term Course?
A Review of Studies of General Patient Populations
European Spine Journal 2003 (Apr); 12 (2): 149–165
Hogg-Johnson, S, Van Der Velde, G, Carroll, LJ et al.
The Burden and Determinants of Neck Pain in the General Population:
Results of the Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders.
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S39–51
Chou, RMD, Atlas, SJMDMPH, Stanos, SPDO, and Rosenquist, RWMD.
Nonsurgical Interventional Therapies for Low Back Pain:
A Review of the Evidence for an American Pain Society Clinical Practice Guideline
Spine (Phila Pa 1976). 2009 (May 1); 34 (10): 1078–1093
National Pain Strategy Task Force.
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain
Interagency Pain Research Coordinating Committee (IPRCC),
National Institutes of Health (NIH), Bethesda, MD; 2015
Epidemiology: Spinal Manipulation Utilization
J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 648–654
Chou, R, Qaseem, A, Snow, V et al.
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
from the American College of Physicians and the American Pain Society
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491
Childs, JD, Cleland, JA, Elliott, JM et al.
Neck pain: clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association.
J Orthop Sports Phys Ther. 2008; 38: A1–A34
Haldeman, S, Carroll, L, Cassidy, JD, Schubert, J, and Nygren, Å.
The Bone and Joint Decade 2000–2010 Task Force on Neck Pain
and Its Associated Disorders: Executive Summary
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S5–7
Hurwitz, EL, Carragee, EJ, van der Velde, G et al.
Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade
2000–2010 Task Force on Neck Pain and Its Associated Disorders
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S123–152
Wenger, HC and Cifu, AS.
Treatment of low back pain.
JAMA. 2017; 318: 743–744
Martin BI, Gerkovich MM, Deyo RA, et al.
The Association of Complementary and Alternative Medicine Use
Health Care Expenditures for Back and Neck Problems
Med Care. 2012 (Dec); 50 (12): 1029–1036
Coulter, ID and Shekelle, PG.
Chiropractic in North America: a descriptive analysis.
J Manipulative Physiol Ther. 2005; 28: 83–89
Mootz, RD, Cherkin, DC, Odegard, CE, Eisenberg, DM, Barassi, JP, and Deyo, RA.
Characteristics of Chiropractic Practitioners, Patients, and Encounters in Massachusetts and Arizona
J Manipulative Physiol Ther. 2005 (Nov); 28 (9): 645–653
Stevans, JM and Zodet, MW.
Clinical, demographic, and geographic determinants of variation in chiropractic episodes of care for adults using the 2005-2008 medical expenditure panel survey.
J Manipulative Physiol Ther. 2012; 35: 589–599
Hurwitz, EL, Coulter, ID, Adams, AH, Genovese, BJ, and Shekelle, PG.
Use of chiropractic services from 1985 through 1991 in the United States and Canada.
Am J Public Health. 1998; 88: 771–776
Cooper, RA and McKee, HJ.
Chiropractic in the United States: trends and issues.
Milbank Q. 2003; 81: 107–138
Côté, P, Cassidy, JD, Carroll, LJ, and Kristman, V.
The annual incidence and course of neck pain in the general population: a population-based cohort study.
Pain. 2004; 112: 267–273
Knauer, SR, Freburger, JK, and Carey, TS.
Chronic low back pain among older adults: a population-based perspective.
J Aging Health. 2010; 22: 1213–1234
Verkerk, K, Luijsterburg, P, Heymans, M et al.
Prognosis and course of pain in patients with chronic non-specific low back pain: A 1-year follow-up cohort study.
Eur J Pain. 2015; 19: 1101–1110
Christensen, MG, Hyland, JK, Goertz, CM, and Kollasch, MW.
Practice Analysis of Chiropractic 2015
National Board of Chiropractic Examiners,
Greeley, CO; 2015
Bender, R and Lange, S.
Adjusting for multiple testing—when and how?.
J Clin Epidemiol. 2001; 54: 343–349
Cedraschi, C, Robert, J, Goerg, D, Perrin, E, Fischer, W, and Vischer, T.
Is chronic non-specific low back pain chronic? Definitions of a problem and problems of a definition.
Br J Gen Pract. 1999; 49: 358–362
Von Korff, M and Miglioretti, DL.
A prognostic approach to defining chronic pain.
Pain. 2005; 117: 304–313
Côté, P, Cassidy, JD, and Carroll, L.
The Treatment of Neck and Low Back Pain: Seeks Care? Who Goes Where?
Med Care. 2001 (Sep); 39 (9): 956–967
Evans, R, Bronfort, G, Nelson, B, and Goldsmith, CH.
Two-year Follow-up of a Randomized Clinical Trial of Spinal Manipulation and Two Types
of Exercise for Patients With Chronic Neck Pain
Spine (Phila Pa 1976). 2002 (Nov 1); 27 (21): 2383–2389
Niemistö, L, Lahtinen-Suopanki, T, Rissanen, P, Lindgren, KA, and Hurri, H.
A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain.
Spine. 2003; 28: 2185–2191
Posner, J and Glew, C.
Ann Intern Med. 2002; 136: 758–759
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