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Low Back Pain and Chiropractic

This section was compiled by Frank M. Painter, D.C.
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Trajectories of Low Back Pain Patient Expectations of Relief

What is Usual Care? Chiropractic and Spinal Pain

Chiropractic Care For Veterans

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Low Back Pain Research

Initial Provider/First Contact and Chiropractic  
A Chiro.Org article collection

Although it's long been suspected, it's finally well-documented that higher patient satisfaction rates, faster return-to-work, and significant savings occur when your first choice for care is with a chiropractor, when you suffer from low back pain, neck pain or headaches.

Chiropractic Care For Veterans
A Chiro.Org article collection

Review this collection of studies detailing the slowly expanding use of chiropractic care for vererans and active military.

The McKenzie Method Page
A Chiro.Org article collection

The McKenzie Method is grounded in finding a cause and effect relationship between the positions the patient usually assumes while sitting, standing, or moving, and the generation of pain as a result of those positions or activities. The therapeutic approach requires a patient to move through a series of activities and test movements to gauge the patient's pain response. The approach then uses that information to develop an exercise protocol designed to centralize or alleviate the pain.

Workers' Compensation and Chiropractic
A Chiro.Org article collection

Studies going back to the 1980s reveal that chiropractic care gets workers back to work faster and cheaper than standard medical care. Drop by and enjoy this new topical collection.

Identifying Motor Control Strategies and Their Role in Low Back Pain:
A Cross-Disciplinary Approach Bridging Neurosciences with Movement Biomechanics

Frontiers in Pain Research 2021 (Aug 11); 2: 715219~ FULL TEXT

Provided that the suggested motor control strategy phenotypes can be reliably identified using the approach described in this article, the knowledge generated might lead to important implications for clinical research and interventions. For example, it has been proposed that a persistent “tight control strategy” may be specifically targeted by reducing muscle excitability and co-contraction while increasing movement variability in motor control exercise. [12] With regards to this, our approach might provide promising behavior- and neuroimaging-based outcomes to test the potential therapeutic effect of individualized motor control exercises and how they compare to other treatment approaches.

Association of Lumbar Spine Radiographic Changes With Severity of Back Pain-Related
Disability Among Middle-aged, Community-Dwelling Women

JAMA Network Open 2021 (May 3);   4 (5):   e2110715~ FULL TEXT

In this cohort of middle-aged, community-dwelling women, there was no evidence to support an association between a higher number of lumbar segments with radiographic changes (K-L grade, osteophytes, and disc space narrowing) and more severe back pain–related disability cross-sectionally or over time. The findings suggest that the changes detected on lumbar radiographs provide limited value for decision-making regarding back pain management in this population.

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading
To Neurogenic Claudication: A Clinical Practice Guideline

Journal of Pain 2021 (Apr 1)   2;   S1526-5900(21)00188-7

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC.

The Effect of Spinal Manipulative Therapy on Pain Relief and Function
in Patients with Chronic Low Back Pain: An Individual
Participant Data Meta-analysis

Physiotherapy 2021 (Mar 17);   112:   121–134 ~ FULL TEXT

Of the 42 RCTs fulfilling the inclusion criteria, we obtained IPD from 21 (n = 4,223). Most trials (s = 12, n = 2,249) compared SMT to recommended interventions. There is moderate quality evidence that SMT vs recommended interventions resulted in similar outcomes on pain (MD –3.0, 95%CI: –6.9 to 0.9, 10 trials, 1,922 participants) and functional status at one month (SMD: –0.2, 95% CI –0.4 to 0.0, 10 trials, 1,939 participants). Effects at other follow-up measurements were similar. Results for other comparisons (SMT versus non-recommended interventions; SMT as adjuvant therapy; mobilization versus manipulation) showed similar findings. SMT versus sham SMT analysis was not performed, because we only had data from one study. Sensitivity analyses confirmed these findings. Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP.

Evaluation Is Treatment for Low Back Pain
J Man Manip Ther 2021 (Feb);   29 (1):   4–13 ~ FULL TEXT

♦   This study shows that the evaluation process by itself plays a big role in the improvement of patients with low back pain at the initial consultation, not just the treatment.

♦   The history taking portion showed to have a larger effect over the physical exam on reducing pain and function during the initial evaluation.

Effects of Spinal Manipulative Therapy on Inflammatory Mediators in Patients
with Non-specific Low Back Pain: A Non-randomized Controlled Clinical Trial

Chiropractic & Manual Therapies 2021 (Jan 8);   29 (1):   3~ FULL TEXT

The short course of SMT treatments of non-specific LBP patients resulted in significant albeit limited and diverse alterations in the production of several of the mediators investigated in this study. This exploratory study highlights the potential of SMT to modulate the production of inflammatory components in acute and chronic non-specific LBP patients and suggests a need for further, randomized controlled clinical trials in this area.

Veteran Response to Dosage in Chiropractic Therapy (VERDICT):
Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain

Pain Medicine 2020 (Dec 12);   21 (Suppl 2):   S37–S44 ~ FULL TEXT

Lack of information on optimal dosing is a significant barrier to planning and operationalizing the continued implementation of VA chiropractic services. Currently, few published data are available to guide the development of DC staffing models that would provide optimal access to care for veterans with cLBP. The extended-care approach of CCPM is not currently used in the VA, in part because of the lack of studies conducted in the United States demonstrating its effectiveness. Accurate information on the effectiveness of different dosing regimens of chiropractic care could greatly assist health systems, including the VA, in modeling the number of DCs that will best meet the needs of patients with cLBP.

Cost Comparison of Two Approaches to Chiropractic Care for Patients with Acute
and Sub-acute Low Back Pain Care Episodes: A Cohort Study

Chiropractic & Manual Therapies 2020 (Dec 14);   28 (1):   68~ FULL TEXT

Low back pain (LBP) imposes a costly burden upon patients, healthcare insurers, and society overall. Spinal manipulation as practiced by chiropractors has been found be cost-effective for treatment of LBP, but there is wide variation among chiropractors in their approach to clinical care, and the most cost-effective approach to chiropractic care is uncertain. To date, little has been published regarding the cost effectiveness of different approaches to chiropractic care. Thus, the current study presents a cost comparison between chiropractic approaches for patients with acute or subacute care episodes for low back pain.

The Lancet Series Call to Action to Reduce Low Value Care
for Low Back Pain: An Update

Pain. 2020 (Sep);   161 (1):   S57–S64 ~ FULL TEXT

The 2018 Lancet Low Back Pain Series, comprising 3 papers written by 31 authors from disparate disciplines and 12 different countries, raised unprecedented awareness of the rising global burden of low back pain partly attributable to poor quality health care. [12, 30, 44] Many people with low back pain get the wrong care, causing harm to millions across the world and wasting valuable health care resources. Based upon an up-to-date, evidence-based synthesis, the series described current guideline recommended care of low back pain, and new strategies that show promise, but require further testing, to reduce low value care. We also proposed a series of actions needed to reverse the alarming global rise in low back pain disability. A better understanding of low back pain in different cultures and changes to the way care for low back pain is delivered and the way clinicians are reimbursed are key to reversing this problem.

Effects of Chiropractic Care on Strength, Balance, and Endurance in Active-Duty
U.S. Military Personnel with Low Back Pain: A Randomized Controlled Trials

J Altern Complement Med 2020 (Jul);   26 (7):   592–601–693

Participants had mean age of 30 years (18-40), 17% were female, 33% were non-white, and 86% reported chronic LBP. Mean maximum pulling strength in the chiropractic group increased by 5.08 kgs and decreased by 7.43 kgs in the wait-list group, with a statistically significant difference in mean change between groups (p = 0.003). Statistically significant differences in mean change between groups were also observed in trunk muscle endurance (13.9 sec, p = 0.002) and balance with eyes closed (0.47 sec, p = 0.01), but not in balance with eyes open (1.19 sec, p = 0.43). Differences in mean change between groups were statistically significant in favor of chiropractic for LBP-related disability, pain intensity and interference, and fear-avoidance behavior. Active-duty military personnel receiving chiropractic care exhibited improved strength and endurance, as well as reduced LBP intensity and disability, compared with a wait-list control.

Experiences With Chiropractic Care for Patients With Low Back or Neck Pain
J Patient Exp 2020 (Jun);   7 (3):   357–364 ~ FULL TEXT

We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points).   The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.

Exposure to a Motor Vehicle Collision and the Risk of Future Back Pain:
A Systematic Review and Meta-Analysis

Accident; Analysis and Prevention 2020 (May 18);   142:  105546 ~ FULL TEXT

We examined the evidence from three studies on the association between exposure to a MVC and future LBP. The three critically appraised studies support the conclusion that there is an increased risk of future LBP in individuals who have been exposed to a prior injury in a MVC compared to individuals without a history of injury in a MVC. The pooled estimate from the studies in the meta-analysis was RR = 2.7 (95 % CI 1.9, 3.8). The estimate of AR from the pooled analysis suggests that for an individual presenting with chronic LBP that has had a past history of an acute MVC-related back injury with no intervening injury, 63 % of the LBP is attributable to the index crash. However, the reviewed literature does not support an association between exposure to a MVC and future LBP where no acute low back injury was reported. These results should help inform patients, clinicians, insurers, governments and the courts on the risk of a MVC on future LBP. Given that only three studies met the criteria for critical appraisal there is a need for additional risk studies, which will allow for more robust findings. Studies from various source populations, such as primary care and emergency departments, would improve the generalizability of the results as well.

Predictors of Visit Frequency for Patients Using Ongoing Chiropractic Care for Chronic
Low Back and Chronic Neck Pain; Analysis of Observational Data

BMC Musculoskeletal Disorders 2020 (May 13);   21 (1):   298 ~ FULL TEXT

According to NIH Medline Plus, a publication of the National Institutes of Health, “chronic pain usually cannot be cured, but it can be managed.” [99] Several provider-based nonpharmacologic therapies have been recommended for chronic spinal pain, and these therapies may be used on an long-term ongoing basis by patients for pain management. Despite this need, ongoing provider-based care is not well-addressed in the evidence or supported in health and payer policies, [25–27] and this adds another barrier to the use of these recommended nonpharmacologic therapies [37]. This study examined data from a large sample of patients with CLBP and/or CNP to see how these real-world patients used chiropractic care over time to manage their pain. Our sample patients’ high pain management self-efficacy and long-term experience living with their conditions make them good source for information on how ongoing provider-based care for pain management might work. Chiropractic patients with CLBP and CNP manage their pain using a range of visit frequencies and the predictors of these frequencies could be useful for developing policies for ongoing provider-based care.

The Effect of Spinal Manipulation on Brain Neurometabolites in Chronic Nonspecific
Low Back Pain Patients: A Randomized Clinical Trial

Irish Journal of Medical Science 2020 (May);   189 (2):   543–550 ~ FULL TEXT

The current study was the first to investigate the metabolites of the brain following lumbopelvic manipulation in patients with NCLBP. The limitations of the current study were its high cost, being time-consuming, and 1.5-T magnetic field strength MRI. It is suggested that 3-T MRI be employed in future studies to measure glutamine and glutamate levels separately. Furthermore, another limitation is that we did not record psychosocial information to evaluate its relationship to changes of metabolites and pain. It is further recommended that the effect of other treatments (thermal therapy, physical therapy, exercise therapy, acupuncture) with spinal manipulation be evaluated on CNS by the 1H-MRS technique in patients with nonspecific chronic low back pain (NCLBP).

Back Complaints in the Elders - Chiropractic (BACE-C): Protocol of an International
Cohort Study of Older Adults with Low Back Pain Seeking Chiropractic Care

Chiropractic & Manual Therapies 2020 (Apr 1);   28 (1):   17 ~ FULL TEXT

This study, to our knowledge, is the first large-scale, prospective, multicenter, international cohort study to be conducted in a chiropractic setting to focus on older adults with low back pain consulting a chiropractor. By understanding the clinical course, satisfaction and safety of chiropractic treatment of this common debilitating condition in the aged population, this study will provide input for informing future clinical trials.

Global Low Back Pain Prevalence and Years Lived with Disability from 1990 to 2017:
Estimates from the Global Burden of Disease Study 2017

Annals of Translational Medicine 2020 (Mar);   8 (6):   299 ~ FULL TEXT

The global prevalence and YLD rates from LBP decreased slightly from the 1990 to 2017, but the number of LBP sufferers and YLDs increased substantially. Prevalence and YLDs were higher in females than males. Prevalence increased with age, and YLDs peaked at around 35 to 49 years of age. Globally, LBP remains the leading global cause of YLDs, yet it continues to be inadequately recognized as a disease burden in the population with the major disparity continuing between the level of burden, and the policy, research and health services response. This will continue to be an urgent need for governments and other donors. [33, 38]

Treatment of Patients with Low Back Pain:
A Comparison of Physical Therapy and Chiropractic Manipulation

Healthcare (Basel). 2020 (Feb 24);   8 (1):   pii: E44 ~ FULL TEXT

This study analyzed these two strategies and showed that in the short term, chiropractic care is a more cost-effective alternative compared to PT for the treatment of acute low back pain. Chiropractic resulted in a lower cost ($48.56) and higher DALY (0.0043) than the PT over a one-month treatment period and five months follow-up. However, the marginal cost-effectiveness of chiropractic over PT suggests that both treatments were quite similar. Such findings are in line with the earlier studies, which found that the effectiveness and total costs of chiropractic and PT as primary treatments were similar to each other right after treatment and after 6 months follow-up. [3, 22, 32]

Baseline Characteristics May Help Indicate the Best Choice of Health Care Provider
for Back Pain Patients in Primary Care: Results From a Prospective Cohort Study

J Manipulative Physiol Ther. 2020 (Jan);   43 (1):   13–23 ~ FULL TEXT

Most of the investigated prognostic factors for developing persistent pain and disability were more strongly associated with outcomes in the GP setting compared with the chiropractic setting. For 5 factors (duration of pain, previous episodes, general health, recovery expectations, and musculoskeletal comorbidity), our results indicated a more pronounced potential advantage of CP in the high-risk groups compared with the low-risk groups. For the 2 remaining factors, depression and pain below the knee, we observed potentially more favorable results in the high-risk groups in the GP setting. However, based on this study, we cannot deduce whether patients with LBP benefit the most from seeking care from a chiropractor or a general practitioner.

Does Manual Therapy Affect Functional and Biomechanical Outcomes of a
Sit-To-Stand Task in a Population with Low Back Pain? A Preliminary Analysis

Chiropractic & Manual Therapies 2020 (Jan 24);   28:   5 ~ FULL TEXT

In conclusion, the current investigation provides preliminary evidence to demonstrate that the biomechanical and functional performance of an sit-to-stand (STS) task by populations with LBP may acutely be altered following a MT intervention. The precise mechanism remains unknown; however, it is possible that changes in performance of a functional movement such as STS might be related to a combination of altered muscle activation strategies and vertebral joint stiffness previously reported. Our findings can support the development of future hypothesis-driven work directed toward investigating the potential impact of MT on performance of functional tasks in populations with LBP.

Inappropriate Use of Skeletal Muscle Relaxants in Geriatric Patients
U. S. Pharmacist 2020 (Jan 21);   45 (1):   25–29 ~ FULL TEXT

Skeletal muscle relaxants are a sedating class of medications used to treat spasticity and pain. Their sedative properties can pose a risk for geriatric patients who are predisposed to falls. It is important for the pharmacist to assess the patient before dispensing medications. Short-term use of skeletal muscle relaxants may be appropriate for certain conditions but should not be used long-term, regardless of interaction. Alternative pharmacologic options exist, but most have drawbacks. Nonpharmacologic therapy may be a better option in both the short term and the long term. Nonpharmacologic education on fall prevention is essential in patients being given skeletal muscle relaxants, regardless of duration of therapy. Not only will appropriate use of skeletal muscle relaxants improve patient outcomes, it can also improve star ratings for both insurance providers and pharmacies.

Exercise Treatment Effect Modifiers in Persistent Low Back Pain: An Individual Participant
Data Meta-analysis of 3514 Participants From 27 Randomised Controlled Tials

British J Sports Medicine 2019 (Nov 28) [Epub] ~ FULL TEXT

Our IPD meta-analysis combined data from 27 randomised trials, which allowed us to examine a large sample with consistent data. We assessed the effectiveness of exercise therapy to provide context to our study and explored the impact of potential treatment effect modifiers. In our sample, exercise therapy was minimally effective for persistent non-specific low back pain outcomes, and it appears that for individuals using medication for low back pain, and possibly for those with no heavy physical demands at work, they may benefit more from exercise than other treatments. This study provides potentially useful information to help design future studies of exercise interventions that are better matched to specific subgroups.

Clinical Decision Guides for Chiropractic Management
A Unique Series of 3 Articles

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain:
Systematic Review and Standardized Terminology Recommendations

J Manipulative Physiol Ther. 2019 (Nov);   42 (9):   651–664   ~ FULL TEXT

This review describes evidence-based diagnostic criteria for common conditions contributing to neuromusculoskeletal low back pain. Understanding the accuracy of tests and the evidence basis from which diagnostic criteria are derived can inform management decisions and the amount of confidence placed in a working diagnosis. Adopting IASP-applicable terminology is recommended to improve communication among health professionals, patients, and researchers, and to improve the quality of diagnosis-related research.

Development of an Evidence-Based Practical Diagnostic Checklist and
Corresponding Clinical Exam for Low Back Pain

J Manipulative Physiol Ther. 2019 (Nov);   42 (9):   665–676   ~ FULL TEXT

Based on a systematic review of the literature, this article describes an office-based examination leading to working diagnoses for common conditions causing or contributing to LBP. A practical diagnostic checklist for clinical evaluation at a primary spine care level may help to efficiently demonstrate evidence for or against working diagnoses.

Development of a Clinical Decision Aid for Chiropractic Management of
Common Conditions Causing Low Back Pain in Veterans:
Results of a Consensus Process

J Manipulative Physiol Ther. 2019 (Nov);   42 (9):   677–693   ~ FULL TEXT

This article offers an evidence-based clinical decision aid for multimodal chiropractic care for veterans with LBP. A 4ñpage document outlines the management process, evidence-based treatments for specific conditions, intervention descriptions, and definitions for 6 essential components of chiropractic care. The decision aid was validated through a web-based consensus process including DCs practicing in VA health care facilities.

The Association Between Depressive Symptoms or Depression and Health
Outcomes in Adults with Low Back Pain with or without
Radiculopathy: Protocol of a Systematic Review

Systematic Reviews 2019 (Nov 8);   8 (1):   267 ~ FULL TEXT

Overall, findings from our systematic review will be relevant to patients, health care providers, researchers, and decision-makers. Understanding the impact of depressive symptoms and depression is necessary to guide expectations and clinical management of LBP among patients and health care providers. Information about prognostic factors can help health care providers identify patients at risk of developing chronic LBP and disability. In turn, appropriate care and management of depressive symptoms and depression in this patient population may help improve LBP recovery. From a health system perspective, our research will help guide better resource allocation for health programs and strategies targeting key prognostic factors for LBP. Our systematic review will also identify key knowledge gaps related to depressive symptoms, depression, and LBP prognosis to inform future research directions. Ultimately, understanding the impact of depressive symptoms and depression on health outcomes for LBP will help tailor resources, health services delivery, and quality of care to improve health outcomes in adults with LBP.

Nonpharmacological Treatment of Army Service Members with Chronic Pain Is
Associated with Fewer Adverse Outcomes After Transition to the
Veterans Health Administration

J General Internal Medicine 2019 (Oct 28) [Epub] ~ FULL TEXT

Our results suggest that nonpharmacological treatments (NPT) provided to active duty service members with chronic pain may reduce their odds of longterm adverse outcomes. Given known associations of these adverse outcomes with morbidity and mortality, providing NPT to service members with chronic pain could potentially save lives. Our results provide further support for the role of NPT as a risk mitigation strategy when long-term opioid therapy is initiated, which is only briefly mentioned in the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. [16] Given that our findings may have been drivenby some NPT modalities more than others, the dose in which these modalities were received, or unmeasured confounding, more research is needed to clarify these effects. As confounders may change during NPT (e.g., daily dose of opioids), it may be important to include time-varying covariates in follow-up research.

The Fear Reduction Exercised Early (FREE) Approach to Management of Low Back Pain
in General Practice: A Pragmatic Cluster-randomised Controlled Trial

PLoS Med. 2019 (Sep 9);   16 (9):   e1002897 ~ FULL TEXT

Findings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP.

Conservative Spine Care Pathway Implementation Is Associated with Reduced
Health Care Expenditures in a Controlled, Before-After Observational Study

Journal of General Internal Medicine 2019 (Aug);   34 (8):   1381-1382 ~ FULL TEXT

In this retrospective, controlled, before-after study, we found that implementation of a conservative spine pain treatment pathway was associated with significant reductions in per-member-per-month (PMPM) healthcare expenditures for spine pain care; most cost savings were attributable to reduction in spine surgery costs. Our Poisson model found relatively reduced opioid utilization and relatively increased manual care costs, both anticipated by-products of guideline implementation. [4] While our findings are preliminary, in an era of increasing healthcare costs and use of complex and expensive spine surgery techniques they show promise for meaningful care cost reduction and value enhancement when providers conservatively manage spine pain. Importantly, our analysis underscores the value of using control groups, formal analytics, and academic partnerships to understand the impact of quality improvement and clinical effectiveness projects, measures that have been recommended to improve the robustness of quality improvement efforts. [5]

Care for Low Back Pain: Can Health Systems Deliver?
Bulletin of the World Health Organization 2019 (Jun 1);   97 (6):   423–433 ~ FULL TEXT

Delivery of guideline-concordant care for low back pain requires system-wide changes. Strong governance at each level of the health system will be key to redefining how society views and manages low back pain. Health systems should prioritize policies that: empower clinicians and consumers to make well-informed choices; encourage clinicians to deliver the right care to those who need it most; provide financial support to evidence-based non-pharmacological treatment; and regulate the influence of those with vested interests in the current situation. Small adjustments to health policy will not work in isolation. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change. Addressing system-level barriers to guideline-based care could be cost-neutral; every year health systems waste billions of dollars on unnecessary tests and treatments for low back pain. Although disinvestment is difficult, redistributing funds to support guideline-concordant care is a promising way forward. Because current approaches to treatment often lack formal evidence, we strongly encourage careful evaluation of any new approach to funding or service delivery.

Model Simulations Challenge Reductionist Research Approaches to Studying
Chronic Low Back Pain

J Orthop Sports Phys Ther. 2019 (Jun);   49 (6):   477–481 ~ FULL TEXT

Research to identify the factors, or group of factors, that contribute to LBP and to understand the ef­ficacy of individual treatment interven­tions is necessary but not sufficient to address the LBP problem effectively. As demonstrated by our unstructured mul­tifactorial model of LBP, simply identi­fying components within the model and not the structure of the model (ie, the in­teractions between these components) is not likely to lead to robust classification or better treatment effects.   To advance LBP research, more so­phisticated modeling methods that con­sider the structure of the system being studied [9, 18] and possibly the dynamics of the system[1] (LBP symptoms and treat­ment effects are not static and change with time) are needed. Future research should involve a paradigm shift toward a systems approach, which allows for integration of knowledge in a more sys­tematic and effective way. [26] A systems approach has been specifically devel­oped to address complexity and success­fully implemented in engineering. Such an approach appears to be well suited for studying medical conditions that are multifactorial in nature. [1]

Spinal Manipulative Therapy and Exercise for Older Adults with Chronic Low Back Pain:
A Randomized Clinical Trial
Chiropractic & Manual Therapies 2019 (May 15);   27:   21 ~ FULL TEXT

241 participants were randomized and 230 (95%) provided complete primary outcome data. The primary analysis showed group differences in pain over the one-year were small and not statistically significant. Pain severity was reduced by 30 to 40% after treatment in all 3 groups with the largest difference (eight percentage points) favoring SMT and home exercise over home exercise alone. Group differences at other time points ranged from 0 to 6 percentage points with no consistent pattern favoring one treatment. One-year post-treatment pain reductions diminished in all three groups. Secondary self-report outcomes followed a similar pattern with no important group differences, except satisfaction with care, where the two combination groups were consistently superior to home exercise alone.

Pain Mechanisms in Low Back Pain: A Systematic Review With Meta-analysis
of Mechanical Quantitative Sensory Testing Outcomes in People
With Nonspecific Low Back Pain

J Orthop Sports Phys Ther. 2019 (Oct);   49 (10):   698–715 ~ FULL TEXT

This meta-analysis revealed that PPT measurements at remote body parts and TS at the lower back differ between people with NSLBP and HC. Results of studies using CPM measurement showed mixed findings. In conclusion, although a clear picture of CS in people with NSLBP was not found, the available literature regarding mechanical somatosensory functioning provides some evidence suggestive of CS in people with NSLBP. Future work should study whether different QST-profiles can be made for patients with NSLBP to distinguish between subgroups of patients with and without CS. In addition, clear cut-off points for QST-measures are mandatory for health care professionals in order to make sound judgements in individual cases.

Awareness of Axial Spondyloarthritis Among Chiropractors and Osteopaths:
Findings From a UK Web-based Survey

Rheumatol Adv Pract. 2019 (Sep 30);   3 (2):   rkz034 ~ FULL TEXT

Of 382 completed responses [237 chiropractors (62%) and 145 osteopaths (38%)], all were familiar with AS, but only 63 and 25% were familiar with the terms axSpA and non-radiographic axSpA, respectively. Seventy-seven per cent were confident with inflammatory back pain. Respondents routinely asked about IBD (91%), psoriasis (81%), acute anterior uveitis (49%), peripheral arthritis (71%), genitourinary/gut infection (56%), enthesitis (30%) and dactylitis (20%). Eighty-seven per cent were aware of the association between axSpA and HLA-B27. Only 29% recognized that axSpA was common in women. Forty per cent recommend an X-ray (pelvic in 80%) and, if normal, 27% would recommend MRI of the sacroiliac joints and whole spine. Forty-four per cent were aware of biologic therapies. Forty-three per cent were confident with the process of onward referral to rheumatology via the general practitioner (GP). The principal perceived barrier to onward referral was reluctance by the GP to accept their professional opinion.

Observational Retrospective Study of the Association of Initial Healthcare Provider
for New-onset Low Back Pain with Early and Long-term Opioid Use

BMJ Open. 2019 (Sep 20);   9 (9):   e028633 ~ FULL TEXT

Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids. Incentivising use of conservative therapists may be a strategy to reduce risks of early and long-term opioid use.

Expectations Influence Treatment Outcomes in Patients with Low Back Pain.
A Secondary Analysis of Data from a Randomized Clinical Trial

European Journal of Pain 2019 (Aug);   23 (7):   1378–1389 ~ FULL TEXT

This study confirms the importance of patient expectations in a clinical setting. Patient expectations predicts the short-term outcome of chiropractic care for LBP. Pain intensity, psychological profile and self-rated health did not modify this relationship.

Group and Individual-level Change on Health-related Quality of Life
in Chiropractic Patients with Chronic Low Back or Neck Pain

Spine (Phila Pa 1976) 2019 (May 1);   44 (9):   647–651 ~ FULL TEXT

The results of this study contribute to the literature by providing evidence that chiropractic care is associated with improvements in functioning and well-being among individuals with chronic low back or neck pain. The study findings provide empirical verification of why some chronic pain patients utilize chiropractic care on a regular basis. It supports the use of chiropractic care as one option for improving functioning and well-being of patients with chronic low back pain or neck pain. While we are unable to infer the underlying mechanism for the observed improvements in patients, spinal manipulation is designed to relieve pain and improve physical functioning. Studies of the biomechanics indicate that spinal manipulation produces reflex responses and movements of vertebral bodies in the paraphysiologic zone. [27]

Patient-reported Improvements of Pain, Disability, and Health-related Quality
of Life Following Chiropractic Care for Back Pain -
A National Observational Study in Sweden

J Bodyw Mov Ther. 2019 (Apr);   23 (2):   241–246 ~ FULL TEXT

246 back pain patients answered baseline questionnaires and 138 (56%) completed follow-up after four weeks. Statistically significant improvements over the four weeks were reported for all PRO by acute back pain patients (n = 81), mean change scores: NRS -2.98 (p < 0.001), ODI -13.58 (p < 0.001), EQ VAS 9.63 (p < 0.001), EQ-5D index 0.22 (p < 0.001); and for three out of four PRO for patients with chronic back pain (n = 57), mean change scores: NRS -0.90 (p = 0.002), ODI -2.88 (p = 0.010), EQ VAS 3.77 (p = 0.164), EQ-5D index 0.04 (p = 0.022).

Guideline Recommendations on the Pharmacological Management of Non-specific
Low Back Pain in Primary Care – Is There a Need to Change?

Expert Rev Clin Pharmacol. 2019 (Feb);   12 (2):   145–157 ~ FULL TEXT

Upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatments; patient education is important to make sure NSLBP patients accept these changes. To improve the quality of NSLBP care, the evidence-practice gap should be closed through guideline implementation strategies.

Differential Patient Responses to Spinal Manipulative Therapy and their Relation
to Spinal Degeneration and Post-treatment Changes in Disc Diffusion

European Spine Journal 2019 (Feb);   28 (2):   259–269

There was no significant difference in structural features between SMT responders and non-responders. However, SMT responders demonstrate a trend of a lower prevalence of severely degenerated facets and relatively high baseline ADC values of the L4–5 discs. Interestingly, SMT responders demonstrate post-SMT increases in apparent diffusion coefficient (ADC) values of discs associated with painful segments. These results suggest that SMT responses may be related to some underlying structural responses. Our findings provide a new hypothesis/direction for further investigating the underlying nature of the differential response to SMT, possible mechanisms of SMT and the existence of treatment-specific forms of LBP.

Self-reported Use of Family Physician, Chiropractor and Physiotherapy Services
Among Adult Canadians with Chronic Back Disorders: An Observational Study

BMC Health Serv Res 2018 (Dec 17);   18 (1):   970 ~ FULL TEXT

This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations. The identified gaps in access to care among certain population groups demonstrates that there is not equitable access to care among Canadians with CBD. Enhancing access to potentially beneficial non-physician services for people with CBD requires rethinking the way front-line back care is delivered in Canada, including pressure on insurers and policy makers to cover and enable greater access to non-pharmacological management treatment options that have demonstrated value. [34, 40]

Centralization and Directional Preference: An Updated Systematic Review with Synthesis
of Previous Evidence

Musculoskelet Sci Pract. 2018 (Dec);   38:   53–62 ~ FULL TEXT

This review has synthesised literature from 62 previous studies, but also evaluated 43 additional studies. The importance of centralization and directional preference as prognostic factors is probably overwhelming; whether they indicate a particular management pathway is not clear. Centralization and directional preference are still very important clinical indicators to monitor during the taking of patients' history and physical examination. Although about a third of patients may demonstrate neither clinical response, they are still common and important prognostic indicators.

Low Back Pain: The Potential Contribution of Supraspinal Motor Control
and Proprioception

Neuroscientist. 2018 (Nov 2) [Epub] ~ FULL TEXT

Research in the past two decades has provided important evidence how motor control adaptions in LBP might contribute to pain chronification through effects on spinal tissue loading, associated itself with degeneration of intervertebral discs and other tissues. However, the underlying biological and psychosocial interactions are still poorly understood and seem to vary across individuals, reflected in the modest effect sizes of motor control exercises, spurring a call for personalized interventional therapies [van Dieën and others 2018a]. Yet, to unleash the full potential of personalized treatments, more basic research on motor adaptions in LBP is mandatory, especially when considering the evolving evidence of cortical circuits in driving motor control adaptions during the course of LBP. Complementary findings from behavioral and neuroimaging studies underscore the prominent role of aberrant sensory processing in LBP.

Coverage of Nonpharmacologic Treatments for Low Back Pain Among
US Public and Private Insurers

JAMA Network Open 2018 (Oct 5);   1 (6):   e183044 ~ FULL TEXT

Insurers are increasingly recognized as influential stakeholders that are well positioned to drive changes in pain treatment practices. One key component of such changes is the greater use of nonpharmacologic approaches to managing chronic, noncancer pain, as has been recommended by the Centers for Disease Control and Prevention, [10] the President’s Commission on Combating Drug Addiction and the Opioid Crisis, [8] and others. [25] To our knowledge, our work represents the most comprehensive assessment of coverage policies regarding the medical necessity, coverage, and management of nonpharmacologic treatments for back pain.

Insurer Coverage of Nonpharmacological Treatments for Low Back Pain -
Time for a Change

JAMA Netw Open. 2018 (Oct 5);   1 (6):   e183037 ~ FULL TEXT

Finally, future payment policies should decrease patient out-of-pocket expenses to strongly encourage earlier use of evidence-based nonpharmacological treatment options. Heyward et al found that median out-of-pocket costs for covered nonpharmacological treatments ranged from $25 to $60 per visit for commercial insurers. The usual dose of treatments such as physical therapy and chiropractic care is commonly between 6 and 12 visits. Thus, out-of-pocket expenses can vary from $150 to $720 or more. In contrast, Lin et al [10] found that the median cost of a 30-day supply of preferred generic opioids by commercial insurers is $10. Given the significant differences in cost, many patients do not realistically have the option of seeking nonpharmacological treatment.

Prevalence of Pain Diagnoses and Burden of Pain Among Active Duty Soldiers, FY2012
Military Medicine 2018 (Sep 1);   183 (9-10):   e330–e337 ~ FULL TEXT

Pain diagnoses are common among non-deployed Army active duty soldiers and pain is frequently chronic. Musculoskeletal conditions are associated with the greatest burden on the MHS among the painful conditions examined in this study. Our findings provide support for the value of the comprehensive stepped approach to pain management given a broad burden of pain and highlight the need for health service planning to minimize the impact on military readiness. Prevention efforts are also valuable to reduce injury and re-injury rates and to promote recovery from pain. For example, Army leaders could incorporate physical activity into unit training that could serve to reduce the likelihood of injury and to aid in recovery. Future research could delve more deeply into the questions of the functional impact of pain diagnoses on military readiness using sources beyond encounter data. The patterns described here could be evaluated by soldier characteristics, such as gender or occupation, and expanded into a deployed population and across all treatment settings. A fuller picture of the burden of pain in this population would also account for the known overlaps with other conditions (e.g., TBI, PTSD, sleep disorders). This encounters-based analysis offers a step forward in understanding the burden of pain across 10 major conditions, but is likely an underestimate of the prevalence of pain, and does not include contextual factors that would offer a more complete understanding of the true effect of pain diagnoses in this population.

The Global Spine Care Initiative: Applying Evidence-based Guidelines on the Non-invasive
Management of Back and Neck Pain to Low- and Middle-income Communities

European Spine Journal 2018 (Sep);   27 (Suppl 6):   851–860 ~ FULL TEXT

Guidelines developed for high-income settings were adapted to inform a care pathway and model of care for medically underserved areas and low- and middle-income countries by considering factors such as costs and feasibility, in addition to benefits, harms, and the quality of underlying evidence. The selection of recommended conservative treatments must be finalized through discussion with the involved community and based on a biopsychosocial approach. Decision determinants for selecting recommended treatments include costs, availability of interventions, and cultural and patient preferences. This information can be used to inform the GSCI care pathway and model of care in medically underserved areas and low- and middle-income countries.
There are more articles like this at our Global Burden of Disease Section

The Global Spine Care Initiative: A Summary of the Global Burden of Low Back and
Neck Pain Studies

European Spine Journal 2018 (Sep);   27 (Suppl 6):   796–801 ~ FULL TEXT

In 2015, low back and neck pain were ranked the fourth leading cause of disability-adjusted life years (DALYs) globally just after ischemic heart disease, cerebrovascular disease, and lower respiratory infection {low back and neck pain DALYs [thousands]: 94 941.5 [95% uncertainty interval (UI) 67 745.5-128 118.6]}. In 2015, over half a billion people worldwide had low back pain and more than a third of a billion had neck pain of more than 3 months duration. Low back and neck pain are the leading causes of years lived with disability in most countries and age groups.
There are more articles like this at our Global Burden of Disease Section

Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain
J Manipulative Physiol Ther. 2018 (Sep);   27 (Suppl 6):   901–914 ~ FULL TEXT

This study provides insight into the characteristics of patients who are successfully managing their chronic low back pain (CLBP) and chronic neck pain (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.

Comparison of Treatment Outcomes in Nonspecific Low-Back Pain Patients with
and without Modic Changes Who Receive Chiropractic Treatment

J Manipulative Physiol Ther. 2018 (Sep);   41 (7):   561–570 ~ FULL TEXT

The presence or absence of MCs and the category of MC, when present, were not related to the outcomes for LBP patients without lumbar disc herniations who were undergoing chiropractic treatment. This calls into question the clinical relevance of particularly MCs I as a serious pain generator and certainly challenges the theory that MCs are due to infection. These results are consistent with the ones found for lumbar disc herniation patients treated with high-velocity, low-amplitude spinal manipulation. This also supports the hypothesis that chiropractic care is a safe conservative treatment for patients presenting with nonspecific LBP, despite the presence of MCs.

Impact of Musculoskeletal Pain on Balance and Concerns of Falling in Mobility-limited,
Community-dwelling Danes over 75 Years of Age: A Cross-sectional Study

Aging Clin Exp Res. 2018 (Aug);   30 (8):   969–975 ~ FULL TEXT

Intense neck pain in mobility-limited older adults is associated with significant changes in postural balance, and intense low back pain is associated with significantly higher concerns of falling.

Effect of Low Back Pain Risk-stratification Strategy on Patient Outcomes and
Care Processes: The MATCH Randomized Trial in Primary Care
J General Internal Medicine 2018 (Aug);   33 (8):   1324–1336 ~ FULL TEXT

In contrast to the positive results of implementing a risk stratification strategy to improve primary care for LBP in England, [15, 16] our adaptation of that strategy to the different circumstances in our setting did not change healthcare utilization or improve patient outcomes. This illustrates the risk of failure when complex interventions developed and found effective in one setting are implemented in a different setting even with strong system support and substantial resources devoted to adapting the intervention to local needs and circumstances. To increase their chances of success, future initiatives to implement complex interventions in primary care should include simple and easily implemented and supported treatment recommendations, automatic alerts in the EHR to make it easy for clinicians to remember to collect risk-stratification information and recommend appropriate matched treatments to their patients, and the provision of regular feedback on their performance adhering to the matched treatment recommendations for patients at each risk stratum are likely to improve the chances of success. Given the limited ability of primary care clinicians to take on new responsibilities, however, innovative approaches (e.g., expanded nurse role) may be necessary to promote the clinical changes necessary to improve patient outcomes.
You may also enjoy their PCORI review titled:
Can Using Patient Reports of Low Back Pain Help to Better Direct Patients to Treatments?

Chiropractic Care and Risk for Acute Lumbar Disc Herniation:
A Population-based Self-controlled Case Series

European Spine Journal 2018 (Jul);   27 (7):   1526–1537 ~ FULL TEXT

Spinal manipulative therapy (SMT) creates health benefits for some while for others, no benefit or even adverse events. Understanding these differential responses is important to optimize patient care and safety. Toward this, characterizing how loads created by SMT relate to those created by typical motions is fundamental. Using robotic testing, it is now possible to make these comparisons to determine if SMT generates unique loading scenarios. In 12 porcine cadavers, SMT and passive motions were applied to the L3/L4 segment and the resulting kinematics tracked. The L3/L4 segment was removed, mounted in a parallel robot and kinematics of SMT and passive movements replayed robotically. The resulting forces experienced by L3/L4 were collected. Overall, SMT created both significantly greater and smaller loads compared to passive motions, with SMT generating greater anterioposterior peak force (the direction of force application) compared to all passive motions. In some comparisons, SMT did not create significantly different loads in the intact specimen, but did so in specific spinal tissues. Despite methodological differences between studies, SMT forces and loading rates fell below published injury values. Future studies are warranted to understand if loading scenarios unique to SMT confer its differential therapeutic effects.

Directional Preference and Functional Outcomes Among Subjects Classified
at High Psychosocial Risk Using STarT

Physiother Res Int. 2018 (Jul);   23 (3):   e1711 ~ FULL TEXT

One hundred nine patients classified as high STarT risk had complete intake and discharge functional status (FS) and directional preference (DP) data. Prevalence rate for DP was 65.1%. A significant and clinically important difference (7.98 FS points; p = .03) in change in function at discharge between DP and No-DP was observed after controlling for all confounding variables in the final model.   Findings suggest that interventions matched to directional preference (DP) are effective for managing high psychological risk patients and may provide physiotherapists with an alternative treatment pathway compared to managing similar patients with cognitive-behavioural approaches. Stricter research designs are required to validate study conclusions.

Chiropractic Spinal Manipulation and the Risk for Acute Lumbar Disc Herniation:
A Belief Elicitation Study

European Spine Journal 2018 (Jul);   27 (7):   1526–1537

Chiropractors expressed the most optimistic belief (median RR 0.56; IQR 0.39–1.03); family physicians expressed a neutral belief (median RR 0.97; IQR 0.64–1.21); and spine surgeons expressed a slightly more pessimistic belief (median RR 1.07; IQR 0.95–1.29). Clinicians with the most optimistic views believed that chiropractic SMT reduces the incidence of acute LDH by about 60% (median RR 0.42; IQR 0.29–0.53). Those with the most pessimistic views believed that chiropractic SMT increases the incidence of acute LDH by about 30% (median RR 1.29; IQR 1.11–1.59).

Low Back Pain: A Major Global Problem For Which the Chiropractic Profession
Needs to Take More Care

Chiropractic & Manual Therapies 2018 (Jun 25);   26:   28 ~ FULL TEXT

An important series of papers have been published in the Lancet. These papers provide a comprehensive update for the major global problem of low back pain, and the challenges that low back pain presents to healthcare practitioners and policy makers. Chiropractors are well placed to reduce the burden of low back pain, but not all that chiropractors do is supported by robust, contemporary evidence. This commentary summarises the Lancet articles. We also make suggestions for how the chiropractic profession should most effectively help people with low back pain by implementing practices supported by high quality evidence.

Association Between Utilization of Chiropractic Services for Treatment
of Low-Back Pain and Use of Prescription Opioids

J Altern Complement Med. 2018 (Jun);   24 (6):   552–556 ~ FULL TEXT

The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower among recipients odf chiropractic care compared with nonrecipients (odds ratio 0.45; 95% confidence interval 0.40–0.47; p < 0.0001). Average charges per person for opioid prescriptions were also significantly lower among recipients.

The Lancet Series on Low Back Pain
    A Unique Series of Articles

Key findings from the 4 papers published in The Lancet:

  • Lower Back pain is the most disabling disease in the world.
    It has risen 54% since 1990.

  • The first choice of therapy should be non-pharmacological care
    such as spinal manipulation, exercise, acupuncture, and massage.

  • Some therapies to avoid:   bedrest, opioids, epidural spinal injections,
    and spinal fusion surgery

  • Imaging should occur only if the clinician suspects a specific condition
    that would require different management for lower back pain.

        Thanks to the Texas Chiropractic Association
        for their concise review of these 3 major studies!
        Please ALSO review their PowerPoint below:

An Introduction to the following 3 LBP articles
Low Back Pain: A Major Global Challenge
Lancet. 2018 (Jun 9);   391 (10137):   2302 ~ FULL TEXT

Low back pain is a major problem throughout the world and it is getting worse — largely because of the ageing and increasing world population. [1] It affects all age groups and is generally associated with sedentary occupations, smoking, obesity, and low socioeconomic status. [2] Years lived with disability caused by low back pain have increased by more than 50% since 1990, especially in low-income and middle-income countries (LMICs). [1, 2] Disability related to low back pain is projected to increase most in LMICs where resources are limited, access to quality health care is generally poor, and lifestyle changes and shifts towards more sedentary work for some mean the risks will only increase.

What Low Back Pain Is and Why We Need to Pay Attention
Lancet. 2018 (Jun 9);   391 (10137):   2356–2367 ~ FULL TEXT

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.

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

Lancet. 2018 (Jun 9);   391 (10137):   2368–2383 ~ FULL TEXT

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.

Low Back Pain: A Call For Action
Lancet. 2018 (Jun 9);   391 (10137):   2384–2388 ~ FULL TEXT

Low back pain is the leading worldwide cause of years lost to disability and its burden is growing alongside the increasing and ageing population. [1] Because these population shifts are more rapid in low-income and middle-income countries, where adequate resources to address the problem might not exist, the effects will probably be more extreme in these regions. Most low back pain is unrelated to specific identifiable spinal abnormalities, and our Viewpoint, the third paper in this Lancet Series, [2, 3] is a call for action on this global problem of low back pain.

The Texas Chiropractic Association developed
this PowerPoint (PPT) presentation for your use.

Just click on the PPT screen to view all 24 slides.

Then click on the underlined citations to review those studies.

You can even click for FULL SCREEN viewing!

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care:
The Consortium Pain Task Force White Paper

Explore (NY). 2018 (May);   14 (3)    177–211 ~ FULL TEXT

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain.

Primary Care Management of Non-specific Low Back Pain:
Key Messages from Recent Clinical Guidelines

Medical J Australia 2018 (Apr 2);   208 (6):   272–275 ~ FULL TEXT

Changes in management as a result of the guidelines:

  • emphasising simple first line care with early follow-up;

  • encouraging non-pharmacological treatments over pharmacological treatments; and

  • recommending against the use of surgery, injections and denervation procedures.

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain:
A Guideline From the Canadian Chiropractic Guideline Initiative

J Manipulative Physiol Ther. 2018 (May);   41 (4):   265–293 ~ FULL TEXT

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).   A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

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

Spine J. 2018 (May);   18 (5):   866–879 ~ FULL TEXT

There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.

Preferences for Web-Based Information Material for Low Back Pain:
Qualitative Interview Study on People Consulting a General Practitioner

JMIR Rehabil Assist Technol. 2018 (Apr 2);   5 (1):   e7 ~ FULL TEXT

Fifteen 45–min interviews were conducted. Participants had a median age of 40 years (range 22–68 years) and reported a median disability of 7 points (range 0–18) using the 23–item Roland Morris Disability Questionnaire. Participants reported that Web-based information should be easy to find and read, easily overviewed, and not be overloaded with information. Subjects found existing Web-based information confusing, often difficult to comprehend, and not relevant for them, and they questioned the motives driving most hosting companies or organizations. The Patient Handbook, a Danish government-funded website that provides information to Danes about health, was mentioned as a trustworthy and preferred site when searching for information and advice regarding LBP.

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans:
Results of a Delphi Consensus Process

J Manipulative Physiol Ther. 2018 (Feb);   41 (2):   137–148 ~ FULL TEXT

The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers.
There are more articles like this at our Chiropractic Care For Veterans Page

Uneven Intervertebral Motion Sharing is Related to Disc Degeneration
and is Greater in Patients with Chronic, Non-Specific Low Back Pain:
An in Vivo, Cross-Sectional Cohort Comparison of Intervertebral
Dynamics Using Quantitative Fluoroscopy

European Spine Journal 2018 (Jan);   27 (1):   145–153 ~ FULL TEXT

Greater inequality and variability of motion sharing was found in patients with CNSLBP than in controls, confirming previous studies and suggesting a biomechanical marker for the disorder at intervertebral level. The relationship between disc degeneration and MSI was augmented in patients, but not in controls during passive motion and similarly for MSV during active motion, suggesting links between in vivo disc mechanics and pain generation.

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

Clin J Pain. 2018 (Jan);   34 (1):   68–75 ~ FULL TEXT

The production of chemotactic cytokines is significantly and protractedly elevated in LBP patients. Changes in chemokine production levels, which might be related to SMT, differ in the acute and chronic LBP patient cohorts.

The Association Between a Lifetime History of Low Back Injury in a Motor Vehicle
Collision and Future Low Back Pain: A Population-based Cohort Study

European Spine Journal 2018 (Jan);   27 (1):   136–144 ~ FULL TEXT

Our analysis suggests that a history of low back injury in a MVC is a risk factor for developing future troublesome LBP. The consequences of a low back injury in a MVC can predispose individuals to experience recurrent episodes of low back pain.

Failure to Define Low Back Pain as a Disease or an Episode Renders Research
on Causality Unsuitable: Results of a Systematic Review

Chiropractic & Manual Therapies 2018 (Jan 9);   21:   6~ FULL TEXT

Recent literature concerning the causality of LBP does not differentiate between the ‘disease’ of LBP and its recurring episodes mainly due to a lack of a clear definition of absence of LBP at baseline. Therefore, current research is not capable of providing a valid answer on this topic.

The Non-pharmacologic Therapies Low Back Pain Guidelines
    A Unique Series of Articles

All 6 of the following guidelines reviewed the medical literature on low back pain and strongly advise medical doctors to first recommend non-pharmacologic therapies, including chiropractic, BEFORE resorting to offering NSAIDs, opiates or other more invasive treatments, for low back (spinal) pain patients.

These recommendations will:

  1.   save money,
  2.   will increase patient satisfaction,
  3.   will improve patient outcomes and
  4.   will reduce chronicity and potential addiction.

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

European Spine Journal 2018 (Jan);   27 (1):   60–75 ~ ~ FULL TEXT

In 2012, the Danish Finance Act appropriated a total of €10.8 mio for the preparation of clinical guidelines. The Danish Health Authority (DHA) was subsequently commissioned to formulate 47 national clinical guidelines to support evidence-based decision making within health areas with a high burden of disease, a perceived large variation in practice, or uncertainty about which care was appropriate. [1] Two of these areas were low back pain (LBP) and lumbar radiculopathy (LR). Consequently in 2014, two working groups were formed with the aim of developing national clinical guidelines for non-surgical interventions for recent onset (<12 weeks) LBP and for recent onset (<12 weeks) LR. The primary target groups for these guidelines were primary sector healthcare providers, i.e., general practitioners, chiropractors, and physiotherapists, but also medical specialists or others in the primary or secondary healthcare sector handling patients with LBP or LR.

Guideline for Opioid Therapy and Chronic Noncancer Pain
CMAJ. 2017 (May 8);   189 (18):   E659–E666 ~ FULL TEXT

This new Canadian guideline published today (May 8, 2017) in the Canadian Medical Association Journal (CMAJ) strongly recommends doctors to consider non-pharmacologic therapy, including chiropractic, in preference to opioid therapy for chronic non-cancer pain.   The guideline is the product of an extensive review of evidence involving input from medical, non-medical, regulatory, and patient stakeholders.

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 ~ FULL TEXT

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.”

Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review
for an American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   480–492

The American College of Physicians (ACP) released updated guidelines this week that recommend the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation.

Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an
American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   493–505 ~ FULL TEXT

This report updates and expands on the earlier ACP/APS review [105] with additional interventions and newer evidence. We found evidence that mind–body interventions not previously addressed — tai chi (SOE, low) and mindfulness-based stress reduction (SOE, moderate) [45–47] — are effective for chronic low back pain; the new evidence also strengthens previous conclusions regarding yoga effectiveness (SOE, moderate). For interventions recommended as treatment options in the 2007 ACP/APS guideline [2], our findings were generally consistent with the prior review. Specifically, exercise therapy, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture are supported with some evidence of effectiveness for chronic low back pain (SOE, low to moderate). Unlike our previous report, which stated that higher-intensity multidisciplinary rehabilitation seemed to be more effective than lower-intensity programs, a stratified analysis based on currently available evidence [54] did not find a clear intensity effect. Our findings generally are consistent with recent systematic reviews not included in our evidence synthesis [106–117]. Although harms were not well-reported, serious adverse events were not described.
You will also enjoy the introductory Editorial, titled:
Management of Low Back Pain: Getting From Evidence-Based Recommendations to High-Value Care

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians

Annals of Internal Medicine 2017 (Apr 4);   166 (7):   514–530 ~ FULL TEXT

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).

Management of Back Pain-related Disorders in a Community With Limited
Access to Health Care Services: A Description of Integration
of Chiropractors as Service Providers

J Manipulative Physiol Ther 2017 (Nov); 40 (9): 635–642 ~ FULL TEXT

Questionnaire data were obtained from 93 patients. The mean age of the sample was 49.0 ± 16.27 years, and 66% were unemployed. More than three-quarters (77%) had had their back pain for more than a month, and 68% described it as constant. According to the Bournemouth Questionnaire, Bothersomeness, and global improvement scales, a majority (63%, 74%, and 93%, respectively) reported improvement at discharge, and most (82%) reported a significant reduction in pain medication. More than three-quarters (77%) did not visit their primary care provider while under chiropractic care, and almost all (93%) were satisfied with the service. According to the EuroQol 5 Domain questionnaire, more than one-third of patients (39%) also reported improvement in their general health state at discharge. Implementation of an integrated chiropractic service was associated with high levels of improvement and patient satisfaction in a sample of patients of low socioeconomic status with subacute and chronic back pain.

Patient-centered Professional Practice Models for Managing Low Back Pain
in Older Adults: A Pilot Randomized Controlled Trial

BMC Geriatr. 2017 (Oct 13);   17 (1):   235 ~ FULL TEXT

Professional practice models that included primary care and chiropractic care led to modest improvements in low back pain intensity and disability for older adults, with chiropractic-inclusive models resulting in better perceived improvement and patient satisfaction over the primary care model alone.

Association Between the Type of First Healthcare Provider and the Duration
of Financial Compensation for Occupational Back Pain

Journal of Occupational Rehabilitation 2017 (Sep);   27 (3):   382-392 ~ FULL TEXT

The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.
Refer to our extensive collection on: Workers' Compensation

Looking Ahead: Chronic Spinal Pain Management
Journal of Pain Research 2017 (Aug 30);   10:   2089–2095 ~ FULL TEXT

Health care practitioners involved in the triage and management of patients with persistent spinal pain will need to become more vigilant about individualizing and coordinating care for each patient, to achieve the best possible outcomes. For example, Cecchi et al concluded that patients with chronic (persistent) lower baseline pain (LBP)- related disability predicted “nonresponse” to standard physiotherapy, but not to spinal manipulation (an intervention commonly employed by chiropractors [7–9]), implying that spinal manipulation should be considered as a first-line conservative treatment. [9] We note that spinal manipulation is now suggested as the first-line intervention by Deyo, [10] since not a single study examined in a recent systematic review found that spinal manipulation was less effective than conventional care. [11]

Feeling Stiffness in the Back: A Protective Perceptual Inference in Chronic Back Pain
Sci Rep. 2017 (Aug 29);   7 (1):   9681 ~ FULL TEXT

Does feeling back stiffness actually reflect having a stiff back? This research interrogates the long-held question of what informs our subjective experiences of bodily state. We propose a new hypothesis: feelings of back stiffness are a protective perceptual construct, rather than reflecting biomechanical properties of the back. This has far-reaching implications for treatment of pain/stiffness but also for our understanding of bodily feelings. Over three experiments, we challenge the prevailing view by showing that feeling stiff does not relate to objective spinal measures of stiffness and objective back stiffness does not differ between those who report feeling stiff and those who do not. Rather, those who report feeling stiff exhibit self-protective responses: they significantly overestimate force applied to their spine, yet are better at detecting changes in this force than those who do not report feeling stiff. This perceptual error can be manipulated: providing auditory input in synchrony to forces applied to the spine modulates prediction accuracy in both groups, without altering actual stiffness, demonstrating that feeling stiff is a multisensory perceptual inference consistent with protection. Together, this presents a compelling argument against the prevailing view that feeling stiff is an isomorphic marker of the biomechanical characteristics of the back.

Effect of Radiofrequency Denervation on Pain Intensity Among Patients With
Chronic Low Back Pain: The Mint Randomized Clinical Trials

JAMA. 2017 (Jul 4);   318 (1):   68–81 ~ FULL TEXT

In 3 randomized clinical trials of participants with chronic low back pain originating in the facet joints, sacroiliac joints, or a combination of facet joints, sacroiliac joints, or intervertebral disks, radiofrequency denervation combined with a standardized exercise program resulted in either no improvement or no clinically important improvement in chronic low back pain compared with a standardized exercise program alone. The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources.

An Observational Study on Recurrences of Low Back Pain During the First
12 Months After Chiropractic Treatment

J Manipulative Physiol Ther. 2017 (Jul);   40 (6):   427–433 ~ FULL TEXT

The recurrence rate of LBP using a stringent definition of recurrence was found to be low in this chiropractic LBP patient population. Nevertheless, the vast majority of patients were not pain free after 1 year. The recurrent course could be distinguished from the fast recovering and chronic patterns, but the differences with respect to the others subgroups were minor. The duration of complaint before treatment was the main predictor for recurrence. Of importance, a subacute duration, defined in the present study as longer than 14 days, significantly increased the odds for an unfavorable course of LBP, which is of clinical relevance.

Advice for Acute Low Back Pain: A Comparison of What Research Supports
and What Guidelines Recommend

Spine J. 2017 (Jul 13) [Epub ahead of print] ~ FULL TEXT

Completeness of reporting was less than ideal for RCTs and extremely poor for guidelines. As such both RCTs and guidelines need to ensure they report on all aspects of advice interventions for acute LBP in future publications. The recommendations made in guidelines of advice for acute LBP were often not concordant with the results of the research literature. Taken together these two findings mean that the potential clinical value of advice interventions for patients with acute LBP are probably not being realised.

Influences of Lumbar Disc Herniation on the Kinematics in
Multi-segmental Spine, Pelvis, and Lower Extremities During
Five Activities of Daily Living

BMC Musculoskelet Disord. 2017 (May 25);   18 (1):   216 ~ FULL TEXT

Lumbar disc herniation (LDH) patients mainly restrict the motion of lower lumbar (LLx) and upper lumbar (ULx) in the spinal region during the five ADLs. Pelvic rotation is an important method to compensate for the limited lumbar motion. Furthermore, pelvic tilt and lower extremities' flexion increased when ADLs were quite difficult for LDH patients.

Do Older Adults with Chronic Low Back Pain Differ from Younger Adults
in Regards to Baseline Characteristics and Prognosis?

European Journal of Pain 2017 (May);   21 (5):   866–873

A total of 14,479 participants were included in the study. Of these 3,087 (21%) patients were older adults, 6,071 (42%) were middle aged and 5,321 (37%) were young adults. At presentation older adults were statistically different to the middle aged and younger adults for most characteristics measured (e.g. less intense back pain, more leg pain and more depression); however, the differences were small. The change in pain and disability over 12 months did not differ between age groups.

Take the Clinical Compass Chiropractic Guideline for Low Back Pain Challenge
ACA News ~ May 15, 2017 ~ FULL TEXT

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.

Clinical Classification in Low Back Pain: Best-evidence Diagnostic Rules
Based on Systematic Reviews

BMC Musculoskelet Disord. 2017 (May 12);   18 (1):   188 ~ FULL TEXT

This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

The Impact of Pain-related Fear on Neural Pathways of Pain Modulation
in Chronic Low Back Pain

Pain Rep. 2017 (Apr 11);   2 (3):   e601 ~ FULL TEXT

Our results might indicate a maladaptive psychobiological interaction in chronic LBP characterized by an attenuation of amygdala-PAG-FC that is modulated by the degree of pain-related fear. Besides the established role of the PAG in the modulation of nociceptive inputs, our results add further evidence to the involvement of the PAG in negative emotional processing not directly related to nociception. [9, 28] Furthermore, while we have previously shown that pain-related fear is positively correlated with amygdala activity in chronic LBP, [16] enhanced pain-related fear seems to simultaneously dampen the neural cross-talk between the amygdala and the PAG. This decreased informaion exchange between 2 key pain modulatory structures might ultimately tip the balance of PAG function to facilitation, ie, increased pronociception. [11] Thus, the decreased cross-talk between the amygdala and the PAG, in conjunction with increased amygdala activity, might be the neurobiological basis of how pain-related fear contributes to pain and its chronification.

Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions
for Low Back Pain: A Systematic Literature Review

Applied Health Economics and Health Policy 2017 (Apr);   15 (2):  173–201 ~ FULL TEXT

Thirty-three studies were identified. Study interventions were categorised as: (1) combined physical exercise and psychological therapy, (2) physical exercise therapy only, (3) information and education, and (4) manual therapy. Interventions assessed within each category varied in terms of their components and delivery. In general, combined physical and psychological treatments, information and education interventions, and manual therapies appeared to be cost effective when compared with the study-specific comparators. There is inconsistent evidence around the cost effectiveness of physical exercise programmes as a whole, with yoga, but not group exercise, being cost effective.

Contemporary Biopsychosocial Exercise Prescription for Chronic Low Back Pain:
Questioning Core Stability Programs and Considering Context

J Can Chiropr Assoc. 2017 (Mar);   61 (1):   6–17 ~ FULL TEXT

Evidence keeps building about the multi-system benefits of exercise [109]; this includes therapeutic exercise for chronic low back pain (CLBP). As suggested throughout this commentary, a focus on gross biological changes alone (muscle strength, endurance etc.) has limited value. Instead, more research is needed to examine the interplay between biological, psychological, and social factors - as this may have novel exercise prescription implications for patients with CLBP. This commentary provided an overview of some of the contextual factors that have biopsychosocial implications. It was described how these contextual factors can facilitate placebo or nocebo effects, impacting patients’ behaviors and outcomes.

Individual Courses of Low Back Pain in Adult Danes: A Cohort Study
with 4-Year and 8-Year Follow-up

BMC Musculoskelet Disord. 2017 (Jan 21);   18 (1):   28 ~ FULL TEXT

In this study, it was evident that when applying the more ‘severe’ definitions of LBP (‘>30 days’, ‘seeking care’, and ‘non-trivial’) as risk factors for future LBP of the same definitions, the associations were stronger than for ‘year’ and ‘month’. We therefore suggest that composite measures of LBP outcomes should be further explored in future epidemiologic studies of risk factors and less attention should be paid to the LBP definitions ‘year’ and ‘month’, which may include both slight LBP with low clinical impact and severe disabling LBP.

Tissue Loading Created During Spinal Manipulation in Comparison to Loading
Created by Passive Spinal Movements

Sci Rep. 2016 (Dec 1);   6:   38107 ~ FULL TEXT

Spinal manipulative therapy (SMT) creates health benefits for some while for others, no benefit or even adverse events. Understanding these differential responses is important to optimize patient care and safety. Toward this, characterizing how loads created by SMT relate to those created by typical motions is fundamental. Overall, SMT created both significantly greater and smaller loads compared to passive motions, with SMT generating greater anterioposterior peak force (the direction of force application) compared to all passive motions. In some comparisons, SMT did not create significantly different loads in the intact specimen, but did so in specific spinal tissues. Despite methodological differences between studies, SMT forces and loading rates fell below published injury values. Future studies are warranted to understand if loading scenarios unique to SMT confer its differential therapeutic effects.

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin:
A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

Journal of Chiropractic Medicine 2016 (Dec);   15 (4):   281–293 ~ FULL TEXT

Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article.

What Do Patients Value About Spinal Manipulation and Home Exercise for
Back-related Leg Pain? A Qualitative Study Within a Controlled Clinical Trial

Man Ther. 2016 (Dec);   26:   183–191 ~ FULL TEXT

This qualitative study illustrates that patient satisfaction is rooted in the quality of the patienteprovider relationship, although perceived symptom improvements, relevant clinical information about sciatica and its treatment, and the distinct qualities of those treatments are important drivers of satisfaction for patients who received non-pharmacological treatments for their back-related leg pain. Global measures of satisfaction may not adequately represent the range of patients' experiences and perceptions of spinal manipulative therapy or home exercise. In addition to providing insight to the quantitative results of the parent trial, these findings suggest that tailored interventions to enhance patienteprovider relationships may facilitate compliance and enhance satisfaction with care.

A Narrative Review of Lumbar Fusion Surgery with Relevance to Chiropractic Practice
Journal of Chiropractic Medicine 2016 (Dec);   15 (4):   259–271 ~ FULL TEXT

This article describes the indications for fusion, common surgical practice, potential complications, and relevant published chiropractic literature. This review includes 10 cases that showed positive benefits from chiropractic manipulation, flexion-distraction, and/or manipulation under anesthesia for postfusion lumbar pain. Chiropractic care may have a role in helping patients in pain who have undergone lumbar fusion surgery.

Epidemiology of Chronic Low Back Pain in US Adults: Data From
the 2009-2010 National Health and Nutrition Examination

Arthritis Care Res (Hoboken) 2016 (Nov);   68 (11):   1688–1694 ~ FULL TEXT

In conclusion, US adults with cLBP in 2009–2010 were less educated, less wealthy, and more likely to smoke, have depression, sleep disturbances, and other medical comorbidities than those without cLBP. They made more frequent healthcare visits and more often carried government-sponsored health insurance to cover the costs. Frequent healthcare visits in the cLBP group were strongly associated with depression and sleep disturbances. While causal inference cannot be established from a cross-sectional study design, the clustering of behavioral, psychosocial, and medical issues should be considered in the care and rehabilitation of Americans with cLBP.

Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain:
A Systematic Review by the Ontario Protocol for Traffic Injury Management
(OPTIMa) Collaboration

European Journal of Pain 2016 (Oct 6). ~ FULL TEXT

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed.

Interdisciplinary Practice Models for Older Adults With Back Pain:
A Qualitative Evaluation

Arthritis Res Ther. 2016 (Oct 13);   18 (1):   237

Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups.

Identification of Subgroups of Inflammatory and Degenerative MRI Findings
in the Spine and Sacroiliac Joints: A Latent Class Analysis of
1037 Patients with Persistent Low Back Pain

Arthritis Res Ther. 2016 (Oct 13);   18 (1):   237 ~ FULL TEXT

In general terms, the profile of each subgroup can be described in the following way.

Patients in Subgroup 1 had no or few MRI findings and therefore were labelled ‘No or few findings’.

Patients in Subgroup 2 had low sum scores on the variables related to spinal degeneration, with no or very few findings at the SIJs, and therefore were labelled ‘Mild spinal degeneration’.

Patients in Subgroup 3 had higher sum scores on the variables related to spinal degeneration than Subgroup 2, with no or very few findings at the SIJs, and therefore were labelled ‘Moderate/severe spinal degeneration’.

Patients in Subgroup 4 had similar sum scores on the variables related to spinal degeneration as Subgroup 3, but also MRI findings at the SIJ, and therefore were labelled ‘Moderate/severe spinal degeneration and mild SIJ findings’.

Patients in Subgroup 5 had lower sum scores of the variables related to spinal degeneration than Subgroup 4, but higher sum scores of findings at the SIJs, and therefore were labelled ‘Mild spinal degeneration and moderate/severe SIJ findings’ (see Figure 2 for details).

Mechanisms of Low Back Pain: A Guide for Diagnosis and Therapy
Version 2. F1000Res. 2016 (Oct 11); 5. pii: F1000 ~ FULL TEXT

Low back pain (LBP) is the most common musculoskeletal condition affecting the adult population, with a prevalence of up to 84%. [1] Chronic LBP (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 12 weeks. [2] Many authors suggest defining chronic pain as pain that lasts beyond the expected period of healing, avoiding this close time criterion. This definition is very important, as it underlines the concept that CLBP has well-defined underlying pathological causes and that it is a disease, not a symptom. CLBP represents the leading cause of disability worldwide and is a major welfare and economic problem. [1] Given this complexity, the diagnostic evaluation of patients with LBP can be very challenging and requires complex clinical decision-making. Answering the question, “what is the pain generator?” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a diagnosis not based on specific pain generator can lead to therapeutic mistakes. This article aims to provide a brief clinical guide that could help in the identification of pain generators through a careful anatomical description, thereby directing clinicians towards the correct diagnosis and therapeutic approach.

Effectiveness and Economic Evaluation of Chiropractic Care for the Treatment of
Low Back Pain: A Systematic Review of Pragmatic Studies

PLoS One. 2016 (Aug 3);   11 (8):   e0160037 ~ FULL TEXT

Moderate evidence suggests that chiropractic care for LBP appears to be equally effective as physical therapy. Limited evidence suggests the same conclusion when chiropractic care is compared to exercise therapy and medical care although no firm conclusion can be reached at this time. No serious adverse events were reported for any type of care. Our review was also unable to clarify whether chiropractic or medical care is more cost-effective. Given the limited available evidence, the decision to seek or to refer patients for chiropractic care should be based on patient preference and values. Future studies are likely to have an important impact on our estimates as these were based on only a few admissible studies.

Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis:
Results of an International Delphi Study

Spine (Phila Pa 1976). 2016 (Aug 1);   41 (15):   1239–1246   ~ FULL TEXT

A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated.

The six top items were

"leg or buttock pain while walking,"
"flex forward to relieve symptoms,"
"feel relief when using a shopping cart or bicycle,"
"motor or sensory disturbance while walking,"
"normal and symmetric foot pulses,"
"lower extremity weakness,"
"low back pain."

Significant change in certainty ceased after six questions at 80% (P < .05).

Neural Correlates of Fear of Movement in Patients with Chronic Low Back Pain
vs. Pain-Free Individuals

Front Hum Neurosci. 2016 (Jul 26);   10:   386 ~ FULL TEXT

In the current fMRI study, we applied a novel approach encompassing: (1) video clips of potentially harmful activities for the back as fear of movement (FOM) inducing stimuli; and (2) the assessment of FOM in both, chronic low back pain (cLBP) patients (N = 20) and age- and gender-matched pain-free subjects (N = 20). Derived from the fear avoidance (FA) model, we hypothesized that FOM differentially affects brain regions involved in fear processing in patients with cLBP compared to pain-free individuals due to the recurrent pain and subsequent avoidance behavior.

Implementation Interventions to Improve the Management of Non-specific Low Back Pain:
A Systematic Review

BMC Musculoskelet Disord. 2016 (Jun 10);   17:   258 ~ FULL TEXT

The results of this review indicate that the most successful interventions to support implementation of best available evidence into clinical practice for NSLBP are those that occur more frequently and are ongoing. Other factors such as intervention type, complexity or target healthcare practitioner or behaviour did not appear to determine the success of the implementation intervention tested. These results must be interpreted with some caution given that many included papers were at high risk of bias. Further high quality studies are needed to robustly test the effectiveness of implementation interventions in this field. The investigators of future implementation studies in this area should develop a strong rationale for the implementation intervention(s) chosen by identifying barriers and facilitators to implementation of best available evidence, select relevant implementation interventions to overcome these barriers and enhance the facilitators and follow best practice guidelines in design, conduct and reporting of their studies. In particular future studies need to give careful consideration to the frequency and duration of their implementation intervention and evaluate cost-effectiveness.

Identifying Patients With Chronic Low Back Pain Who Respond Best to Mechanical Diagnosis
and Therapy: Secondary Analysis of a Randomized Controlled Trial

Phys Ther. 2016 (May);   96 (5):   623–630 ~ FULL TEXT

Being older met our criteria for being a potentially important effect modifier; however, the effect occurred in the opposite direction to our hypothesis. Older people had 1.27 points more benefit in pain reduction from MDT (compared with Back School) than younger participants after 1 month of treatment.

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

PLoS Med. 2016 (May 17);   13 (5):   e1002019 ~ FULL TEXT

At 3 mo, 30% of the patients in the development sample were classified as having chronic LBP.   Table 4 shows predictors and regression coefficients for the primary model (PICKUP) and the two secondary models that were fitted in this sample. PICKUP contained five predictors. We did not detect significant non-linearity in any continuous predictor variables.

Variations in Patterns of Utilization and Charges for the Care of Low Back Pain
in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   252–262 ~ FULL TEXT

A major strength of the study was the large amount of low back pain claims made available to us for analysis. The data were from 3,159,362 claims generated by approximately 66,0000 persons over the 2000–2009 decade in North Carolina, in several different pathways of healthcare services. This study and the series of papers it has generated on the treatment of low back pain, neck pain [25] and headache, [26] provides unique economic examination for healthcare policy makers and legislators.   When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population.   This is an opportunity to view costs laterally versus a confined, vertical analysis.
This is one of 3 of the Cost-Effectiveness Triumvirate articles.

Importance of the Type of Provider Seen to Begin Health Care for a New Episode
Low Back Pain: Associations with Future Utilization and Costs

J Eval Clin Pract. 2016 (Apr);   22 (2):   247–252 ~ FULL TEXT

The RESULTS portion of this Abstract only partially discusses the findings, comparing 3 different professions' treatment, costs, and outcomes for low back pain.   In it they only mention the costs associated with medical management, while in reviewing chiropractic care vs. physical thereapy portions, they choose to emphasize:

  • Entry in chiropractic was associated with an increased episode of care duration
  • Entry in physical therapy no patient entering in physical therapy had surgery.

That *seems* to suggest that physical therapy *may* entail less expense, or shorter durations of care, or that chiropractic patients are more likely to end up with surgery.   None of that is true.   Their own Table 2 plainly reveals that chiropractic care was the least expensive form of care provided to the 3 groups.

Symptomatic, MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes
Depending on the Type and Anatomical Axial Location of the Hernia in Patients
Treated With High-Velocity, Low-Amplitude Spinal Manipulation

J Manipulative Physiol Ther. 2016 (Mar);   39 (3):   192–199 ~ FULL TEXT

The majority of patients in this study had either extruded or sequestered disc herniations. Patients with sequestered herniations treated with SMT to the level of herniation reported significantly higher levels of leg pain reduction at 1 month and a higher proportion reported improvement at all data collection time points compared to patients with extruded disc herniations but this did not reach statistical significance. Further investigation is needed to determine mechanisms for this finding. This also calls into question the seriousness of disc sequestration in determining appropriate treatment.

Prediction of Outcome in Patients with Low Back Pain -- A Prospective Cohort
Study Comparing Clinicians' Predictions with those of the Start Back Tool

Manual Therapy 2016 (Feb);   21:   120–127 ~ FULL TEXT

The accuracies of predictions made by clinicians (AUC .58-.63) and the STarT Back Screening Tool (SBT) (AUC .50-.61) were comparable and low. No substantial increase in the predictive capability was achieved by combining clinicians' expectations and the SBT. In conclusion, chiropractors' predictions were associated with well-established prognostic factors but not simply a product of these. Chiropractors were able to predict differences in outcome on a group level, but prediction of individual patients' outcomes were inaccurate and not substantially improved by the SBT.

Absence of Low Back Pain to Demarcate an Episode:
A Prospective Multicentre Study in Primary Care

Chiropractic & Manual Therapies 2016 (Feb 18);   24:   3 ~ FULL TEXT

A logical relationship exists between the prevalence of four consecutive pain free weeks and the study population, it being most common in the general population, followed by the primary care population and least common in the secondary care sector Further, absence of LBP is less common in patients from the primary care sector with a previous long duration of pain than in those with previous shorter pain duration. Therefore, a period of four consecutive pain free weeks may be applied both for research purposes and in clinical practice to demarcate a LBP episode.

Assessment of Chiropractic Treatment for Active Duty, U.S. Military Personnel
with Low Back Pain: Study Protocol for a Randomized Controlled Trial

Trials. 2016 (Feb 9); 17: 70 ~ FULL TEXT

Because low back pain is one of the leading causes of disability among U.S. military personnel, it is important to find pragmatic and conservative treatments that will treat low back pain and preserve low back function so that military readiness is maintained. Thus, it is important to evaluate the effects of the addition of chiropractic care to usual medical care on low back pain and disability.

The Association Between Use of Chiropractic Care and Costs of Care Among Older
Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities

J Manipulative Physiol Ther. 2016 (Feb);   39 (2):   63–75 ~ FULL TEXT

After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided.

Workers' Compensation, Return to Work, and Lumbar Fusion for Spondylolisthesis
Orthopedics. 2016 (Jan);   39 (1):   e1–8 ~ FULL TEXT

In this study, researchers reviewed the files of 686 workers who underwent fusion surgery for spondylolisthesis between 1993 and 2013, revealing that only 29.9% of them ever returned to work (for at least 6 months).   The failure rate (meaning return-to-work) was 70.1%.

Clinical Practice Guideline: Chiropractic Care for Low Back Pain
J Manipulative Physiol Ther. 2016 (Jan);   39 (1):   1–22 ~ FULL TEXT

To facilitate best practices specific to the chiropractic management of patients with common, primarily musculoskeletal disorders, the profession established the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) in 1995. [6] The organization sponsored and/or participated in the development of a number of “best practices” recommendations on various conditions. [21–32] With respect to chiropractic management of LBP, a CCGPP team produced a literature synthesis [8] which formed the basis of the first iteration of this guideline in 2008. [9] In 2010, a new guideline focused on chronic spine-related pain was published, [12] with a companion publication to both the 2008 and 2010 guidelines published in 2012, providing algorithms for chiropractic management of both acute and chronic pain. [10] Guidelines should be updated regularly. [33, 34] Therefore, this article provides the clinical practice guideline (CPG) based on an updated systematic literature review and extensive and robust consensus process. [9–12]

Characteristics of Patients with Low Back and Leg Pain Seeking Treatment in Primary Care:
line Results from the ATLAS Cohort Study

BMC Musculoskelet Disord. 2015 (Nov 4);   16:   332 ~ FULL TEXT

In summary, in this unselected primary care cohort of patients seeking care for back and leg pain, disability levels are higher as compared with cohorts including mixed populations of LBP patients with and without pain in the leg(s) and similar for both sciatica and referred leg pain presentations. Nearly three quarters of the participants were clinically diagnosed as having sciatica. Approximately half of this cohort was likely to have pain of neuropathic nature as measured with self-reported scales. In contrast to non-specific LBP, minimal treatment was applicable to only a very small number of patients in this cohort. MRI findings of nerve root compression were present in just over half of the participants. There were differences between the sciatica and referred leg pain groups in terms of leg pain levels, neuropathic pain, bothersomeness due to the sciatic symptoms and MRI findings. Follow-up of this cohort will investigate the prognostic value of their baseline characteristics and explore the clinical relevance of the differences between those with sciatica and referred leg pain for the course of the low back and leg pain episode.

Low Back Pain Patients in Sweden, Denmark and the UK Share Similar
Characteristics and Outcomes: A Cross-National Comparison
of Prospective Cohort Studies

BMC Musculoskelet Disord. 2015 (Nov 26);   16 (1):   367 ~ FULL TEXT

Chiropractic patients with low back pain had similar characteristics and clinical course across three Northern European countries. It is unlikely that culture have substantially different impacts on the course of LBP in these countries and the results support knowledge transfer between the investigated countries.

A Tailored Exercise Program Versus General Exercise for a Subgroup of
Patients with Low Back Pain and Movement Control Impairment:
A Randomised Controlled Trial with One-year Follow-up

Manual Therapy 2015 (Oct);   20 (5):   672–679 ~ FULL TEXT

Patient Specific Function Scale (PSFS) showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year.   This study found no additional benefit of specific exercises targeting movement control impairment (MCI)

Prognosis and Course of Pain in Patients With Chronic Non-Specific Low Back Pain:
A 1-year Follow-Up Cohort Study

European Journal of Pain 2015 (Sep);   19 (8):   1101–1110 ~ FULL TEXT

Patient-reported intensity of back pain decreased from 55.5 (SD 23.0) at baseline to 37.0 (SD 23.8), 35.3 (SD 26.1) and 32.3 (SD 26.9) at 2-, 5- and 12-month follow-up, respectively. Younger age, back pain at baseline, no psychological/physical dysfunction (Symptom Check List-90, item 9), and higher baseline scores on the physical component scale and mental component scale of quality of life (Short Form-36) were positively associated with recovery at 5 and 12 months. At 5-month follow-up, higher work participation at baseline was also a prognostic factor for both definitions of recovery. At 12-month follow-up, having co-morbidity was predictive for both definitions.

Interview with Michael Schneider, DC, PhD, on a Non-surgical Approach to Spinal Stenosis
Topics in Integrative Health Care 2015 (Sep 29);   6 (2) ~ FULL TEXT

Michael Schneider, DC, PhD, is an Associate Professor at the School of Health and Rehabilitation Sciences at the University of Pittsburgh.   Schneider was the only chiropractor to receive a grant as part of the Patient Centered Outcomes Research Institute’s (PCORI) first wave of 25 grants, in late 2012.   PCORI was created as an independent entity by the Patient Protection and Affordable Care Act, with a mission to fund high-quality comparative effectiveness research.   The topic of Dr. Schneider’s research is A Comparison of Nonsurgical Treatment Methods for Patients with Lumbar Spinal Stenosis.

Collaborative Care for a Patient with Complex Low Back Pain and
Long-term Tobacco Use: A Case Report

J Can Chiropr Assoc. 2015 (Sep);   59 (3):   216–225 ~ FULL TEXT

Few examples of interprofessional collaboration by chiropractors and other healthcare professionals are available. This case report describes an older adult with complex low back pain and longstanding tobacco use who received collaborative healthcare while enrolled in a clinical trial. A doctor of chiropractic and a doctor of osteopathy provided collaborative care based on patient goal setting and supported by structured interdisciplinary communication, including record sharing and telephone consultations. Collaborative care facilitated active involvement of the patient and resulted in decreased radicular symptoms, improvements in activities of daily living, and tobacco use reduction.

Do Participants with Low Back Pain who Respond to Spinal Manipulative Therapy Differ
Biomechanically From Nonresponders, Untreated Controls or Asymptomatic Controls?

Spine (Phila Pa 1976). 2015 (Sep 1);   40 (17):   1329–1337 ~ FULL TEXT

After the first SMT, SMT responders displayed statistically significant decreases in spinal stiffness and increases in multifidus thickness ratio sustained for more than 7 days; these findings were not observed in other groups. Similarly, only SMT responders displayed significant post-SMT improvement in apparent diffusion coefficients.   Those reporting post-SMT improvement in disability demonstrated simultaneous changes between self-reported and objective measures of spinal function. This coherence did not exist for asymptomatic controls or no-treatment controls. These data imply that SMT impacts biomechanical characteristics within SMT responders not present in all patients with LBP. This work provides a foundation to investigate the heterogeneous nature of LBP, mechanisms underlying differential therapeutic response, and the biomechanical and imaging characteristics defining responders at baseline.

First-Contact Care With a Medical vs Chiropractic Provider After Consultation With
a Swiss Telemedicine Provider: Comparison of Outcomes, Patient Satisfaction, and
Health Care Costs in Spinal, Hip, and Shoulder Pain Patients

J Manipulative Physiol Ther. 2015 (Sep);   38 (7):   477–483 ~ FULL TEXT

JMPT's Editor-in-Chief Claire Johnson, DC, MEd, emphasized the importance of the latest findings:
“Comparative studies – in other words, research that compares the outcomes between two different providers or modalities – are rare for chiropractic care,” she said.   “Thus, this study by Houweling, et al., is especially important if payers and policy-makers are to better understand the 'triple aim' as it relates to chiropractic. Specifically, this study helps us better understand what type of care provides better patient satisfaction, is more cost effective, and improves population health.”

Association of Worker Characteristics and Early Reimbursement for Physical Therapy, Chiropractic
and Opioid Prescriptions With Workers' Compensation Claim Duration, For Cases of
Acute Low Back Pain: An Observational Cohort Study

BMJ Open. 2015 (Aug 26);   5 (8):   e007836

Our analysis found that early WSIB reimbursement for physiotherapy or chiropractic care, in claimants fully off work for more than 4 weeks, was not associated with claim duration, and that early reimbursement for opioids predicted prolonged claim duration. Well-designed randomised controlled trials are needed to verify our findings and establish causality between these variables and claim duration.

Prediction of Pain Outcomes in a Randomized Controlled Trial of Dose-response
of Spinal Manipulation for the Care of Chronic Low Back Pain

BMC Musculoskelet Disord. 2015 (Aug 19);   16:   205 ~ FULL TEXT

Internal validation of prediction models showed that participant characteristics preceding the start of care were poor predictors of at least 50% improvement and the individual's future pain intensity. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best.

Regional Supply of Chiropractic Care and Visits to Primary Care Physicians
for Back and Neck Pain

J Am Board Fam Med. 2015 (Jul);   28 (4):   481–490 ~ FULL TEXT

Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11–14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services. When extrapolated to the nation (based on our predictions from our adjusted model), we estimate that chiropractic care is associated with a reduction of 0.37 million visits to PCPs for back and/or neck pain at a total cost of $83.5 million (Table 3).

Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain
at Risk of Developing Chronic Pain

Spine J. 2015 (Jul 1);   15 (7):   1577–1586 ~ FULL TEXT

Despite these limitations, we conclude that our study provides a clinical decision rule that is urgently needed for one of the most frequent and most costly conditions in primary care. [50] It contains 8 items for the 6–month and 8 items for the 2–year risk classification (5 are common to both) into 3 levels of risk for developing chronic pain in patients presenting in primary care with a new-onset episode of strictly defined acute low back pain. The next step is to prospectively validate this tool in an independent population.

The Chiropractic Hospital-Based Interventions Research Outcomes Study:
Consistency of Outcomes Between Doctors of Chiropractic
Treating Patients With Acute Lower Back Pain

J Manipulative Physiol Ther. 2015 (Jun);   38 (5):   311–323 ~ FULL TEXT

The findings of this study show that regardless of the treating DC, most patients with acute LBP without radiculopathy appear to experience consistent levels of improvement in terms of back pain and general physical functioning (PF) after receiving guidelines-based treatment that includes a component of standardized HVLA SMT.

Low Back Pain: Guidelines for the Clinical Classification of Predominant
Neuropathic, Nociceptive, or Central Sensitization Pain

Pain Physician. 2015 (May);   18 (3):   E333–346   ~ FULL TEXT

Modern pain neuroscience has advanced our understanding about pain, including the role of central sensitization (CS) in amplifying pain experiences. CS is defined as “an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” [11], “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input” [3], or “an augmentation of responsiveness of central neurons to input from unimodal and polymodal receptors”. [12] Although one might say that these definitions differ substantially, they all point to the same underlying neurophysiological mechanism of increased neuronal response to stimuli in the central nervous system (i.e., central hyperexcitability). The definitions originate from laboratory research, but the awareness that the concept of CS should be translated to the clinic is growing. [13, 14]

Deconstructing Chronic Low Back Pain in the Older Adult
A Unique Series of Articles

Edirorial Comment:

This is a fascinating series of articles.

NOTE:   However, they ignore all the widely accepted guidelines that I have grown accustomed to over the last 10 years, and are solely allopathic in their treatment pattern (drugs, and more drugs) with virtually no mention of spinal manipulation as an option.

Even so, they are spot-on in their assessment and diagnosis sections, and it comes as no surprise that they only recommend what they were trained to provide, and ignore (mostly) all the *alternative* forms of care, unless they directly control them (like physical therapy).

They are listed here for their contribution to our current understanding of the allopathic approach for managing *Chronic Low Back Pain in the Older Adult*.

Deconstructing Chronic Low Back Pain in the Older Adult –
Shifting the Paradigm from the Spine to the Person
The Introduction to the Article Series

Pain Medicine 2015 (May);   16 (5):   881–885 ~ FULL TEXT

Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled [1], and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket. [1–3]   Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected.   This issue of Pain Medicine contains the first in a series of articles on how to systematically and comprehensively rethink our approach to evaluating and designing management for older adults with chronic low back pain (CLBP).

Deconstructing Chronic Low Back Pain in the Older Adult –
Part I: Hip Osteoarthritis

Pain Medicine 2015 (May);   16 (5):   886–897 ~ FULL TEXT

An estimated one in two people with hip osteoarthritis (OA) has low back pain (LBP). [1] The Hip-Spine Syndrome (HSS) was first described by Offierski in 1983. [2] Three types of patients were described – those with “simple” HSS who had pathology of both the hip and lumbar spine, but disability related to only one source; those with “complex” HSS who had symptoms from both the hip and spine without a clear single source of disability, such as patients with low back and leg pain and who have clinical evidence of both lumbar spinal stenosis and hip OA [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part II: Myofascial Pain

Pain Medicine 2015 (Jul);   16 (7):   1282–1289 ~ FULL TEXT

Myofascial pain (MP) as first described by Travell and Simons, is defined by a localized region of palpable tightness and tenderness within a muscle that is characterized by resistance to passive elongation, and reproduction of a predictable pattern of referred pain on palpation. [1] The pathogenesis of MP is not fully understood, but can be a local muscle response to underlying mechanical factors (postural abnormalities, biomechanical faults, chronic strain), or a response to altered neurotrophic factors secondary to spondylosis. [2–4]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part III: Fibromyalgia Syndrome

Pain Medicine 2015 (Sep);   16 (9):   1709–1719 ~ FULL TEXT

Fibromyalgia syndrome (FMS) is a challenging diagnosis for many health care providers given the breadth of symptoms patients have on presentation and the paucity of specific objective findings. Twenty-five years ago, FMS was initially described as a syndrome characterized by widespread musculoskeletal pain that could not be explained by another diagnosis. [1] FMS has been increasingly recognized to encompass additional features such as fatigue and nonrestorative sleep, and these other symptoms are included in the updated 2010 American College of Rheumatology (ACR) criteria. [2] The prevalence of FMS increases with age, has a female preponderance, peaks in the seventh decade, and varies from <1% to 5%. [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part IV: Depression

Pain Medicine 2015 (Nov);   16 (11):   2098–2108 ~ FULL TEXT

Major depressive disorder (MDD) has a reported 1–year prevalence of 6–12% in older adults in both Veterans Affairs and civilian settings. In addition to MDD, the prevalence of clinically significant subsyndromal depressive symptoms in late-life (generally defined as ≥65 years) is estimated to be even higher. This may be due to under-recognition in the context of complex comorbidities. [1, 2] Depression is often a recurrent illness, triggered, and exacerbated by both psychological stress and medical illnesses. High medical burden in older adults contributes to treatment response variability such as delayed response to antidepressant pharmacotherapy and increased likelihood of recurrence. [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part V: Maladaptive Coping

Pain Medicine 2016 (Jan);   17 (1):   64–73 ~ FULL TEXT

Older adults who experience chronic low back pain (CLBP) develop behavioral and cognitive coping strategies to tolerate or reduce pain. These coping strategies have been shown to significantly predict pain, functional capacity, and chronification of LBP. For example, adaptive coping strategies are generally associated with reduced pain, positive affect, and better psychological adjustment [1], whereas maladaptive coping strategies have been linked with negative outcomes such as psychological distress, increased pain, and heightened disability. [2–4] Please see Table 1 for examples of maladaptive and adaptive coping strategies.

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VI: Lumbar Spinal Stenosis

Pain Medicine 2016 (Mar);   17 (3):   501–510 ~ FULL TEXT

Lumbar spinal stenosis (LSS) is a common source of pain and diminished function among older adults with chronic low back pain (CLBP). Lumbar spinal stenosis results from narrowing of the lumbar spinal canal, and/or intervertebral foramina most often resulting from degenerative changes in the spine including facet joint arthrosis, loss of intervertebral disk height, degenerative spondylolisthesis, ligament thickening, post-surgical fibrosis, etc. [1] The prevalence of LSS based on imaging criteria is estimated to be almost 50% in individuals over age 60, but many older adults with imaging evidence of anatomical stenosis are asymptomatic. [2] Lumbar spinal stenosis is the most common indication for spinal surgery among Medicare recipients, [3, 4] occurring at a rate of 135.5 surgeries per 100,000 Medicare beneficiaries in 2007. [5]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VII: Insomnia

Pain Medicine 2016 (May);   17 (5):   851–863 ~ FULL TEXT

Sleep problems are a highly prevalent comorbidity and consequence of chronic low back pain (CLBP), impacting an estimated 50–80% of individuals with CLBP. [1–3] Insomnia – dissatisfaction with sleep quantity or quality related to difficulty initiating, maintaining, and/or early morning awakenings [4] – is the most common sleep disorder in the general population and among those with CLBP. [5] Insomnia also significantly increases the risk of developing CLBP, even after controlling for socioeconomic, self-reported health, lifestyle behaviors, and anthropometric variables. [6]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VIII: Lateral Hip and Thigh Pain

Pain Medicine 2016 (May);   17 (5):   851–863 ~ FULL TEXT

Many physicians assume that an older adult with low back pain (LBP) and concomitant lateral hip/thigh pain has lumbar spinal stenosis. However, in reality there are myriad causes of lateral hip/thigh pain in older adults and the diagnosis of this pain can be challenging due to pain referral patterns. First, the hip and nearby lumbopelvic structures share innervation from common nerve roots, so pain referral patterns from pathology of these structures overlap. [1, 2] Second, faulty mechanics of the lumbar spine and/or hip can lead to compensatory movement patterns and eventually result in multiple pain generators. These challenges are illustrated in a study by Sembrano and colleagues. In a sample of 200 patients presenting for evaluation by a spine surgeon, only 65% had isolated spine pain, whereas 17.5% had a combination of hip, spine, and/or sacroiliac (SI) joint pain. [3] Lastly, diagnosing the etiology of hip and lumbopelvic pain in older adults is challenging in that many people have structural abnormalities on imaging studies that are asymptomatic. For instance, 93% of asymptomatic people 60–80 years old have MRI evidence of disc degeneration, 36% have a herniated disc, and 21% have spinal stenosis. [4] Additionally, only 46.5% of women ages 65 years and older who have radiographic evidence of hip osteoarthritis (OA) report hip pain “on most days for at least 1 month”. [5]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part IX: Anxiety

Pain Medicine 2016 (Aug);   17 (8):   1423–1435 ~ FULL TEXT

Patients with chronic low-back pain (CLBP) commonly exhibit increased levels of emotional distress. [1]   For example, anxious mood and other symptoms of anxiety are commonly seen in patients with CLBP. [2]   Prevalence of anxiety disorders in CLBP patients (19–31%) has been found to be greater than that of the general population (10–25%). [3–5]   Polatin and colleagues (1993) also found that approximately 95% of adults with a lifetime history of anxiety disorders experienced these symptoms prior to the onset of low back pain, with only 5% reporting the development of anxiety after the onset of low-back pain. [3]   Additionally, symptoms of psychological distress (e.g., anxiety and somatization) have been found to predict subsequent onset of new episodes of low back pain. [6, 7]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part X: Sacroiliac Joint Syndrome

Pain Medicine 2016 (Sep);   17 (9):   1638–1647 ~ FULL TEXT

The algorithm and drug table developed to systematically identify and address SIJ pain in the older adult is presented here. The process should begin with recognizing the presenting symptoms of CLBP stemming from the SI region, and supporting physical exam testing using the compression test and thigh thrust maneuver. Identification of the SIJ as a pain generator is followed by assessment and treatment of contributory factors. SIJ pain treatment should begin with education and self-management including exercise, and may escalate to include interventional procedures and/or referral to a pain rehabilitation program.

Deconstructing Chronic Low Back Pain in the Older Adult –
Part XI: Dementia

Pain Medicine 2016 (Sep);   17 (9):   1638–1647 ~ FULL TEXT

Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.

Deconstructing Chronic Low Back Pain in the Older Adult –
Part XII: Leg Length Discrepancy

Pain Medicine 2016 (Dec);   17 (12):   2230–2237 ~ FULL TEXT

Leg length discrepancies are associated with numerous postural alignment challenges that may lead to low back pain. The goal of the presented algorithm is to provide an evidence-based instrument to aid the clinician in a practical approach to evaluation and treatment. The case presented underscores that the older adult with CLBP may prioritize goals other than pain management per se, which include improving balance, reducing stiffness, and improving function. As with all older adults, utilization of a patient-centered approach is critical. We have developed this series of algorithms on CLBP to facilitate such an approach.

A Qualitative Study of Changes in Expectations Over Time Among Patients
with Chronic Low Back Pain Seeking Four CAM Therapies

BMC Complement Altern Med. 2015 (Feb 5);   15:   12 ~ FULL TEXT

These findings suggest the value of further research into the potential of the CAM therapeutic process to assist patients in taking control of their health management and wellness. Sointu [58] argues that CAM use is becoming increasingly common because the “discourse of well-being” (9) embedded in CAM interactions (see also [24, 25]) resonates with how people understand their bodies and selves. Our data support the finding that CAM participants report greater awareness of the need for ongoing engagement in their own care, an increased sense of control or empowerment, and motivation to seek effective coping strategies. [ Editorial Comment: These are all things that conventional medicine struggles with.]

Clinical Examination Findings as Prognostic Factors in Low Back Pain:
A Systematic Review of the Literature

Chiropractic & Manual Therapies 2015 (Mar 23);   23:   13 ~ FULL TEXT

A total of 5,332 citations were retrieved and screened for eligibility, 342 articles were assessed as full text and 49 met the inclusion criteria. Due to clinical and statistical heterogeneity, qualitative synthesis rather than meta-analysis was performed. Associations between clinical tests and outcomes were often inconsistent between studies. In more than one third of the tests, there was no evidence of the tests being associated with outcome. Only two clinical tests demonstrated a consistent association with at least one of the outcomes: centralization and non-organic signs.

Pain Location Matters: The Impact of Leg Pain on Health Care Use,
Disability and Quality of Life in Patients with Low Back Pain

European Spine Journal 2015 (Mar);   24 (3):   444–451 ~ FULL TEXT

Patients with self-reported leg pain below the knee utilise more health care are more likely to be unemployed and have poorer quality of life than those with LBP only 12 months following primary care consultation. The presence of leg pain warrants early identification in primary care to explore if targeted interventions can reduce the impact and consequences of leg pain.

Evaluation of a Modified Clinical Prediction Rule For Use With Spinal
Manipulative Therapy in Patients With Chronic Low Back Pain:
A Randomized Clinical Trial

Chiropractic & Manual Therapies 2014 (Nov 18);   22 (1):   41 ~ FULL TEXT

Recent literature has highlighted the lack of definitive data to emerge from RCTs evaluating Chronic Lower Back Pain (CLBP), with no treatment producing consistently superior outcomes. [29-32] In keeping with this previous literature and supporting our first hypothesis, we found clinically and statistically significant improvements in outcomes from baseline to follow up in the groups receiving Spinal Manipulative Therapy (SMT) and Active Exercise Therapy (AET), which are both recognized as evidence based interventions for CLBP. [10, 31]

What Are Patient Beliefs and Perceptions About Exercise for Nonspecific
Chronic Low Back Pain? A Systematic Review of Qualitative Studies

Clin J Pain. 2014 (Nov);   30 (11):   995–1005 ~ FULL TEXT

Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue.   People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

Occupational Low Back Pain in Primary and High School Teachers:
Prevalence and Associated Factors

J Manipulative Physiol Ther. 2014 (Nov);   37 (9):   702–708 ~ FULL TEXT

The prevalence of low back pain (LBP) in teachers appears to be high. High school teachers were more likely to experience LBP than primary school teachers. Factors such as age, body mass index, length of employment, job satisfaction, and work-related activities were significant factors associated with LBP in this teacher population.

Low Back Pain in Primary Care: A Description of 1250 Patients
with Low Back Pain in Danish General and Chiropractic Practice

Int J Family Med. 2014 (Nov 4);   2014:   106102 ~ FULL TEXT

Four out of five patients had had previous episodes, one-fourth were on sick leave, and the LBP considerably limited daily activities. The general practice patients were slightly older and less educated, more often females, and generally worse on all disease-related parameters than chiropractic patients. All differences were statistically significant.

Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic
Back-related Leg Pain: A Trial With Adaptive Allocation
Ann Intern Med. 2014 (Sep 16);   161 (6):   381—391 ~ FULL TEXT

Of the 192 enrolled patients, 191 (99%) provided follow-up data at 12 weeks and 179 (93%) at 52 weeks. For leg pain, SMT plus HEA had a clinically important advantage over home exercise and advice (HEA) (difference, 10 percentage points [95% CI, 2 to 19]; P=0.008) at 12 weeks but not at 52 weeks (difference, 7 percentage points [CI, –2 to 15]; P=0.146). Nearly all secondary outcomes improved more with SMT plus HEA at 12 weeks, but only global improvement, satisfaction, and medication use had sustained improvements at 52 weeks. No serious treatment-related adverse events or deaths occurred.   For patients with back-related leg pain (BRLP), SMT plus home exercise and advice (HEA) was more effective than HEA alone after 12 weeks, but the benefit was sustained only for some secondary outcomes at 52 weeks.

Dose-response and Efficacy of Spinal Manipulation for Care of Chronic Low Back Pain:
A Randomized Controlled Trial

Spine J. 2014 (Jul 1);   14 (7):   1106–1116 ~ FULL TEXT

For the primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks and sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per six manipulation sessions at 12 and 52 weeks for both variables (p<.025). At 12 weeks, the greatest differences from the no-manipulation control were found for 12 sessions (8.6 pain and 7.6 disability points, p<.025); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points, p<.025).

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain
Journal of Pain 2014 (Jun);   15 (6):   569–585 ~ FULL TEXT

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The NIH Pain Consortium therefore charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination.

Cost Analysis Related to Dose-response of Spinal Manipulative Therapy for
Chronic Low Back Pain: Outcomes from a Randomized Controlled Trial

J Manipulative Physiol Ther. 2014 (Jun);   37 (5):   300–311 ~ FULL TEXT

Lost productivity accounts for most societal costs of chronic LBP. Cost of treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were greater age (P = .03), greater disability (P = .01), lower quality-adjusted life year scores (P = .01), and higher costs in the period preceding enrollment (P < .01). Pain-free and disability-free days were greater for all SMT doses compared with control, but only SMT 12 yielded a statistically significant benefit of 22.9 pain-free days (P = .03) and 19.8 disability-free days (P = .04). No statistically significant group differences in quality-adjusted life years were noted.

CONCLUSIONS:   A dose of 12 SMT sessions yielded a modest benefit in pain-free and disability-free days. Care of chronic LBP with SMT did not increase the costs of treatment plus lost productivity.

The Global Burden of Low Back Pain:
Estimates from the Global Burden of Disease 2010 study

Ann Rheum Dis. 2014 (Jun);   73 (6):  968–974 ~ FULL TEXT

Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden disability-adjusted life years (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age.
There are more articles like this at our Global Burden of Disease Section

Tracking Low Back Problems in a Major Self-Insured Workforce:
Toward Improvement in the Patient's Journey

J Occup Environ Med. 2014 (Jun);   56 (6):   604–620 ~ FULL TEXT

This comprehensive new study from the Journal of Occupational and Environmental Medicine reveals that chiropractic care costs significantly less than other forms of low back care, and appears to comply with guideline recommendations more closely than than any of the other 4 comparison groups.

Short Term Treatment Versus Long Term Management of Neck and Back
Disability in Older Adults Utilizing Spinal Manipulative Therapy and
Supervised Exercise: A Parallel-group Randomized Clinical Trial
Evaluating Relative Effectiveness and Harms

Chiropractic & Manual Therapies 2014 (May 23);   22:   21 ~ FULL TEXT

This is one of the first full-scale randomized clinical trials to compare short term treatment and long term management using SMT and exercise to treat spine-related disability in older adults. It builds on previous research by the investigative team showing improvement with three months of SMT and exercise in similar populations, which regressed to baseline values in long term follow up without further intervention 88. As back and neck pain in older adults are often chronic and among several co-morbidities [6, 8], we theorized that long term management may result in sustained improvement compared to short term treatment. Identifying the most favorable duration of treatment is a pragmatic question common to patients, clinicians, policy makers, and third-party payers alike. [25, 89] This is especially important to address in an older population, whose long term functional ability is essential to maintaining vitality and independence.

A Modern Neuroscience Approach to Chronic Spinal Pain: Combining Pain
Neuroscience Education with Cognition-targeted Motor Control Training

Phys Ther. 2014 (May);   94 (5):   730–738 ~ FULL TEXT

Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed.

The Efficacy of Manual Therapy and Exercise for Different Stages
of Non-specific Low Back Pain: An Update of Systematic Reviews

J Man Manip Ther. 2014 (May);   22 (2):   59–74 ~ FULL TEXT

This SR, based on low-risk of bias studies, has provided a comprehensive review of different MT approaches in patients with different stages of LBP, informing evidence-based-practice. Based on the results of this SR, a variety of manual procedures combined or not with other interventions, including exercise, may improve patient management. The summary findings of this review are both comprehensive and novel and may be used to guide clinical practice and future studies of this topic.

Predictors of Response to Exercise Therapy for Chronic Low Back Pain:
Result of a Prospective Study With One Year Follow-up

Eur J Phys Rehabil Med. 2014 (Apr); 50 (2):   143–151 ~ FULL TEXT

The individually designed exercise therapy program for chronic LBP was associated to clinically significant functional improvement both on discharge and at 1 year. Only severe pain intensity predicted poor treatment response on discharge. At one year, younger age and better mental health predicted improved outcome, while use of drugs and previous LBP treatments were associated with worse response. Adherence to the exercise program almost doubled the probability of a favorable outcome.

Health Care Utilization and Costs Associated with Adherence to Clinical Practice Guidelines for
Early Magnetic Resonance Imaging Among Workers with Acute Occupational Low Back Pain

Health Serv Res. 2014 (Apr);   49 (2):   645–665 ~ FULL TEXT

Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.

Outcomes of Acute and Chronic Patients With Magnetic Resonance Imaging–
Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity,
Low-Amplitude, Spinal Manipulative Therapy: A Prospective
Observational Cohort Study With One-Year Follow-Up

J Manipulative Physiol Ther 2014 (Mar);   37 (3):   155–163 ~ FULL TEXT

Significant improvement for all outcomes at all time points was reported (P < .0001). At 3 months, 90.5% of patients were “improved” with 88.0% “improved” at 1 year. Although acute patients improved faster by 3 months, 81.8% of chronic patients reported “improvement” with 89.2% “improved” at 1 year. There were no adverse events reported.

Patient with Low Back Pain and Somatic Referred Pain Concomitant with
Intermittent Claudication in a Chiropractic Practice

Topics in Integrative Health Care 2014 (Mar 27); 5 (1) ~ FULL TEXT

Chiropractic care was provided and the low back pain improved. The patient developed leg weakness. Radiographic evaluation showed calcification of abdominal aorta and common iliac arteries. The patient was referred for medical evaluation and diagnostic ultrasound findings of arterial occlusion lead to surgical referral. The surgeon reported a “significant amount” of blockage of the left external iliac artery. Leg weakness resolved following placement of surgical stents.

Spinal Manipulative Therapy-specific Changes in Pain Sensitivity in Individuals with Low Back Pain
Journal of Pain 2014 (Feb);   15 (2):   136–148 ~ FULL TEXT

Participants receiving the SMT and placebo SMT received their assigned intervention 6 times over 2 weeks. Pain sensitivity was assessed prior to and immediately following the assigned intervention during the first session. Clinical outcomes were assessed at baseline and following 2 weeks of participation in the study. Immediate attenuation of suprathreshold heat response was greatest following SMT (P = .05, partial η2 = .07). Group-dependent differences were not observed for changes in pain intensity and disability at 2 weeks. Participant satisfaction was greatest following the enhanced placebo SMT.

A Path Analysis of the Effects of the Doctor-patient Encounter and Expectancy
in an Open-label Randomized Trial of Spinal Manipulation for the
Care of Low Back Pain

BMC Complement Altern Med. 2014 (Jan 13);   14:   16 ~ FULL TEXT

The doctor-patient encounter (DPE) can have a relatively important effect on outcomes in open-label randomized trials of treatment efficacy. Therefore, attempts should be made to balance the DPE across treatment groups and report degree of success in study publications. We balanced the DPE across groups with minimal training of treatment providers.

Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain:
Identification of Potentially Useful Questions and Test of Their Predictive Capacity

Chiropractic & Manual Therapies 2014 (Jan 17); 22: 4 ~ FULL TEXT

Pain and depression often co-exist [1–3] , and although the causal relation between the two is not clear, [4, 5] evidence suggests that pain negatively affects outcome in depression as well as vice versa [6]. Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health [7] for which the risk of a poor prognosis is increased in the presence of depression [8, 9] . It is a condition for which there is no generally effective treatment, but non-pharmacological treatment addressing psychological symptoms in addition to the physical symptoms has been demonstrated to improve outcome in LBP patients with high scores on psychological questions [10].

Worsening Trends in the Management and Treatment of Back Pain
JAMA Internal Medicine 2013 (Sep 23);   173 (17):   1573–1581 ~ FULL TEXT

We identified 23,918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P< .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P< .001). In contrast, narcotic use increased from 19.3% to 29.1% (P< .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P< .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P< .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.   Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.

Perspectives of Older Adults on Co-management of Low Back Pain by Doctors of Chiropractic
and Family Medicine Physicians: A Focus Group Study

BMC Complement Altern Med. 2013 (Sep 16);   13:   225 ~ FULL TEXT

Low back pain (LBP) is a leading cause of disability and disease burden. [1, 2] People age 65 years and older report a 25% monthly LBP prevalence rate [3, 4] with recurrent or debilitating LBP common in older populations. [4–6] Chronic LBP is linked to difficulties with activities of daily living (ADLs) [7, 8], depression [4, 7, 9, 10], sleep problems [7, 9], and decreased performance on physical function [7, 11] and neuropsychological tests. [11] An estimated 2.3% of annual physician visits in the U.S. are for LBP. [3] Persons with LBP and other spine conditions have increased healthcare expenditures for medications, spinal imaging, injections and surgery [3, 4, 9, 12–14]. Medicare charges among older adults with back disorders have demonstrated significant increases for patient visits, imaging and spinal injections [12, 15] without translation to better health outcomes for LBP patients. [13–15]

Chronic Low-Back Pain: Is Infection a Common Cause?
ACA News ~ September 2013 ~ FULL TEXT

A 2013 randomized trial by Hanne Albert and colleagues at the University of Southern Denmark, published in the European Spine Journal, [1] found that 100 days of treatment with a disc-penetrating antibiotic was significantly more effective than a placebo for relief of chronic low-back pain (CLBP) in people whose MRI exam showed Modic Type 1 changes, which are associated with degeneration and inflammation. If confirmed by other studies, this would mean that disc infection is a far more common cause of CLBP than previously known.

An Evidence-based Diagnostic Classification System For Low Back Pain
J Can Chiropr Assoc. 2013 (Sep);   57 (3):   189–204 ~ FULL TEXT

This article describes and discusses the strength of evidence surrounding diagnostic categories for an in-office, clinical exam and checklist tool for LBP diagnosis. The use of a standardized tool for diagnosing low back pain in clinical and research settings is encouraged.

Evidence-based Classification Of Low Back Pain In The General Population:
One-year Data Collected With SMS Track

Chiropractic & Manual Therapies 2013 (Sep 2);   21:   30 ~ FULL TEXT

In all, 261 study subjects were included in the analyses, for which 7 distinct LBP subsets could be identified. These could be grouped into three major clusters; those mainly without LBP (35%), those with episodic LBP (30%) and those with persistent LBP (35%). There was a positive association between number of episodes and their duration.

The Collateral Benefits Of Having Chiropractic Available In A Public Central Hospital
Journal of Hospital Administration 2013 (Aug 8);   2 (4):   138–143 ~ FULL TEXT

Following previous reports on the co-operation between a chiropractor and a central hospital, experiences from the past five years are presented. The objective of this paper is to show that improved management of muscular and skeletal problems within a hospital setting depends on the availability of chiropractic health care as a treatment option.

Early Predictors of Lumbar Spine Surgery After Occupational Back Injury:
Results From a Prospective Study of Workers in Washington State

Spine (Phila Pa 1976). 2013 (May 15);   38 (11):   953-964 ~ FULL TEXT

Significant worker baseline variables in a multivariate model predicting one or more lumbar spine surgeries within 3 years of claim submission included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and first seeing a surgeon for the injury. Participants younger than 35 years, females, Hispanics, and participants whose first visit for the injury was to a chiropractor had lower odds of surgery.

Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients with Acute
Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study
Spine (Phila Pa 1976). 2013 (Apr 15);   38 (8):   627–634

The results of this trial suggest that CMT in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP.

Spinal High-velocity Low Amplitude Manipulation in Acute Nonspecific
Low Back Pain: A Double-blinded Randomized Controlled Trial
in Comparison With Diclofenac and Placebo

Spine 2013 (Apr 1);   38 (7):   540–548

A total of 101 patients with acute LBP (for <48 hr) were recruited from 5 outpatient practices, exclusion criteria were numerous and strict. Outcomes registered by a second and blinded investigator included self-rated physical disability, function (SF–12), off-work time, and rescue medication between baseline and 12 weeks after randomization. In a subgroup of patients with acute nonspecific LBP, spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo.

Clinical Course of Non-specific Low Back Pain: A Systematic Review of
Prospective Cohort Studies Set in Primary Care

European Journal of Pain 2013 (Jan);   17 (1):   5–15 ~ FULL TEXT

This systematic review shows that spontaneous recovery from non-specific LBP occurs in the first 3 months after onset of LBP in about one-third of patients, but the majority of patients (65%) still experience pain 1 year after onset of LBP. These findings indicate that the assumption underlying current guidelines that spontaneous recovery occurs in a large majority of patients is not justified. There should be more focus on intensive follow-up and monitoring of patients who have not recovered within the first 3 months. Future research should be directed at improvement of classification of non-specific LBP in more specific groups.

Aging Baby Boomers and the Rising Cost of Chronic Back Pain:
Secular Trend Analysis of Longitudinal Medical Expenditures
Panel Survey Data for Years 2000 to 2007

J Manipulative Physiol Ther. 2013 (Jan);   36 (1):   2–11 ~ FULL TEXT

The prevalence of back pain, especially chronic back pain, is increasing. To the extent that the growth in chronic back pain is caused, in part, by an aging population, the growth will likely continue or accelerate. With relatively high cost per adult with chronic back pain, total expenditures associated with back pain will correspondingly accelerate under existing treatment patterns. This carries implications for prioritizing health policy, clinical practice, and research efforts to improve care outcomes, costs, and cost-effectiveness and for health workforce planning.

Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain
Topics in Integrative Health Care 2012 (Dec 31);   3 (4) ID: 3.4007 ~ FULL TEXT

The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1–3]

Years Lived with Disability (YLDs) for 1160 Sequelae of 289 Diseases and
Injuries 1990-2010: A Systematic Analysis for the
Global Burden of Disease Study 2010

Lancet. 2012 (Dec 15);   380 (9859):   2163–2196 ~ FULL TEXT

Rates of years lived with disability (YLD) per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world.
There are more articles like this at our Global Burden of Disease Section

Patients with Low Back Pain Differ From Those Who Also Have Leg Pain
or Signs of Nerve Root Involvement - A Cross-sectional Study

BMC Musculoskelet Disord. 2012 (Nov 28);   13:   236 ~ FULL TEXT

LBP patients with pain referral to the legs were more severely affected than those with local LBP, and patients with signs of nerve root involvement were the ones most severily affected. These findings underpin the concurrent validity of the Quebec Task Force Classification. However, the small size of many between-subgroup differences amid the large variability in this sample of cross-sectional data also underlines that the heterogeneity of patients with LBP is more complex than that which can be explained by leg pain patterns alone. The implications of the observed differences also require investigation in longitudinal studies.

Use of Chiropractic Spinal Manipulation in Older Adults is Strongly Correlated with Supply
Spine (Phila Pa 1976). 2012 (Sep 15);   37 (20):   1771–1777

The supply of US chiropractors and utilization of CSM by older US adults varied widely by region. The variations cannot be entirely explained by basic patient characteristics or clinical indication, and there is insufficient evidence to explain the variation by patient preferences. Increased chiropractic supply was associated with increased CSM use, but not with increased CSM utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference. To better inform the most advantageous allocation and patient-centered utilization of chiropractic resources, more research is needed on how and why patients do or do not choose chiropractic care.

New Oregon LBP Guidelines: Try Chiropractic First
Dynamic Chiropractic ~ FULL TEXT

This new State of Oregon Evidence-Based Clinical Guidelines for the Evaluation and Management of Low Back Pain recommends spinal manipulation as the only nonpharmacological treatment for acute lower back pain. The guidelines, which have been adopted by the Oregon Health Authority, are a collaborative effort between the Center for Evidence-Based Practice, Oregon Corporation for Health Care Quality, Oregon Health and Sciences University's Center for Evidence-based Policy, and the new Oregon Health Evidence Review Commission.

Stabilizing The Pelvis, Using the Modified Kemps and Straight Leg Raise Tests And PIR
By Frank M. Painter, D.C.

Dr. Leonard Faye reminds us in Chapter 6 of Schafer's text “Motion Palpation” that:   “In all low-back pain cases, it is essential to test for hamstring, quadriceps, and psoas length.”.   Let's review those tests together right now.

Predictors of Functional Outcome in Patients with Chronic Low Back Pain
Undergoing Back School, Individual Physiotherapy or Spinal Manipulation

Eur J Phys Rehabil Med. 2012 (Sep);   48 (3):   371–378

Of the 205 patients who completed treatment (140/205 women, age 58+14 years), non-responders were 72 (34.2%). SM showed the highest functional improvement and the lowest non-response rate. In a multivariable logistic regression, lower baseline RM score (OR 0.82, 95% CI 0.76–0.89, P<0.001) and received treatment (OR 0.32, 95% CI 0.21–0.50, P<0.001) were independent predictors of non-response. Being in the lowest tertile of baseline RM score (<6) predicted non response to treatment for back school (BS) and individual physiotherapy (IP), but not for spinal manipulation (SM) (same risk for all tertiles).   In our patients with cLBP lower baseline pain-related disability predicted non-response to physiotherapy, but not to spinal manipulation.

Clinical Presentation of a Patient with Thoracic Myelopathy at a Chiropractic Clinic
Journal of Chiropractic Medicine 2012 (Sep);   11 (2):   115–120 ~ FULL TEXT

After receiving a diagnosis of a diffuse arthritic condition and kidney stones based on lumbar radiograph interpretation at a local urgent care facility, a 45–year-old woman presented to an outpatient chiropractic clinic with primary complaints of generalized low back pain, bilateral lower extremity paresthesias, and difficulty walking. An abnormal neurological examination result led to an initial working diagnosis of myelopathy of unknown cause. The patient was referred for a neurological consult.   Computed tomography revealed severe multilevel degenerative spondylosis with diffuse ligamentous calcification, facet joint hypertrophy, and disk protrusion at T9–10 resulting in midthoracic cord compression. The patient underwent multilevel spinal decompressive surgery. Following surgical intervention, the patient reported symptom improvement.

Where the United States Spends its Spine Dollars: Expenditures on Different
Ambulatory Services for the Management of Back and Neck Conditions

Spine (Phila Pa 1976). 2012 (Sep 1);   37 (19):   1693–1701 ~ FULL TEXT

Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008).

  • Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians.
  • Over the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable;

  • While physical therapy was the most costly service overall, in recent years those costs have contracted.

CONCLUSION:   Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions.

Predictors of Improvement in Patients With Acute and Chronic Low Back Pain
Undergoing Chiropractic Treatment

J Manipulative Physiol Ther. 2012 (Sep);   35 (7):   525–533 ~ FULL TEXT

An important and unique finding in this current study is that although 123 (23%) of the patients with acute LBP and 71 (24%) of the patients with chronic LBP were diagnosed by their chiropractors as having radiculopathy, this finding was not a negative predictor of improvement. Radiculopathy was not simply defined as leg pain but required clinical signs of nerve root compression as determined by the examining chiropractor. Previous studies investigating outcomes from patients with LBP undergoing spinal manipulation have purposely excluded patients with radiculopathy, [2, 10, 29] and others have found that the presence of leg pain is a negative predictor of improvement. [12, 24, 30] This study purposely included these patients to evaluate this subgroup. It is quite common for patients with LBP experiencing radiculopathy to seek chiropractic care in Switzerland and to receive spinal manipulative therapy as one of the treatment options.

Pulmonary Embolism in a Female Collegiate Cross-country
Runner Presenting as Nonspecific Back Pain

Journal of Chiropractic Medicine 2012 (Sep);   11 (3):   215–220 ~ FULL TEXT

A 20–year-old female collegiate cross-country runner presented to a chiropractic clinic with pain in the right scapular area that was severe, stabbing, and worsened with respiration. She had a cough and experienced difficulty lying on her right side. She had an elevated d-dimer. Chest radiograph demonstrated pleural effusion, prompting a thoracic computed tomographic angiogram that showed a large right lower lobe embolus and pulmonary infarct.

Conservative Management of a 31 Year Old Male With Left Sided Low Back
and Leg Pain: A Case Report

J Can Chiropr Assoc. 2012 (Sep);   56 (3):   225–232 ~ FULL TEXT

This case demonstrates positive results for the treatment of a sub-acute lumbar disc injury with conservative care. It should be noted that results cannot be extrapolated to other cases, since this is only a single case report and the rapid resolution of this patient’s symptoms could be due to the natural history of the condition or the use of multiple interventions. Sitting and slouching have been shown to aggravate low back pain, especially when a disc injury is involved. Standing and extension exercises have been shown to help combat this. There are many reports of asymptomatic disc herniations and spontaneous resolutions, as well as muscular atrophy associated with this type of injury. The prognosis of disc herniation related low back pain relates to the extent of radiation, duration of pain and other psychosocial factors. Recommended conservative care includes spinal stabilization exercises, McKenzie assessment and treatment, neural mobilizations and chiropractic modalities, including spinal manipulative therapy. Conservative management may decrease pain and increase function for the treatment of lumbar disc injuries. Active patient participation in rehabilitative care is recommended before surgical referral.

Manual Therapy Followed by Specific Active Exercises Versus a Placebo
Followed by Specific Active Exercises on the Improvement of Functional
Disability in Patients with Chronic Non Specific Low Back Pain:
A Randomized Controlled Trial

BMC Musculoskelet Disord. 2012 (Aug 28);   13:   162 ~ FULL TEXT

This study confirmed the immediate analgesic effect of manual therapy (MT) over sham therapy (ST). Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic mechanisms at cortical level should be investigated more thoroughly.

A Model of Integrative Care for Low-back Pain
J Altern Complement Med. 2012 (Apr);   18 (4):   354–362 ~ FULL TEXT

Historically, federal agencies including the National Institutes of Health, the Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid, the Department of Defense, and the Veterans Administration have not sponsored research aimed at evaluating the cost effectiveness — or lack thereof — of emerging models of multidisciplinary, “integrative care” in the treatment of common medical conditions. This study argues that such comparative effectiveness research in this area is feasible, promising, and warranted, at least with regard to adults with persistent LBP.

New Study Reveals That Back Surgery Fails 74% of the Time
Chiro.org Editorial Commentary:

Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses. After two years, just 26 percent of those who had surgery had actually returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.

Will Shared Decision Making Between Patients with Chronic Musculoskeletal Pain
and Physiotherapists, Osteopaths and Chiropractors Improve Patient Care?

Fam Pract. 2012 (Apr);   29 (2):   203–212 ~ FULL TEXT

Seeking care for any condition is not static but a process particularly for long-term conditions such as chronic musculoskeletal pain (CMP). This may need to be taken into account by both CMP patients and their treating health professionals, in that both should not assume that their views about causation and treatment are static and that instead they should be revisited on a regular basis. Adopting a shared decision-making approach to treatment may be useful particularly for long-term conditions; however, in some cases, this may be easier said than done due to both patients' and health professionals' sometimes discomfort with adopting such an approach. Training and support for both health professionals and patients may be helpful in facilitating a shared decision-making approach.

Pain in the Three Spinal Regions: The Same Disorder?
Data From a Population-based Sample of 34,902 Danish Adults

Chiropractic & Manual Therapies 2012 (Apr 5);   20:   11 ~ FULL TEXT

In all, 34,902 (74%) twin individuals representative of the general Danish population, aged 20 to 71, participated in a cross-sectional nation-wide survey. Identical questions from the Standardised Nordic Questionnaire for each of the three spinal regions were used for lumbar, mid-back and neck pain respectively: Pain past year, pain ever, radiating pain, and consequences of back pain (care-seeking, reduced physical activities, sick-leave, change of work/work duties and disability pension). The relative prevalence estimates of these variables were compared for the three spinal regions.

The Relationships Between Measures of Stature Recovery, Muscle Activity
and Psychological Factors in Patients with Chronic Low Back Pain

Manual Therapy 2012 (Feb);   17 (1):   27–33 ~ FULL TEXT

Patients who demonstrated higher paraspinal muscle activity were those with more severe CLBP and the mediational analysis also indicated that muscle activity may affect disability via its influence on pain. The results therefore support the clinical relevance of this measure and suggest that treatments that reduce muscle activity may improve outcome. In addition, muscle activity was significantly correlated with a number of psychological factors and was found to act as a partial mediator between self-efficacy and pain, confirming the link between psychological and biomechanical factors in CLBP. Furthermore, it suggests that there may be particular benefit in reducing muscle activity in those with low self-efficacy.

Prevalence of Pain-free Weeks in Chiropractic Subjects With Low Back Pain -
A Longitudinal Study Using Data Gathered With Text Messages

Chiropractic & Manual Therapies 2011 (Dec 14);   19:   28 ~ FULL TEXT

It was uncommon that chiropractic subjects with non-specific LBP experienced an entire week without bothersome LBP during a course of 18 weeks. When this occurred, it was most commonly reported for brief periods only. Hence, recovery in the short term, in the sense that patients become absolutely pain free for longer periods, is rare, even in a primary care population.

Brief Psychosocial Education, Not Core Stabilization, Reduced Incidence of Low Back Pain:
Results from the Prevention of Low Back Pain in the Military (POLM) Cluster Randomized Trial

BMC Medicine 2011 (Nov 29);   9:   128 ~ FULL TEXT

The European Guidelines for Prevention of Low Back Pain [6] indicated a high priority for rigorous randomized clinical trials that investigate primary prevention of LBP. Completion of the POLM trial meets this priority and has provided additional data for those interested in primary prevention of LBP. Specifically, our results suggest that exercise programs that target core lumbar musculature may offer no additional preventative benefit when compared to traditional lumbar exercise programs. Also, brief psychosocial education may be an important adjunct to exercise programs as they may prevent the seeking of health care when experiencing LBP. These are novel findings and, since this study was done in a military setting, future research is necessary to determine whether these education programs could be implemented in civilian populations with similar efficacy. In addition, future studies should consider the cost-benefit of education programs that reduce LBP incidence resulting in the seeking of health care.

Application of a Diagnosis-Based Clinical Decision Guide
in Patients with Low Back Pain

Chiropractic & Manual Therapies 2011 (Oct 22);   19:   26 ~ FULL TEXT

Low back pain (LBP) affects approximately 80% of adults at some time in life [1] and occurs in all ages [2, 3]. Despite billions being spent on various diagnostic and treatment approaches, the prevalence and disability related to LBP has continued to increase [4]. There has been a recent movement toward comparative effectiveness research [5], i.e., research that determines which treatment approaches are most effective for a given patient population. In addition, there is increased recognition of the importance of practice-based research which generates data in a “real world” environment as a tool for conducting comparative effectiveness research [6, 7]. This movement calls for greater participation of private practice environments in clinical research [7].

Does Maintained Spinal Manipulation Therapy for Chronic
Non-specific Low Back Pain Result in Better Long Term Outcome?

Spine (Phila Pa 1976) 2011 (Aug 15);   36 (18):   1427–1437

This new, single blinded placebo controlled study, conducted by Mansoura Faculty of Medicine at Mansoura University, conclusively demonstrates that maintenance care (aka Preventive Care) provides significant benefits for those with chronic low back pain.
This study re-confirms the findings of a virtually identical study by Descarreaux (JMPT 2004)
and the ground-breaking article:   Rupert (JMPT 2000).

Cost-Effectiveness of General Practice Care for Low Back Pain: A Systematic Review
European Spine Journal 2011 (Jul);   20 (7):   1012–1023 ~ FULL TEXT

Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual general practitioner (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.

The Trials of Evidence: Interpreting Research and the Case for Chiropractic
The Chiropractic Report ~ July 2011 ~ FULL TEXT

For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources – whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. [1]), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society [2]) or interdisciplinary (the European Back Pain Guidelines [3]).

Neurophysiologic Effects of Spinal Manipulation in Patients With Chronic Low Back Pain
BMC Musculoskelet Disord. 2011 (Jul 22);   12:   170 ~ FULL TEXT

Low back pain (LBP) is one of the most common reasons for seeking medical care and accounts for over 3.7 million physician visits per year in the United States alone. Ninety percent of adults will experience LBP in their lifetime, 50% will experience recurrent back pain, and 10% will develop chronic pain and related disability [1–4]. According to the most recent national survey more than 18 million Americans over the age of 18 years received manipulative therapies in 2007 at a total annual out of pocket cost of $3.9 billion with back pain being the most common clinical complaint of these individuals [5].

Cost-effectiveness of Guideline-endorsed Treatments for Low Back Pain:
A Systematic Review

European Spine Journal 2011 (Jul);   20 (7):   1024–1038 ~ FULL TEXT

This systematic review of the cost-effectiveness of treatments endorsed in the APS–ACP guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, as were other methods usually within the chiropractor’s scope of practice (interdisciplinary rehabilitation, exercise, and acupuncture). For acute low back pain, this review found insufficient evidence for reaching a conclusion about the cost-effectiveness of spinal manipulation. It also found no evidence at all on the cost-effectiveness of medication for low back pain.

Chiropractic Management of Postsurgical Lumbar Spine Pain:
A Retrospective Study of 32 Cases

J Manipulative Physiol Ther 2011 (Jul);   34 (6):   408–412 ~ FULL TEXT

Little has been published on the effects of Cox flexion distraction manipulation (Fig 1) on pain experienced in patients who previously underwent lumbar spinal surgery. The results of this study demonstrate that postsurgical patients with subsequent low back pain seem to respond positively to Cox flexion distraction manipulation treatments. These results are similar to previous case reports in terms of their positive outcomes; however, the data included in this article stratify treatment results based on surgical type and include a much larger sample size than previously documented.

Supervised Exercise, Spinal Manipulation, and Home Exercise
for Chronic Low Back Pain: A Randomized Clinical Trial
Spine J. 2011 (Jul);   11 (7):   585–598

A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term.

Clustering Patients on the Basis of Their Individual Course
of Low Back Pain Over a Six Month Period

BMC Musculoskelet Disord. 2011 (May 17);   12:   99 ~ FULL TEXT

Four clusters with distinctly different clinical courses were described and further validated against clinical baseline variables and outcomes. Cluster 1, a "stable" cluster, where the course was relatively unchanged over time, contained young patients with good self- rated health. Cluster 2, a group of "fast improvers" who were very bothered initially but rapidly improved, consisted of patients who rated their health as relatively poor but experienced the fewest number of days with bothersome pain of all the clusters. Cluster 3 was the "typical patient" group, with medium bothersomeness at baseline and an average improvement over the first 4–5 weeks. Finally, cluster 4 contained the "slow improvers", a group of patients who improved over 12 weeks. This group contained older individuals who had more LBP the previous year and who also experienced most days with bothersome pain of all the clusters.

Neck and Back Pain in Children: Prevalence and Progression Over Time
Musculoskelet Disord. 2011 (May 16);   12:   98 ~ FULL TEXT

The following article appears to be the first study to track and review the progression of back pain in the same group of children, over a prolonged period, to see how (or if) it is a contributor to those same complains in adulthood. Of particular interest is Table 2, because it breaks down and tracks complaints of either neck, mid back, or low back pain in the same group of children at 3 different time periods: ages 9, 13 and 15 years old.
There are more articles like this at our Pediatrics Section

Health Maintenance Care in Work-Related Low Back Pain
and Its Association With Disability Recurrence

J Occupational and Environmental Medicine 2011 (Apr);   53 (4):   396–404 ~ FULL TEXT

In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than with chiropractic services or no treatment.

Chiropractic and Self-care for Back-related Leg Pain:
Design of a Randomized Clinical Trial
Chiropractic & Manual Therapies 2011 (Mar 22);   19:   8 ~ FULL TEXT

Back-related leg pain (BRLP) is a costly and often disabling variation of the ubiquitous back pain conditions. As health care costs continue to climb, the search for effective treatments with few side-effects is critical. While SMT is the most commonly sought CAM treatment for LBP sufferers, there is only a small, albeit promising, body of research to support its use for patients with BRLP.This study seeks to fill a critical gap in the LBP literature by performing the first full scale RCT assessing chiropractic SMT for patients with sub-acute or chronic BRLP using important patient-oriented and objective biomechanical outcome measures.

Psychosocial Risk Factors For Chronic Low Back Pain in Primary Care —
A Systematic Review

Fam Pract. 2011 (Feb);   28 (1):   12–21 ~ FULL TEXT

Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.

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

Man Ther. 2011 (Feb);   16 (1):   15–20 ~ FULL TEXT

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.

A Hospital-Based Standardized Spine Care Pathway:
Report of a Multidisciplinary, Evidence-Based Process

J Manipulative Physiol Ther 2011 (Feb);   34 (2):   98–106 ~ FULL TEXT

A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as "excellent.

Long-term Outcomes of Lumbar Fusion Among Workers'
Compensation Subjects: An Historical Cohort Study

Spine (Phila Pa 1976) 2011 (Feb 15);   36 (4):   320–331

Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses. After two years, just 26 percent of those who had surgery returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.

Consequences of Spinal Pain: Do Age and Gender Matter? A Danish Cross-sectional
Population-based Study of 34,902 Individuals 20–71 Years of Age

BMC Musculoskelet Disord. 2011 (Feb 8);   12:   39 ~ FULL TEXT

Almost two-thirds of individuals with spinal pain did not report any consequence. Generally, consequences due to LBP were more frequently reported than those due to NP or MBP. Regardless of area of complaint, care seeking and reduced physical activities were the most commonly reported consequences, followed by sick-leave, change of work, and disability pension. There was a small mid-life peak for care-seeking and a slow general increase in reduced activities with increasing age. Increasing age was not associated with a higher reporting of sick-leave but the duration of the sick-leave increased somewhat with age. Disability pension due to spinal pain was reported exceedingly rare before the age of 50. Typically, women slightly more often than men reported some kind of consequences due to spinal pain.

SPECT/CT Imaging of the Lumbar Spine in Chronic Low Back Pain: A Case Report
Chiropractic & Manual Therapies 2011 (Jan 11);   19:   2 ~ FULL TEXT
Formerly known as:   “Chiropractic & Osteopathy”

Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localization to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies.

The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO)
Study: A Randomized Controlled Trial on the Effectiveness of Clinical Practice
Guidelines in the Medical and Chiropractic Management of Patients with Acute
Mechanical Low Back Pain

Spine J. 2010 (Dec);   10 (12):   1055–1064

This is the first reported randomized controlled trial comparing evidence-based clinical practice guideline treatment (CPGs) (which includes reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar chiropractic spinal manipulative care, and return to work within 8 weeks), to family physician-directed UC in the treatment of patients with AM–LBP. Compared to family physician-directed UC, full CPG–based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.

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

European Spine Journal 2010 (Dec);   19 (12):   2075–2094 ~ FULL TEXT

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.

Cost of Care for Common Back Pain Conditions Initiated With
Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy
as First Physician: Experience of One Tennessee-Based
General Health Insurer

J Manipulative Physiol Ther 2010 (Nov);   33 (9):   640–643 ~ FULL TEXT

Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient's costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. This clearly demonstrates the savings that are possible when a patient is permitted to choose a chiropractor, rather than an MD for their care.

Integrative Care for the Management of Low Back Pain:
Use of a Clinical Care Pathway
BMC Health Serv Res. 2010 (Oct 29);   10:   298 ~ FULL TEXT

Thirteen providers representing 5 healthcare professions collaborated to provide integrative care to study participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into treatment plans.

NASS Contemporary Concepts in Spine Care:
Spinal Manipulation Therapy for Acute Low Back Pain

Spine J. 2010 (Oct);   10 (10):   918–40

Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.

Synthesis of Recommendations for the Assessment and Management of
Low Back Pain from Recent Clinical Practice Guidelines

Spine J. 2010 (Jun);   10 (6):   514–529

Recommendations for assessment of LBP emphasized the importance of ruling out potentially serious spinal pathology, specific causes of LBP, and neurologic involvement, as well as identifying risk factors for chronicity and measuring the severity of symptoms and functional limitations, through the history, physical, and neurologic examination. Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy. For chronic LBP, the addition of back exercises, behavioral therapy, and short-term opioid analgesics was suggested.

The Nordic Back Pain Subpopulation Program:
A Predictive Series of Studies
  (From oldest to newest)

     The Initial Study

Can Patient Reactions to the First Chiropractic Treatment Predict
Early Favorable Treatment Outcome in
Persistent Low Back Pain?

J Manipulative Physiol Ther. 2002 (Sep);   25 (7):   450–454 ~ FULL TEXT

Of the 115 patients in the most favorable prognostic group, 84% (95% confidence interval, 77–91) reported to be "definitely improved" by the 4th visit versus 63% (59–67) of the 384 patients in the intermediate prognostic group, and 30% (22–38) of the 116 patients in the least favorable prognostic group. No major interactions from the covariates could explain these results.   Among chiropractic patients with persistent low back pain, it is possible to predict which patients will report definite improvement early in the course of treatment.

     The Predictive Series

The Nordic Back Pain Subpopulation Program: Demographic and
Clinical Predictors for Outcome in Patients Receiving
Chiropractic Treatment for Persistent Low–Back Pain

J Manipulative Physiol Ther. 2004 (Oct);   27 (8):   493–502 ~ FULL TEXT

Treatment outcome at the fourth visit was best predicted by a model containing the following 5 variables: sex, social benefit, severity of pain, duration of continuous pain at first consultation, and additional neck pain (odds ratios between 2.2 and 4.3). A similar profile was found at 3 months, but 2 different variables (relating to disability) were the final variables in relation to the 12–month status. These final models were best at predicting absence of treatment success. Being low-back pain free at the fourth visit was a strong predictor for being low-back pain free both at 3 months and 12 months, with relative risks of 3.0 (2.2–4.8) and 3.1 (1.5–6.5), respectively.

The Nordic Back Pain Subpopulation Program: A 1-year Prospective
Multicenter Study of Outcomes of Persistent Low-back Pain
in Chiropractic Patients

J Manipulative Physiol Ther. 2005 (Feb);   28 (2):   90–96 ~ FULL TEXT

Considerable improvement was noted between baseline and the fourth visit both for mean values and in numbers of LBP-free patients. There was virtually no further mean improvement up to the third month, whereas the number of LBP-free individuals doubled. At 12 months, no additional improvement was noted, and 80% reported that they had experienced recurrent problems. Less than 1% reported considerable worsening. Severity of symptoms at baseline determined the subsequent outcome, mild symptoms tending to worsen, and severe symptoms tending to improve.   The outcome pattern is similar to that found in other clinical studies. Treatment outcome should be measured early with follow-up at 3 rather than at 12 months, because patients will improve or recover quickly but may experience recurring problems. Numbers "cured" appear to be a feasible outcome variable in this type of study population.

The Nordic Back Pain Subpopulation Program: Can Patient Reactions
to the First Chiropractic Treatment Predict Early Favorable Treatment
Outcome in Nonpersistent Low Back Pain?

J Manipulative Physiol Ther. 2005 (Mar);   28 (3):   153–158 ~ FULL TEXT

Information was provided on 708 patients, of which 674 questionnaires were valid. Of the 223 patients in the hypothesized best prognostic group, 91% (95% CI, 79–100) reported to be "definitely improved" by the fourth visit, vs 76% (72–80) of the 420 patients in the intermediate prognostic group, and 36% (19–53) of the 31 patients in the least favorable prognostic group. These results were not altered after controlling for the covariates.   For chiropractic patients with nonpersistent LBP, these findings show that it is possible to predict already by the second visit which patients may or may not report improvement at the fourth visit.

The Nordic Back Pain Subpopulation Program: Validation and Improvement
of a Predictive Model for Treatment Outcome in Patients With Low Back Pain
Receiving Chiropractic Treatment

J Manipulative Physiol Ther. 2005 (Jul);   28 (6):   381–385 ~ FULL TEXT

In this study, patients with LBP who also had leg pain and LBP occurring sufficiently frequently or having lasted sufficiently long to add up to at least 30 days in the past year, and who did not report definite general improvement by the second treatment were not good candidates for short-term recovery. It is suggested that patients who fit the criteria of potential nonresponders should be carefully monitored to allow a selective approach of care.

The Nordic Back Pain Subpopulation Program: The Long-term
Outcome Pattern in Patients With Low Back Pain
Treated by Chiropractors in Sweden

J Manipulative Physiol Ther. 2005 (Sep);   27 (7):   472–478 ~ FULL TEXT

Patients were spread in a U-shaped fashion from benign to severe with the 2 extreme groups being most prevalent. About half the participants reported "no LBP in the past week" at 3 months and somewhat fewer at 12 months. Almost 75% claimed to be definitely better at 3 months, and approximately 50% at 12 months. Specific predictive subgroups can be identified, mainly in relation to the past-year history of LBP. Improvement at the fourth visit is a predictor of long-term outcome.

The Nordic Back Pain Subpopulation Program: Predicting Outcome
Among Chiropractic Patients in Finland

Chiropractic & Osteopathy 2008 (Nov 7);   16:   13 ~ FULL TEXT

The Swedish model was reproduced in this study sample. An alternative model including leg pain (yes/no), improvement at 2nd visit (yes/no) and BMI (underweight/normal/overweight or obese) was also identified with similar predictive values. Common throughout the testing of various models was that improvement at the 2nd visit had an odds ratio of approximately 5. Additional analyses revealed a dose-response in that 84% of those patients who fulfilled none of these (bad) criteria were classified as "definitely better" at the 4th visit, vs. 75%, 60% and 34% of those who fulfilled 1, 2 or all 3 of the criteria, respectively.

The Nordic Back Pain Subpopulation Program: Individual Patterns
of Low Back Pain Established by Means of Text Messaging:
A Longitudinal Pilot Study

Chiropractic & Osteopathy 2009 (Nov 17);   17:   11 ~ FULL TEXT

A total of 110 patients were included from 5 chiropractic clinics, and the study sample consisted of the 78 patients who participated at least until week 12. Nine of the predefined patterns were identified within this population. The majority of patients improved within the first four weeks (63%), and such early improvement was associated with a generally favourable course. Patients with nonspecific LBP were shown to have a number of different course-patterns. The next step is to explore whether the identified patterns relate to different LBP diagnoses.

The Nordic Subpopulation Research Program: Prediction of Treatment
Outcome in Patients With Low Back Pain Treated By Chiropractors --
Does the Psychological Profile Matter?

Chiropractic & Osteopathy 2009 (Dec 30);   17:   14 ~ FULL TEXT

In all, 55 of 99 invited chiropractors collected information on 731 patients. At the 4(th )visit data were available on 626 patients and on 464 patients after 3 months. At the three months follow-up, duration of pain in the past year, and pain in other parts of the spine in the past year were independently associated with outcome. However, both the sensitivity and specificity were relatively low (60% and 50%). The addition of the psychological variables did not improve the models and none of the psychological variables remained significant in the final analyses. Psychological factors were not found to be relevant in the prediction of treatment outcome in Swedish chiropractic patients with LBP.

The Nordic Back Pain Subpopulation Program: Course Patterns
Established Through Weekly Follow-ups in Patients Treated
For Low Back Pain

Chiropractic & Osteopathy 2010 (Jan 15);   18:   2 ~ FULL TEXT

We suggest that follow-ups in studies concerning primary sector LBP care are conducted in week seven after treatment was initiated and at some later point which cannot be established from this study. In clinical practice we recommend that patients' LBP status is systematically followed for the first four weeks since lack of improvement during that period should cause watchfulness.

The Nordic Back Pain Subpopulation Program: Can Low Back Pain Patterns
Be Predicted From the First Consultation With a Chiropractor?
A Longitudinal Pilot Study

Chiropractic & Osteopathy 2010 (Apr 29);   18:   8 ~ FULL TEXT

A total of 110 patients were included and 76 (69%) completed follow-up. Thirty-five patients were examined by two chiropractors. The agreement regarding diagnostic classes was 83% (95% CI: 70 – 96). The diagnostic classes were associated with the pain course patterns and number of LBP days. Patients with disc pain had the highest number of LBP days and patients with muscular pain reported the fewest (35 vs. 12 days, p < 0.01). Men had better outcome than women (17 vs. 29 days, p < 0.01) and patients without leg pain tended to have fewer LBP days than those with leg pain (21 vs.31 days, p = 0.06). Duration of LBP at the first visit was not associated with outcome.

     Other Key Studies For Predicting Candidates and Outcomes

A Clinical Model for the Diagnosis and Management of Patients
With Cervical Spine Syndromes

Australasian Chiropractic & Osteopathy 2004 (Nov);   12 (2):   57–71 ~ FULL TEXT

Neck pain and related disorders are a group of conditions that are common and often disabling. It can be argued that the importance of these disorders is under-appreciated. Because of the prevalence of low back pain and its great cost to society, much clinical attention and research dollars are focused on the low back. But epidemiological research suggests that cervical related disorders are as common and may be more costly to society than low back disorders. [1–4]

A Theoretical Model For The Development Of A Diagnosis-based
Clinical Decision Rule For The Management Of Patients With Spinal Pain

BMC Musculoskelet Disord. 2007 (Aug 3);   8:   75 ~ FULL TEXT

In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.

Outcome of Pregnancy-Related Lumbopelvic Pain Treated
According to a Diagnosis-Based Decision Rule:
A Prospective Observational Cohort Study

J Manipulative Physiol Ther 2009 (Oct);   32 (8):   616–624 ~ FULL TEXT

Fifty-seven patients (73%) reported their improvement as either "excellent" or "good." The mean patient-rated improvement was 61.5%. The mean improvement in BDQ was 17.8 points. The mean percentage of improvement in BDQ was 39% and the median was 48%. Mean improvement in pain was 2.9 points. Fifty-one percent of the patients had experienced clinically significant improvement in disability and 67% patients had experienced clinically significant improvement in pain. Patients were seen an average 6.8 visits. Follow-up data for an average of 11 months after the end of treatment were collected on 61 patients. Upon follow-up, 85.5% of patients rated their improvement as either "excellent" or "good." The mean patient-rated improvement was 83.2%. The mean improvement in BDQ was 28.1 points. The mean percentage of improvement in BDQ was 68% and the median was 87.5%. Mean improvement in pain was 3.5 points. Seventy-three percent of the patients had experienced clinically significant improvement in disability and 82% patients had experienced clinically significant improvement in pain
There are more articles like this at our Pediatrics Section

Application of a Diagnosis-Based Clinical Decision Guide in Patients with Low Back Pain
Chiropractic & Manual Therapies 2011 (Oct 22);   19:   26 ~ FULL TEXT

Low back pain (LBP) affects approximately 80% of adults at some time in life [1] and occurs in all ages [2, 3]. Despite billions being spent on various diagnostic and treatment approaches, the prevalence and disability related to LBP has continued to increase [4]. There has been a recent movement toward comparative effectiveness research [5], i.e., research that determines which treatment approaches are most effective for a given patient population. In addition, there is increased recognition of the importance of practice-based research which generates data in a “real world” environment as a tool for conducting comparative effectiveness research [6, 7]. This movement calls for greater participation of private practice environments in clinical research [7].

Predictors of Outcome in Neck Pain Patients Undergoing
Chiropractic Care: Comparison of Acute and Chronic Patients

Chiropractic & Manual Therapies 2012 (Aug 24);   20 (1):   27 ~ FULL TEXT

The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients.
There are many similar articles at our Diagnosis and Management Page

Perceived Benefit of Complementary and Alternative
Medicine (CAM) for Back Pain: A National Survey

Journal of the American Board of Family Medicine 2010 (May);   23 (3):  354–62 ~ FULL TEXT

This new reports on interviews with 31,044 individuals who used CAM for low back pain.
The results are quite fascinating:

  • The top 6 CAM therapies for LBP, from the most-used are chiropractic, massage, herbal therapy, acupuncture, yoga/tai chi/qi gong, and relaxation techniques.
  • Chiropractic use (76% of respondents) was greater than all the other 5 therapies combined (see Figure 1)

Money and Spinal Surgery: What Happened to the Patient?
J. American Medical Association 2010 (Apr 7);   303 (13):   1259–1265 ~ FULL TEXT

There is a lack of evidence-based support for the efficacy of complex fusion surgeries over conservative surgical decompression for elderly stenosis patients. There is, however, a significant financial incentive to both hospitals and surgeons to perform the complex fusions. Spinal stenosis is the most frequent cause for spinal surgery in the elderly. There has been a slight decrease in these surgeries between 2002 and 2007. However, there has also been an overall 15 fold increase in the more complex spinal fusions (360 degree spine fusions).

Deyo et. al. in yesterday’s issue (April 7, 2010) of the Journal of the American Medical Association concludes that

“It is unclear why more complex operations are increasing. It seems implausible that the number of patients with the most complex spinal pathology increased 15–fold in just 6 years. The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications... financial incentives to hospitals and surgeons for more complex procedures may play a role...”

There is a significant difference in mean hospital costs for simple decompression versus complex surgical fusion. The cost of decompression is $23,724 compared to an average of $80,888 for complex fusion. Despite the much higher cost, there is no evidence of superior outcomes and there is greater morbidity associated with the complex fusion. The surgeon is typically reimbursed only $600 to $800 for simple decompression and approximately ten times more, $6,000 to $8,000 for the complex fusion.

Individualized Chiropractic and Integrative Care for Low Back Pain: The Design
of a Randomized Clinical Trial Using a Mixed-methods Approach

Trials. 2010 (Mar 8);   11:   24 ~ FULL TEXT

This mixed-methods randomized clinical trial assesses clinical effectiveness, cost-effectiveness, and patients' and providers' perceptions of care, in treating non-acute LBP through evidence-based individualized care delivered by monodisciplinary or multidisciplinary care teams.

Resolution of Low Back and Radicular Pain in a 40-year-old Male United States
Navy Petty Officer After Collaborative Medical and Chiropractic Care

Journal of Chiropractic Medicine 2010 (Mar);   9 (1):   17–21 ~ FULL TEXT

This article has described the case management of an active duty United States Navy Petty Officer who presented to his PCM with LBP and right leg pain. Radiologic studies confirmed posterior disk extrusion at L4/L5, abutting the right L5 nerve root, and posterior bulging of the L5/S1 disk.   The primary purpose of this case report was to describe the interdisciplinary collaboration of chiropractic and medical services in a military setting. This article does not go into detail of the chiropractic treatments rendered, as several studies and trials on the use of manipulation and other forms of conservative care to treat patients with acute lumbar radiculopathy may be found in a systematic review by Lawrence et al. [21] Rather, it hoped to depict the unique inclusion of chiropractic management as part of available treatments within a military treatment facility.

Effectiveness of Manual Therapies: The UK Evidence Report
Chiropractic & Manual Therapies 2010 (Feb 25);   18 (1):   3 ~ FULL TEXT

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.

Interventions to Improve Adherence to Exercise for
Chronic Musculoskeletal Pain in Adults

Cochrane Database Syst Rev 2010 (Jan 20);   2010 (1):   CD005956 ~ FULL TEXT

Authors' conclusions:

  • The type of exercise prescribed does not appear to influence levels of exercise adherence. Patient preference should therefore be considered in an attempt to increase motivation to initiate and maintain an exercise programme

  • Including simple educational and behavioural strategies, such as providing feedback or using an exercise contract, as part of routine delivery of exercise for chronic musculoskeletal pain may enhance adherence

  • Providing supervised exercise, follow up to reinforce exercise behaviour, and supplementing face-to-face instruction with other material all may have a positive influence on levels of exercise adherence

  • Although supplementing home exercise with a group exercise programme may improve overall physical activity levels, attendance at group sessions may be limited if session times are inconvenient, and missed sessions cannot be rescheduled. The type of exercise setting should therefore again be directed by patient preference

Commentary on the United Kingdom Evidence Report About
the Effectiveness of Manual Therapies

Chiropractic & Manual Therapies 2010 (Feb 25);   18 (1):   4 ~ FULL TEXT

Bronfort et al [1] are to be congratulated on the production of this review of the clinical studies and systematic reviews of the scientific literature that have been published on the efficacy of the manual therapies and other treatments commonly offered by chiropractors. Although there are multiple other more detailed systematic reviews on the management of specific disorders I am not aware of any publication that has addressed the broader scope of manual therapy and chiropractic. His document should be of value to all chiropractors, medical physicians who work closely with chiropractors, as well as payers and health care policy makers. Although it is possible to argue over specific wording and disagree on the quality of some of the quoted studies in this document it is not possible to question the depth and scientific integrity of this work.

Management of Chronic Low Back Pain in Active Individuals
Curr Sports Med Rep 2010 (Jan);   9 (1):   60–66 ~ FULL TEXT

The best available evidence currently suggests that in the absence of serious spinal pathology, nonspinal causes, or progressive or severe neurologic deficits, the management of chronic LBP should focus on patient education, self-care, common analgesics, and back exercises. Short-term pain relief may be obtained from spinal manipulative therapy or acupuncture. For patients with psychological comorbidities, adjunctive analgesics, behavioral therapy, or multidisciplinary rehabilitation also may be appropriate. Given the importance of active participation in recovery, patient preference should be sought to help select from among the recommended treatment options.

Spinal Manipulation Compared with Back School and with Individually
Delivered Physiotherapy for the Treatment of Chronic Low Back Pain:
A Randomized Trial with One-year Follow-up

Clin Rehabil 2010 (Jan);   24 (1):   26–36 ~ FULL TEXT

Researchers followed patients with lumbar radiculopathy secondary to disk herniation treated after a diagnosis-based clinical decision rule. A prospective observational cohort study was conducted at a multidisciplinary, integrated clinic that includes chiropractic and physical therapy health care services. Data on 49 consecutive patients were collected at baseline, at the end of conservative, nonsurgical treatment and a mean of 14.5 months after cessation of treatment. Disability was measured using the Bournemouth Disability Questionnaire (BDQ) and pain using the Numerical Rating Scale for pain. Fear beliefs were measured with the Fear-Avoidance Beliefs Questionnaire (FABQ). Patients also self-rated improvement. Mean duration of complaint was 60.5 weeks. Mean self-rated improvement at the end of treatment was 77.5%. Improvement was described as "good" or "excellent" in nearly 90% of patients.

A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy
Secondary to Herniated Disk: A Prospective Observational Cohort
Study With Follow-Up

J Manipulative Physiol Ther 2009 (Nov);   32 (9):   723–733 ~ FULL TEXT

A randomized trial by researchers at an outpatient rehabilitation department in Italy involving 210 patients with chronic, nonspecific low back pain compared the effects of spinal manipulation, physiotherapy and back school. The participants were 210 patients (140 women and 70 men) with chronic, non-specific low back pain, average age 59. Back school and individual physiotherapy were scheduled as 15 1–hour-sessions for 3 weeks. Back school included group exercise and education/ergonomics. Individual physiotherapy included exercise, passive mobilization and soft-tissue treatment. Spinal manipulation included 4–6 20–minute sessions once-a-week. Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

Outcome of Pregnancy-Related Lumbopelvic Pain Treated According to a
Diagnosis-Based Decision Rule: A Prospective Observational Cohort Study

J Manipulative Physiol Ther 2009 (Oct);   32 (8):   616–624 ~ FULL TEXT

Fifty-seven patients (73%) reported their improvement as either "excellent" or "good." The mean patient-rated improvement was 61.5%. The mean improvement in BDQ was 17.8 points. The mean percentage of improvement in BDQ was 39% and the median was 48%. Mean improvement in pain was 2.9 points. Fifty-one percent of the patients had experienced clinically significant improvement in disability and 67% patients had experienced clinically significant improvement in pain. Patients were seen an average 6.8 visits. Follow-up data for an average of 11 months after the end of treatment were collected on 61 patients. Upon follow-up, 85.5% of patients rated their improvement as either "excellent" or "good." The mean patient-rated improvement was 83.2%. The mean improvement in BDQ was 28.1 points. The mean percentage of improvement in BDQ was 68% and the median was 87.5%. Mean improvement in pain was 3.5 points. Seventy-three percent of the patients had experienced clinically significant improvement in disability and 82% patients had experienced clinically significant improvement in pain.
There are more articles like this at our Pediatrics Section

Do Chiropractic Physician Services for Treatment of Low-Back and
Neck Pain Improve the Value of Health Benefit Plans?

Mercer Health and Benefits LLC ~ October 12, 2009 ~ FULL TEXT

This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.

Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation
for Low Back Pain: An Evidence-based Clinical Practice Guideline
from the American Pain Society

Spine (Phila Pa 1976). 2009 (May 1);   34 (10):   1066–1077

Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.
You will want to review the complete:
Guideline for the Evaluation and Management of Low Back Pain: Evidence Review

(482 page Adobe Acrobat file)

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

Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
You will want to review the complete:
Guideline for the Evaluation and Management of Low Back Pain: Evidence Review

(482 page Adobe Acrobat file)

Consumer Reports: Chiropractic Top Rated Treatment for Back Pain
Consumer Reports ~ May 2009

A study in the May issue of Consumer Reports shows that hands-on therapies were tops among treatments for relief of back pain. The study, which surveyed more than 14,000 consumers, was conducted by the Consumer Reports Health Ratings Center. The report states that, “eighty-eight percent of those who tried chiropractic manipulation said it helped a lot, and 59 percent were ‘completely’ or ‘very’ satisfied with their chiropractor.”

Doctors Likely to Encounter Children With Musculoskeletal Complaints
Have Low Confidence in Their Clinical Skills

The Journal of Pediatrics 2009 (Feb);   154 (2):   267–271

Questionnaires, filled out by a broad spectrum of medical providers in England [Primary Care (n = 75), Pediatrics (n = 39), Emergency (n = 39), Orthopedics (n = 40), and experienced doctors in Primary Care (n = 93), and Pediatrics (n = 60).], revealed that 74% of them scored their personal confidence in pediatric musculoskeletal clinical assessment as "no" to "low".

Overtreating Chronic Back Pain: Time to Back Off?
J Am Board Fam Med. 2009 (Jan);   22 (1):   62–68

Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses.

Chiropractic Management of Low Back Disorders: Report From a Consensus Process
J Manipulative Physiol Ther 2008 (Nov);   31 (9):   651–658 ~ FULL TEXT

A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature
Chiropractic & Osteopathy 2008 (Aug 11);   16:   7 ~ FULL TEXT

Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.

Chiropractic Management of Low Back Pain and Low Back-Related Leg Complaints:
A Literature Synthesis

J Manipulative Physiol Ther 2008 (Nov);   31 (9):   659–674 ~ FULL TEXT

As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Prognosis in Patients with Recent Onset Low Back Pain in Australian
Primary Care: Inception Cohort Study

British Medical Journal 2008 (Jul 7);   337:   a171 ~ FULL TEXT

This BMJ study contradicts Clinical Practice Guidelines that suggest that recovery from an episode of recent onset low back pain is usually rapid and complete.   Their findings with 973 consecutive primary care patients was that recovery was slow for most patients, and almost 1/3 of patients did not recover within one year (when following standard medical recommendations).

A Comparison Between Chiropractic Management and Pain Clinic Management for
Chronic Low-back Pain in a National Health Service Outpatient Clinic

J Alternative and Complementary Medicine 2008 (Jun);   14 (5):   465–473

At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group than for the pain-clinic group. Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group. This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a sub-population of patients with chronic low-back pain (CLBP).

Prospective Case Series on the Effects of Lumbosacral Manipulation
on Dysmenorrhea

J Manipulative Physiol Ther 2008 (Mar);   31 (3):   237–246 ~ FULL TEXT

This prospective case series suggests the possibility that menstrual pain associated with primary dysmenorrhea may be alleviated by treating motion segment restrictions of the lumbosacral spine with a drop table technique. The research team needs to conduct a well-designed feasibility trial to further evaluate the effectiveness of this specific spinal manipulative technique for primary dysmenorrhea.

A Systematic Review of Low Back Pain Cost of Illness Studies in the United States and Internationally
Spine J 2008 (Jan);   8 (1):   8–20~ FULL TEXT

This review identified several studies that have previously attempted to estimate the direct, indirect, or total costs associated with LBP, both in the United States and internationally. Study methodology differed considerably, making direct cost comparisons across studies and between countries difficult. The largest components of direct medical costs were PT, inpatient services, pharmacy, and primary care. From studies conducted outside the United States, it appears that direct medical costs represent only a small portion of the total costs of LBP, suggesting that interventions that are able to reduce LOD may present the opportunity for cost savings from a societal perspective. Further studies are required in the United States to estimate the total costs of LBP and inform decision making for this complex and challenging condition.

A Supermarket Approach to the Evidence-informed Management of Chronic Low Back Pain
Spine J. 2008 (Jan);   8 (1):   1–7 ~ FULL TEXT

Patients with chronic low back pain (CLBP) are finding it increasingly difficult to make sense of the growing list of treatment approaches promoted as solutions to this widespread problem. Their confusion is compounded by the financial and emotional cost of previous failed attempts. This frustration is felt not only by patients, but by all interested stakeholders, including clinicians trying to offer accurate advice and provide the most effective treatment to their patients, and third-party payers responsible for providing access to reasonable and necessary care. All share a common goal and wish to use limited healthcare resources to support those interventions most likely to result in clinically meaningful improvements in symptoms and functional capacity. The current approach to the management of CLBP makes this goal virtually unobtainable.

Evidence-informed Management of Chronic Low Back Pain with
Spinal Manipulation and Mobilization

Spine J. 2008 (Jan);   8 (1):   213–225 ~ FULL TEXT

For CLBP, there is moderate evidence that SMT with strengthening exercise is similar in effect to prescription nonsteroidal anti-inflammatory drugs with exercise in both the short term and long term. There is also moderate evidence that flexion-distraction MOB is superior to exercise in the short term and superior/similar in the long term. There is moderate evidence that a regimen of high-dose SMT is superior to low-dose SMT in the very short term. There is limited to moderate evidence that SMT is better than physical therapy and home exercise in both the short and long term. There is also limited evidence that SMT is as good or better than chemonucleolysis for disc herniation in the short and long term. There is limited evidence that MOB is inferior to back exercise after disc herniation surgery.

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 ~ FULL TEXT

Low back pain is the fifth most common reason for all physician visits in the United States [1, 2]. Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months [2], and 7.6% reported at least 1 episode of severe acute low back pain (see Glossary) within a 1–year period [3]. Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998 [4]. In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year [5]. You will enjoy these recommendations because their ONLY recommendation for active treatment of acute low back pain is spinal adjusting (manipulation).

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society/
American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2007 (Oct 2);   147 (7):   492–504 ~ FULL TEXT

Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.

Medications for Acute and Chronic Low Back Pain: A Review of the Evidence for an
American Pain Society/American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2007 (Oct 2);   147 (7):   505–514 ~ FULL TEXT

Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications.

Chiropractic and Exercise for Seniors With Low Back Pain or Neck Pain:
The Design of Two Randomized Clinical Trials
  NCT00269308   and   NCT00269321
BMC Musculoskelet Disord. 2007 (Sep 18);   8:   94 ~ FULL TEXT

To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers. This article presents the rationale and design of two mixed methods clinical trials, each consisting of an RCT, with cost-effectiveness and qualitative studies conducted alongside the central trial. Both are anticipated to be completed in 2007, at which time the results will be made available.

Back and Pelvic Pain in an Underserved United States Pregnant Population:
A Preliminary Descriptive Survey

J Manipulative Physiol Ther. 2007 (Feb);   30 (2):   130–134 ~ FULL TEXT

Low back pain (LBP) in the general population is recognized as a major health concern, and left untreated, this malady can lead to chronic, disabling morbidity. [1, 2] Accordingly, chronic pain is a major health care expense in the United States, and LBP is responsible for the majority of chronic musculoskeletal pain. [3] Low back pain and pelvic pain (PP) in pregnancy, however, are frequently viewed as transient conditions that are anticipated to subside after childbirth. In fact, recent studies have identified that women who do have LBP/PP during pregnancy receive little recommendations and/or treatment for their complaints. [4, 5]

A Theoretical Model For the Development of a Diagnosis-based Clinical Decision Rule
for the Management of Patients With Spinal Pain

BMC Musculoskelet Disord. 2007 (Aug 3);   8:   75 ~ FULL TEXT

In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.

Pathophysiological Model for Chronic Low Back Pain
Integrating Connective Tissue and Nervous System Mechanisms

Medical Hypotheses 2007 (Jan);   68 (1):   74–80 ~ FULL TEXT

Although chronic low back pain (cLBP) is increasingly recognized as a complex syndrome with multifactorial etiology, the pathogenic mechanisms leading to the development of chronic pain in this condition remain poorly understood. We hypothesize that pain-related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation, nervous system sensitization and further decreased mobility. In addition to providing a new, testable framework for future mechanistic studies of cLBP, the integration of connective tissue and nervous system plasticity into the model will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise).
You will also enjoy Dr. Dan Murphy's Key Points.

The UCLA Low Back Pain Study
A Unique Series of Articles

A Randomized Trial of Medical Care with and without Physical Therapy and Chiropractic Care
with and without Physical Modalities for Patients with Low Back Pain:
6-month Follow-up Outcomes From the UCLA Low Back Pain Study

Spine (Phila Pa 1976) 2002 (Oct 15);   27 (20):   2193–2204 ~ FULL TEXT

Of 1,469 eligible patients, 681 were enrolled; 95.7% were followed through 6 months. The mean changes in low back pain intensity and disability of participants in the medical and chiropractic care-only groups were similar at each follow-up assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95% confidence interval, –0.32–0.86; average pain, 0.22, –0.25–0.69; and disability, 0.75, –0.29–1.79). Physical therapy yielded somewhat better 6–month disability outcomes than did medical care alone (1.26, 0.20–2.32).   After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

A Randomized Trial of Chiropractic and Medical Care for Patients with
Low Back Pain: Eighteen-month Follow-up Outcomes from the
UCLA Low Back Pain Study

Spine (Phila Pa 1976). 2006 (Mar 15);   31 (6):   611–621 ~ FULL TEXT

Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18–month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80–2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08–2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62–1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.   Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.

     The Comparison Studies

The Effectiveness of Physical Modalities Among Patients with Low Back Pain
Randomized to Chiropractic Care: Findings from the UCLA Low Back Pain Study

J Manipulative Physiol Ther. 2002 (Jan);   25 (1):   10–20 ~ FULL TEXT

Almost 60% of the subjects had baseline LBP episodes of more than 3 months' duration. The 6–month follow-up was 96%. The adjusted mean differences between groups in improvements in average and most severe pain and disability were clinically insignificant at all follow-up assessments. Clinically relevant improvements in average pain and disability were more likely in the modalities group at 2 and 6 weeks, but this apparent advantage disappeared at 6 months. Perceived treatment effectiveness was greater in the modalities group.   Physical modalities used by chiropractors in this managed-care organization did not appear to be effective in the treatment of patients with LBP, although a small short-term benefit for some patients cannot be ruled out.

Comparing the Satisfaction of Low Back Pain Patients Randomized to Receive
Medical or Chiropractic Care: Results From the UCLA Low-back Pain Study

Am J Public Health. 2002 (Oct);   92 (10):   1628–1633 ~ FULL TEXT

The mean satisfaction score for chiropractic patients was greater than the score for medical patients (crude difference = 5.5; 95% confidence interval = 4.5, 6.5). Self-care advice and explanation of treatment predicted satisfaction and reduced the estimated difference between chiropractic and medical patients' satisfaction.   Communication of advice and information to patients with low back pain increases their satisfaction with providers and accounts for much of the difference between chiropractic and medical patients' satisfaction.

Cross-sectional and Longitudinal Associations of Low-back Pain and Related Disability
with Psychological Distress Among Patients Enrolled in the UCLA Low-Back Pain Study

J Clin Epidemiol. 2003 (May);   56 (5):   463–471

The objectives of the study are to test the hypotheses that psychological distress affects subsequent low-back pain, and pain affects subsequent distress. Six hundred eighty-one participants in a randomized clinical trial of low-back pain treatments were followed for 18 months with assessments for pain, disability, and psychological distress at 6 weeks and 6, 12, and 18 months. Multivariable logistic regression modeling with generalized estimating equations was used to estimate effects.   Current pain and disability increased the odds of subsequent psychological distress [pain: adjusted odds ratio (OR)=1.36, 95% confidence interval (CI)=1.07, 1.72; disability: adjusted OR=1.23, 95% CI=0.98, 1.55], and current distress increased the odds of subsequent pain and disability (pain: adjusted OR=1.51, 95% CI=1.24, 1.86; disability: adjusted OR=1.49; 95% CI=1.20, 1.85).

Satisfaction as a Predictor of Clinical Outcomes Among Chiropractic
and Medical Patients Enrolled in the UCLA Low Back Pain Study

Spine (Phila Pa 1976). 2005 (Oct 1);   30 (19):   2121–2128 ~ FULL TEXT

Greater satisfaction increased the odds of remission from clinically meaningful pain and disability at 6 weeks (adjusted odds ratio [OR] for 10–point increase in satisfaction = 1.61, 95% confidence interval [CI] = 0.99, 2.68), but not at 6, 12, or 18 months (6 months: adjusted OR = 1.05, 95% CI = 0.73, 1.52; 12 months: adjusted OR = 0.94, 95% CI = 0.67, 1.32; 18 months: adjusted OR = 1.07; 95% CI = 0.76, 1.50). Perception of improvement was greater among highly satisfied than less satisfied patients throughout the 18–month follow-up period. The estimated effects of satisfaction on clinical outcomes were similar for medical and chiropractic patients.   Patient satisfaction may confer small short-term clinical benefits for low back pain patients. Long-term perceived improvement may reflect, in part, perceived past improvement as measured by satisfaction.

Effects of Recreational Physical Activity and Back Exercises on Low Back Pain
and Psychological Distress: Findings from the UCLA Low Back Pain Study

Am J Public Health. 2005 (Oct);   95 (10):   1817–1824 ~ FULL TEXT

Participation in recreational physical activities was inversely associated -- both cross-sectionally and longitudinally -- with low back pain, related disability, and psychological distress. By contrast, back exercise was positively associated — both cross-sectionally and longitudinally — with low back pain and related disability.   These results suggest that individuals with low back pain should refrain from specific back exercises and instead focus on nonspecific physical activities to reduce pain and improve psychological health.

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

Chiropractic & Osteopathy 2006 (Aug 24);   14:   19 ~ FULL TEXT

Based on one-year follow-up data imputed for complete analysis, participants who received physical therapy (exercise program) during a clinical trial attended a higher number of visits to any health care provider and to general practitioners during the year after care when compared to participants who received chiropractic care (flexion distraction) within the trial. Further studies are needed to verify these data.

Diagnosis and Treatment of Low Back Pain
British Medical Journal 2006 (Jun 17);   332 (7555):   1430–1434 ~ FULL TEXT

The accumulated evidence from randomised trials and systematic reviews regarding the value of diagnostic and therapeutic interventions has now been incorporated in clinical guidelines. A few initial surveys have shown that these guidelines are being followed to some extent, but there is still room for improvement, especially in those countries and settings in which a large discrepancy exists between recommendations in guidelines and actual management in clinical practice. Measures should be taken to minimise this gap. Simply developing and publishing evidence based guidelines and subsequently disseminating these guidelines may not be effective enough to change practice. Implementation seems essential in changing clinical practice. Several trials have evaluated implementation of guidelines and its effect on patient and process outcomes. [25] [w8] These trials show modest effects at best. More intensive multifaceted interventions might be needed to achieve further progress in this area.

Back and Neck Pain in Seniors-Prevalence and Impact
European Spine Journal 2006 (Jun);   15 (6):   802–806~ FULL TEXT

Neck pain (NP) and back pain (BP) are common symptoms in old age and 10–20% of persons over 70 reports moderate or severe NP or BP on a monthly basis. Overall, older women report more BP and NP than older men. Altering or diminishing physical activities and seeking of treatment due to NP or BP are relatively common in the older age groups, again especially among women. 1–year prevalence estimates of NP and BP in seniors may suffer from recall bias.

Hormonal and Reproductive Factors Are Associated with Chronic Low Back Pain and
Chronic Upper Extremity Pain in Women -- The MORGEN Study

Spine (Phila Pa 1976) 2006 (Jun 1);   31 (13):   1496–1502

Although LBP is suggested to be linked to hormonal and reproductive factors in women, results from previous studies are inconclusive. For this reason, a cross-sectional study of 11,428 Dutch women aged 20–59 years was accomplished. Multivariate logistic regression models were used to examine associations between hormonal and reproductive factors (independent variables) and, respectively, chronic LBP, chronic UEP (upper extremity pain) and combined chronic LBP/UEP. Past pregnancy, young maternal age at first birth, duration of oral contraceptive use, and use of estrogens during menopause were associated with chronic LBP, while young age at menarche was associated with chronic UEP. Irregular or prolonged menstruation and hysterectomy were associated both with chronic LBP and chronic UEP. No positive associations were found for current pregnancy and number of children.

Chiropractic Manipulation in the Treatment of Acute Back Pain and Sciatica
with Disc Protrusion: A Randomized Double-blind Clinical Trial of Active
and Simulated Spinal Manipulations

Spine J. 2006 (Mar);   6 (2):   131–137 ~ FULL TEXT

A total of 64 men and 38 women aged 19–63 years were randomized to manipulations (53) or simulated manipulations (49). Manipulations appeared more effective on the basis of the percentage of pain-free cases (local pain 28 vs. 6%; p<.005; radiating pain 55 vs. 20%; p<.0001), number of days with pain (23.6 vs. 27.4; p<.005), and number of days with moderate or severe pain (13.9 vs. 17.9; p<.05). Patients receiving manipulations had lower mean VAS1 (p<.0001) and VAS2 scores (p<.001). A significant interaction was found between therapeutic arm and time. There were no significant differences in quality of life and psychosocial scores. There were only two treatment failures (manipulation 1; simulated manipulation 1) and no adverse events.

Is Comorbidity in Adolescence a Predictor for Adult Low Back Pain?
A Prospective Study of a Young Population

BMC Musculoskelet Disord 2006 (Mar 16);   7:   29 ~ FULL TEXT

Your chiropractic care may be working out “kinks” in your lower back that have been around a lot longer than you realize. This new study of 10,000 Danish residents shows a link between adolescent and adult low back pain (LBP). Researchers studied twins born between 1972 and 1982 by sending out questionnaires in 1994 and again in 2002. The outcomes showed that a high percentage of those who had LBP in 1994 still suffered from LBP in 2002. They also found that those with persistent LBP were 4.5 times more likely than the average person to have future LBP episodes!
There are more articles like this at our Pediatrics Section

The Course of Low Back Pain from Adolescence to Adulthood:
Eight-year Follow-up of 9600 Twins

Spine 2006 (Feb 15);   31 (4):   468–472

High prevalence rates of low back pain among children and adolescents have been demonstrated in several studies, and it has been theorized that low back pain in childhood may have important consequences for future low back pain. Almost 10,000 Danish twins born between 1972 and 1982 were surveyed by means of postal questionnaires in 1994 and again in 2002. The questionnaires dealt with various aspects of general health, including the prevalence of low back pain, classified according to number of days affected (0, 1–7, 8–30, >30). Low back pain in adolescence was found to be a significant risk factor for low back pain in adulthood with odds ratios as high as four. We also demonstrated a dose-response association: the more days with low back pain at baseline, the higher the risk of future low back pain.
There are more articles like this at our Pediatrics Section

Chiropractic Spinal Manipulation for Low Back Pain of Pregnancy:
A Retrospective Case Series

J Midwifery Womens Health 2006 (Jan);   51 (1):   e7–10

Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0–13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1–5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.
There are more articles like this at our Pediatrics Section

Estimating the Global Burden of Low Back Pain Attributable to
Combined Occupational Exposures

American J Industrial Medicine 2005 (Dec);   48 (6):   459–469 ~ FULL TEXT

Worldwide, 37% of LBP was attributed to occupation, with twofold variation across regions. The attributable proportion was higher for men than women, because of higher participation in the labor force and in occupations with heavy lifting or whole-body vibration. Work-related LBP was estimated to cause 818,000 disability-adjusted life years lost annually. Occupational exposures to ergonomic stressors represent a substantial source of preventable back pain. Specific research on children is needed to quantify the global burden of disease due to child labor.
There are more articles like this at our Global Burden of Disease Section

Effects of a Managed Chiropractic Benefit on the Use of Specific Diagnostic
and Therapeutic Procedures in the Treatment of Low Back and Neck Pain

J Manipulative Physiol Ther 2005 (Oct);   28 (8):   564–569 ~ FULL TEXT

For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Classification of Low Back Pain in Primary Care: Using "Bothersomeness"
to Identify the Most Severe Cases

Spine (Phila Pa 1976) 2005 (Aug 15);   30 (16):   1887–1892 ~ FULL TEXT

This study has investigated the use of a single question on bothersomeness in primary care patients with LBP, and provided evidence of its construct and predictive validity as a measure of severity. Its potential for use in clinical practice has been established as a method to identify in a standard way the most severely affected patients and predict outcome 6 months later. However, its usefulness and practicality in a clinical setting has not been studied, and further work is needed to clarify this. In conclusion, a simple question on bothersomeness could be useful for classifying patients with LBP at primary care consultation, and for standardized reporting and audit in clinical practice.

Cost-effectiveness of Medical and Chiropractic Care for Acute
and Chronic Low Back Pain

J Manipulative Physiol Ther 2005 (Oct);   28 (8):   555–563 ~ FULL TEXT

Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain.
There are more articles like this at our Cost-Effectiveness Section.

Pragmatic Application of a Clinical Prediction Rule in Primary Care
to Identify Patients with Low Back Pain with a Good Prognosis
Following a Brief Spinal Manipulation Intervention

BMC Fam Pract. 2005 (Jul 14);   6 (1):   29 ~ FULL TEXT

Individuals with "non-specific" LBP are not a homogenous group, and different sub-groups of patients are likely to preferentially respond to different therapeutic management strategies. One sub-group consists of those patients with a good prognosis following spinal manipulation intervention. The results of this study demonstrate an association between two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, and outcome of a manipulation intervention.

An Epidemiologic Study of MRI and Low Back Pain in 13-year-old Children
Spine (Phila Pa 1976). 2005 (Apr 1);   30 (7):   798–806

In children, degenerative disc findings are relatively common, and some are associated with LBP. There appears to be a gender difference. Disc protrusions, endplate changes, and anterolisthesis in the lumbar spine were strongly associated with seeking care for LBP.
There are more articles like this at our Pediatrics Section

A Clinical Prediction Rule to Identify Patients with Low Back Pain Most Likely
to Benefit from Spinal Manipulation: A Validation Study

Annals of Internal Medicine 2004 (Dec 21);   141 (12):   920–928 ~ FULL TEXT

Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7).

End Medical Mis-Management of LBP

The medical "debate" has been going on for years...is spinal adjusting (a.k.a manipulation) effective for Low Back Pain? The original Meade study (British Medical Journal 1990) demonstrated that chiropractic was much more effective for LBP than conventional medical care.

In 1993 the province of Ontario, Canada hired the esteemed health care economist Pran Manga, PhD to examine the benefits of chiropractic care for low back pain (LBP) and to make a set of recommendations on how to contain and reduce health care costs.

His report
A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain
cited research demonstrating that:

(1)   chiropractic manipulation is safer than medical management for LBP;

(2)   that spinal manipulation is less safe and effective when performed by non-chiropractic professionals;

(3)   that there is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management; and

(4)   that there would be highly significant cost savings if more management of LBP was transferred from medical physicians to chiropractors.

He also stated that "A very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the Workers' Compensation System in Ontario."

In 1994 Medicine was horrified when the
Agency for Health Care Policy and Research (AHCPR) confirmed the untested, questionable or harmful nature of many current medical therapies for LBP , and also stated that, of all forms of management they reviewed, only chiropractic care could both reduce pain AND improve function.

In 1995, Meade did a follow-up to his 1990 BMJ article, again publishing in the
British Medical Journal 1995. It demonstrated that those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals, especially for those who suffered from chronic (or long-term) low back pain!

A recent study in
SPINE Journal 2004 reveals that health care expenditures for back pain sufferers was a staggering $90.7 billion in 1998, and that prescription drugs accounted for more than 15% of that figure! This is alarming, since muscle relaxants have been associated with slower recovery rates, and steroid injections offer minimal relief.   One needs to ask why drug costs continue to climb with a track record like that? Even care by physical therapists has been shown to prolong recovery from low back pain.

A chronic pain study at the University of Washington School of Medicine recently compared which treatments were most effective at
reducing pain for neuromuscular diseases and found that Chiropractic scored the highest pain relief rating (7.33 out of 10), scoring higher than the relief provided by either nerve blocks (6.75) or opioid analgesics (6.37). WOW!!!

A recent 4–year retrospective study of
700,000 health plan members revealed that offering chiropractic services within a managed-care environment could save insurers 27% in back pain episode-related costs! The Cost-effectiveness Page documents many other studies with similar findings.

In December 2004, the
British Medical Research Council published 2 papers in the British Medical Journal demonstrating both the efficacy and cost-effectiveness of chiropractic compared with medical management.

These two papers revealed:

Spinal Manipulation, with or without exercise, improved symptoms more than medical care did at both 3 and 12 months.
The authors concluded: “We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice.”

The most recent in a long line of articles showing the clear superiority of chiropractic management was published in May of 2007. Clinical and cost utilization based on 70,274 member-months over a 7–year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% less hospital days, 62.0% less outpatient surgeries and procedures, and 83% less pharmaceutical costs when compared with conventional medicine IPA performance.

That is rather significant savings, is it not?

So...what's the holdup?

Spinal Manipulation, Epidural Injections, and Self-care for Sciatica:
A Pilot Study for a Randomized Clinical Trial

J Manipulative Physiol Ther. 2004 (Oct);   27 (8):   503–508 ~ FULL TEXT

At week 12 (the end of the treatment phase), the outcome measures indicating the most improvement/change were the Oswestry disability score (mean, 22.9; SD, 19.9; effect size [ES], 1.8), leg pain severity (mean, 2.9; SD, 1.7; ES, 1.7), and if the symptoms were bothersome (mean, 25.2; SD, 16.0; ES, 1.6). Twenty-four patients were either "very satisfied" or "completely satisfied," and 22 of 32 patients reported 75% or 100% improvement. After 52 weeks, the outcome measure showing the most improvement/change was leg pain severity (mean, 2.3; SD, 2.6; ES, 1.35), followed by the Oswestry disability score (mean, 15.6; SD, 20; ES, 1.2) and if symptoms were bothersome (mean, 18.1; SD, 22.6; ES, 1.1). Eighteen patients were either "very satisfied" or "completely satisfied," and 15 of 32 patients reported 75% or 100% improvement.

The British Medical Research Council (MRC) Trial Finds
Adding Spinal Manipulation and Exercise to GP Care
Provides Relief for Back Pain

The British Medical Research Council (MRC)

A Medical Research Council (MRC) trial to assess the effectiveness of adding different treatments to “best care” in general practice for patients with lower back pain has found that spinal manipulation, in the form of chiropractic, osteopathy, or manipulative physiotherapy, followed by a programme of exercise, provides significant relief of symptoms and improvements in general health. The results of the trial are published online today, Friday 19 November, in the British Medical Journal.

Post Partum and Beyond: Managing Back Pain in Women
Dr. Diane Benizzi DiMarco ~ FULL TEXT

The post partum patient retains a higher risk for potential injury as compared to the patient who has not endured pregnancy or has not been pregnant for an extended period of time. Fertilization propels the release of estrogen, progesterone and relaxin, hormones essential to the growth and development of the embryo and fetus. These hormones that are essential to the pregnancy cause global relaxation to the ligaments and muscles in the female pregnant patient. A conglomerate of anatomical changes created by the global laxity in muscles and ligaments compromises the stability of the spine.

End Medical Mis-Management of Musculoskeletal Complaints

Q.   Are medical doctors well trained to diagnose or treat musculoskeletal complaints?

A.   Read the unsettling answer in this series of articles

Chiropractors pride themselves in their ability to diagnose and manage neuro-musculo-skeletal (NMS) complains. According to all the surveys, this is our bread and butter, and no one on the planet is better trained to diagnose (locate) and treat (correct) neck, low back, or peripheral joint (knee, elbow etc) complaints. But, don't just take my word for it. Read on.

Orthopedic surgeons are supposed to be the *gods* of medicine, the pinnacle of medical knowledge. First they become MDs, then rotate through a variety of specialties, and finally take residence in a highly competitive orthopedic program. You may want to review this
interesting description of the requirements for the UCLA Orthopedic Surgery's Residency Program.

The following is a long and sad tale about the weakness of modern medical education. This series of articles were all mostly published in the prestigious Journal of Bone and Joint Surgery, the Number One journal for orthopedic surgeons.

In 1998, two medical doctors at the University of Pennsylvania School of Medicine in Philadelphia, contacted all 157 chairpersons of orthopedic residency programs in the United States. Together they developed and validated a basic-competency examination in musculoskeletal medicine to give to the first year residents.

The results were astounding, because 82% of the eighty-five medical school graduates failed this BASIC competency exam!

Four years later they redesigned the exam (or changed the scoting). Even though the passing grade was LOWERED from 74% to 70%, 78% of them again failed the exam, with a mean test score average of 59.9 percent.

Isn't that frightening?

To add insult to injury, this exact same test was given to a group of 51 chiropractic students during their last semester of schooling. The results? 70% of the students passed the test. This is in contrast to an 80% failure rate for the MDs.

For clarity sake, you need appreciate the difference between the chiropractic and the medical participants in these studies.

  • The chiropractic group were still JUST STUDENTS in their last undergrad year

  • The medical group had already graduated medical school, been awarded their MD degrees, completed all their hospital rotations, and finally been accepted into highly competitive orthopedic residencies.

One would expect that, during their 5 years of medical training, followed by endless hours of hospital rotations and residency programs, that all these doctors *might have* picked up a little more musculoskeletal knowledge along the way.

Evidently this is NOT the case.

These medical authors concluded that residents in orthopedic surgery programs are not provided with sufficient training in NMS analysis. The truth is, they are incompetent in musculoskeletal assessment or treatment. This situation was not corrected during the 4–year interim between the publication of the 1st and 2nd article, and still has not been corrected 11 years later.

Since that time there has been a storm brewing at medical schools, but in the 11 years since Dr. Freedman published his first paper, medical students still continue to fail on basic musculoskeletal exams, as documented by the following series of peer-reviewed studies. This is a huge problem because “conditions affecting the musculoskeletal system are the primary reason patients seek medical care from physicians, accounting for nearly 100 million office visits per year. [1]   Furthermore, musculoskeletal conditions are the most common cause of long-term pain and physical disability. [2]” [3]

What's the best solution? If you have spinal pain, seek care from someone who is properly trained to assess and manage your care. That person is a chiropractor.

The following articles are listed from the oldest to the newest, so that you can follow the lack of progress in correcting this issue at medical schools.

The Adequacy of Medical School Education in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 1998 (Oct);   80–A (10):   1421–1427

This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that "we therefore believe that medical school preparation in musculoskeletal medicine is inadequate" and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints.

Educating Medical Students About Musculoskeletal Problems:
Are Community Needs Reflected in the Curricula of Canadian Medical Schools?

Journal of Bone and Joint Surgery 2001 (Sept);   83–A (9):   1317–1320

Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. (So they conclude:) There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.

A Comparison of Chiropractic Student Knowledge Versus Medical Residents
Proceedings of the World Federation of Chiropractic Congress 2001 Pgs. 255

A previously published knowledge questionnaire designed by chief orthopedic residents was given to a Chiropractic student group for comparison to the results of the medical resident group. Based on the marking scale determined by the chief residents, the Chiropractic group (n = 51) showed statistically significant higher average grade than the orthopedic residents. Expressed in other terms, 70% of chiropractic students passed the knowledge questionnaire, compared to an 80% failure rate for the residents.

Educational Deficiencies in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 2002 (Apr);   84–A (4):   604–608

According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate. NOTE: This is a follow-up article to the study cited below, which demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. What would the headlines scream if, after 4 years, our profession had failed to improve it's skills in musculoskeletal assessment and management? Ask your self why medicine is shown more slack than?

Musculoskeletal Knowledge: How Do You Stack Up?
Physician and Sportsmedicine 2002 (Aug); 30 (8) August

One of every 4 or 5 primary care visits is for a musculoskeletal problem. Yet undergraduate and graduate training for this burden of illness continues to constitute typically less than 3% of the medical curriculum. This is an area of clear concern, but also one in which sports medicine practitioners can assume leadership.

Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov); 32 (11)

It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5–year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment. This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.[ 1 ] While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.

Adequacy of Education in Musculoskeletal Medicine
J Bone Joint Surg Am 2005 (Feb);   87 (2):   310–314

In this study, 334 medical students, residents and staff physicians, specializing in various fields of medicine, were asked to take a basic cognitive examination consisting of 25 short-answer questions – the same type of test administered in the original JBJS 1998 study. The average score among medical doctors, students and residents who took the exam in 2005 was 2.7 points lower than those who took the exam in 1998. Just over half of the staff physicians (52%) scored a passing grade or higher on the 2005 exam. Only 21% of the residents registered a passing grade, and only 3% of the medical students passed the exam. Overall, Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination.

More Evidence of Educational Inadequacies in Musculoskeletal Medicine
Clin Orthop Relat Res 2005 (Aug);   (437):   251–259

A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.

Why is the Bone and Joint Decade Important?
Welcome to the United States Bone and Joint Decade

The Bone and Joint Decade initiative is a global campaign to improve quality of life for people with musculoskeletal conditions and to advance understanding and treatment of these conditions through research, prevention, and education. [ 1 ] The Decade aims to raise the awareness of the increasing societal impact of musculoskeletal injuries and disorders; empower patients to participate in decisions about their care; increase funding for prevention activities and research; and promote cost-effective prevention and treatment of musculoskeletal injuries and disorders.

Doctors Likely to Encounter Children With Musculoskeletal Complaints
Have Low Confidence in Their Clinical Skills

The Journal of Pediatrics 2009 (Feb);   154 (2):   267–271

Questionnaires, filled out by a broad spectrum of medical providers in England [Primary Care (n = 75), Pediatrics (n = 39), Emergency (n = 39), Orthopedics (n = 40), and experienced doctors in Primary Care (n = 93), and Pediatrics (n = 60).], revealed that 74% of them scored their personal confidence in pediatric musculoskeletal clinical assessment as "no" to "low".

Orthopaedists' and Family Practitioners' Knowledge of Simple
Low Back Pain Management

Spine 2009 (Jul 1);   34 (15):   1600–1603

One hundred forty family practitioners and 253 orthopaedists responded to the questionnaire. The mean family practitioners' score (69.7) was significantly higher than the orthopaedists' score (44.3) (P < 0.0001). No relation was found between the results and physician demographic factors, including seniority. Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs.

The Inadequacy of Musculoskeletal Knowledge After Foundation Training
in the United Kingdom

Journal of Bone and Joint Surgery Br 2009 (Nov);   91 (11):   1413–1418

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment.


1.   Musculoskeletal conditions in the United States.
Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999

2.   Burden of major musculoskeletal conditions
Bull World Health Organ 2003;   81 (9):   646–656

Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov);   32 (11)

Palmer Research Center Conducting Several Clinical Trials on Back Pain
The Palmer Center for Chiropractic Research is currently studying back pain through several groundbreaking clinical trials at its research clinic. About 500 people from throughout the Quad-City region who suffer from back pain are being recruited to participate in two separate clinical trials, expected to last up to 18 months. Both studies are funded through federal grants totaling $2.4 million.

Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain
and Related Disabilities: A Preliminary Study

J Manipulative Physiol Ther 2004 (Oct);   27 (8):   509–514 ~ FULL TEXT

This study demonstrated two important points: (1) Chiropractic is effective for chronic low back pain (LBP), and (2) that ongoing supportive care can reduce disability levels, as measured by the Oswestry Low Back Pain Disability questionnaire.

Dose-response for Chiropractic Care of Chronic Low Back Pain
Spine J 2004 (Sep);   4 (5):   574–583 ~ FULL TEXT

There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.

A Randomized Clinical Trial Comparing Chiropractic Adjustments to
Muscle Relaxants for Subacute Low Back Pain

J Manipulative Physiol Ther 2004 (Jul);   27 (6):   388–398 ~ FULL TEXT

Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing Global Impression of Severity Scale (GIS).

Complementary and Alternative Medical Therapies for Chronic Low Back Pain:
What Treatments Are Patients Willing To Try?

BMC Complement Altern Med. 2004 (Jul 19);   4:   9 ~ FULL TEXT

Most patients with chronic back pain in our sample were interested in trying therapeutic options that lie outside the conventional medical spectrum. This highlights the need for additional studies evaluating their effectiveness and suggests that researchers conducting clinical trials of these therapies may not have difficulties recruiting patients.

Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain:
A Systematic Review and Best Evidence Synthesis

Spine Journal (of the North American Spine Society) 2004 (May);   4 (3):   335–356

Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and neck pain. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.

Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations:
A Systematic Review and Risk Assessment

J Manipulative Physiol Ther 2004 (Mar);   27 (3):   197–210 ~ FULL TEXT

Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or cauda equina syndrome (CES) in patients presenting with LDH was calculated. This was compared with estimates of the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and surgery in the treatment of LDH.   An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million.

A Practice-Based Study of Patients With Acute and Chronic Low Back Pain
Attending Primary Care and Chiropractic Physicians:
Two-Week to 48-Month Follow-up

J Manipulative Physiol Ther 2004 (Mar);   27 (3):   160–169 ~ FULL TEXT

This study found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients' first year of symptoms.

Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations:
A Systematic Review and Risk Assessment

J Manipulative Physiol Ther 2004 (Mar);   27 (3):   197–210 ~ FULL TEXT

An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million. The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.

The Not-So-Hidden Costs of Back Pain
Dynamic Chiropractic – February 12, 2004

Some "experts" – ironically, those outside the chiropractic profession – have attempted to describe back pain as a harmless, self–limiting condition that requires only rest and time for resolution, despite evidence to the contrary. If that's the case, how do these experts explain the results of a study published in the Jan. 1, 2004 issue of Spine?

Biomechanical and Neurophysiological Responses to Spinal Manipulation
in Patients With Lumbar Radiculopathy

J Manipulative Physiol Ther. 2004 (Jan);   27 (1):   1–15 ~ FULL TEXT

Because spinal manipulation (SM) is a mechanical intervention, it is inherently logical to assume that its mechanisms of therapeutic benefit may lie in the mechanical properties of the applied force (mechanical mechanisms), the body's response to such force (mechanical or physiologic mechanisms), or a combination of these and other factors. Basic science research, including biomechanical and neurophysiological investigations of the body's response to SM, therefore, should assist researchers, educators, and clinicians to understand the mechanisms of SM, to more fully develop SM techniques, to better train clinicians, and ultimately attempt to minimize risks while achieving better results with patients.

FCER Critiques 2 LBP Articles in Annals of Internal Medicine
The June 3, 2003 issue of Annals of Internal Medicine featured two studies which questioned the clinical and cost-effectiveness of spinal manipulation.

The first is titled Spinal Manipulative Therapy for Low Back Pain: A Meta-Analysis of Effectiveness Relative to Other Therapies.

The second study is titled A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain.

After careful review of these articles, Anthony L. Rosner, Ph.D., Director of Research for the Foundation for Chiropractic Education and Research (FCER), authored critical responses on behalf of the chiropractic profession.   In addition to sharing his understanding of what constitutes research of clinical utility, Dr. Rosner has been able to apply his knowledge of the better research offering significant support for spinalmanipulation, helping the chiropractic profession and the public recognize potentially flawed conclusions.

The Course of Low Back Pain in a General Population.
Results From a 5-year Prospective Study

J Manipulative Physiol Ther. 2003 (May);   26 (4):   213–219 ~ FULL TEXT

Low back pain should not be considered transient and therefore neglected, since the condition rarely seems to be self-limiting but merely presents with periodic attacks and temporary remissions. On the other hand, chronicity as defined solely by the duration of symptoms should not be considered chronic.

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

The results of the review showed that the reported proportion of patients who still experienced pain after 12 months was 62% on average (range 42–73%)...the percentage who experienced relapses of pain was 60% (range 44–78%), and the percentage who had relapses of work absence was 33% (range 26–37%)...The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.

Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain:
A Randomized, Controlled Trial With 1-Year Follow-Up

Spine (Phila Pa 1976) 2003 (Mar 15);   28 (6):   525–531 ~ FULL TEXT

Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. Immediately after the 2–month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work (P < 0.01), a relative difference that was maintained throughout the follow-up period.

Evaluation of Chiropractic Management of Pediatric Patients with Low Back Pain:
A Prospective Cohort Study

J Manipulative Physiol Ther 2003 (Jan);   26 (1):   1–8 ~ FULL TEXT

Fifteen chiropractors provided data on 54 consecutive pediatric patients with LBP. The average age of the patients was 13.1 years, 57% were male, 61% were acute, with 47% attributing onset to a traumatic event (most commonly sports-related); 24% reported an episode duration of greater than 3 months. Almost 90% of cases presented with uncomplicated mechanical LBP, most frequently diagnosed as lumbar facet dysfunction or subluxation.
There are more articles like this at our Pediatrics Section

A Clinical Prediction Rule for Classifying Patients with Low Back Pain
who Demonstrate Short-term Improvement with Spinal Manipulation

Spine (Phila Pa 1976). 2002 (Dec 15);   27 (24):   2835–2843 ~ FULL TEXT

Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.

Locating and Treating Low Back Pain of Myofascial Origin by Ischemic Compression
Journal of the Canadian Chiropractic Assoc 2002 (Dec);   46 (4)

The purpose of this article is to describe a method to identify and treat trigger points of myofascial origin by ischemic compression among patients with low back pain. In addition to a review of the literature, the author draws upon his own clinical experience to accomplish this goal. In general, thumb pressure is used for the identification, localization and treatment of trigger points and tender spots within the muscles of the lumbar, pelvic, femoral and gluteal areas. The management of low back pain of myofascial origin by ischemic compression can be used in any setting, without the need of specialized equipment. In addition to clinical effectiveness within a wide range of safety, this approach is easy on the practitioner and well tolerated by the patient.

Back, Neck, and Shoulder Pain in Finnish Adolescents: National Cross Sectional Surveys
British Medical Journal 2002 (Oct 5);   325 (7367):   743–745 ~ FULL TEXT

To study changes in the prevalence of pain in the back or neck in adolescents between the years 1985 and 2001, the authors compared biennial nationwide postal surveys, between 1985–2001, and annual classroom surveys, from 1996–2001. They found that pain in the neck, shoulder, and lower back is becoming more common in Finnish adolescents. This pain suggests a new disease burden of degenerative musculoskeletal disorders for future adults. Prevalence of pain in the back and neck was greater in the 1990s than in the 1980s and increased steadily from 1993 to 1997. Pain of the neck and shoulder and pain of the lower back was much more common in 1999 than in 1991 and in 2001 than in 1999. Pain was more common among girls and older groups: pain of the neck and shoulder affected 24% of girls and 12% of boys in 14 year olds, 38% of girls and 16% of boys in 16 year olds, and 43% of girls and 19% of boys in 18 year olds; pain in the lower back affected 8% of girls and 7% of boys in 14 year olds, 14% of girls and 11% of boys in 16 year olds, and 17% of boys and 13% of girls in 18 year olds.
There are more articles like this at our Pediatrics Section

A Randomized Trial of Medical Care with and without Physical Therapy and Chiropractic Care
with and without Physical Modalities for Patients with Low Back Pain:
6-month Follow-up Outcomes From the UCLA Low Back Pain Study

Spine (Phila Pa 1976) 2002 (Oct 15);   27 (20):   2193–2204 ~ FULL TEXT

After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain:
Risk Factors for Long–Term Disability and Work Loss

New Zealand Guidelines Group (2002) ~ FULL TEXT

This guide is to be used in conjunction with the New Zealand Acute Low Back Pain Guide. It provides an overview of risk factors for long–term disability and work loss, and an outline of methods to assess these at risk. Identification should lead to appropriate early management targeted towards the prevention of chronic pain and disability.

The Centralization Phenomenon in Chiropractic Spinal Manipulation
of Discogenic Low Back Pain and Sciatica

J Manipulative Physiol Ther. 2001 (Nov);   24 (9):   596–602 ~ FULL TEXT

Assessment of the centralization phenomenon provided valuable diagnostic and prognostic information regarding chiropractic side-posture manipulation in this case series.

Clinical Guidelines for the Management of Low Back Pain in Primary Care:
An International Comparison

Spine (Phila Pa 1976) 2001 (Nov 15);   26 (22):   2504–2513

Clinical guidelines from 11 different countries published from 1994 until 2000 were included in this review. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions.
You may review more articles like this in the: LOWBACK GUIDELINES Page.

The Treatment of Neck and Low Back Pain: Seeks Care? Who Goes Where?
Med Care. 2001 (Sep);   39 (9):   956–967

Twenty-five percent of individuals with neck or low back pain visited a health care provider. Seeking health care was associated with disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning. Compared with medical patients, fewer chiropractic patients lived in rural areas or reported arthritis, but they reported better social and physical functioning. More patients consulting both providers reported disabling neck or back pain.   Individuals seeking care for neck or back pain have worse health status than those who do not seek care. Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors.

Pain, Disability, and Satisfaction Outcomes and Predictors of Outcomes:
A Practice-based Study of Chronic Low Back Pain Patients Attending
Primary Care and Chiropractic Physicians

J Manipulative Physiol Ther. 2001 (Sep);   24 (7):   433–439 ~ FULL TEXT

Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study.

A Prospective Study of Back Belts for Prevention of Back Pain and Injury
J American Medical Association 2000 (Dec 6);   284 (21):  2727–2732 ~ FULL TEXT

In the largest prospective cohort study of back belt use, adjusted for multiple individual risk factors, neither frequent back belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain.

Nonoperative Treatments for Sciatica: A Pilot Study for a Randomized Clinical Trial
J Manipulative Physiol Ther. 2000 (Oct);   23 (8):   536–544

A total of 706 persons were screened by phone to determine initial eligibility. Of these, over 90% of those persons contacted did not meet the entrance criteria. The most common reason for disqualification was that the duration of the complaint was longer than 3 months. Twenty patients were randomized into the study. All 3 groups showed substantial improvements in the main patient-rated outcomes at the end of the 12-week intervention phase. For leg pain, back pain, frequency and bothersomeness of leg symptoms, and Roland-Morris disability score, the percent improvement varied from 50% to 84%, and the corresponding effect sizes ranged from 0.8 to 2.2. Bothersomeness of leg symptoms was the most responsive outcome associated with the largest magnitude of effect size. All within-group changes from baseline were statistically significant (P <.01). No between-group comparisons were planned or performed because of the insufficient sample size and high risk of committing type I and type II errors.

Stability: From Biomechanical Concept to Chiropractic Practice
J Can Chiropr Assoc 1999 (Jun);   43 (2):   75–88 ~ FULL TEXT

The rehabilitation field is continuing to embrace techniques that consider notions of stability. Past emphasis, in some cases, was on issues such the production of torque, enhancing range of motion etc. Fortunately, the laws of physics, and techniques of engineering, are being recognized by clinicians who can then ensure that first a system must be stable before presented with a physical challenge. Furthermore of particular importance to chiropractic, is the need to consider the role of stabilizing exercise when joint stability may be altered from treatment. We will continue our work to understand the contributions to stability of various components of the anatomy at particular joints - and the ideal ways to enhance their contribution; to understand what magnitudes of muscle activation are required to achieve sufficient stability; to identify the best methods to re-educate faulty motor control systems to both achieve sufficient stability and reduce the risk of inappropriate motor patters occurring in the future. Our challenge for the future, as clinicians like yourselves and scientists like myself, is to tackle in a collaborative and scientifically substantiated way, the pain and mobility problems that are so important for quality of life.

A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision
of an Educational Booklet for the Treatment of Patients with Low Back Pain

New England Journal of Medicine 1998 (Oct 8);   339 (15):   1013–1029

This amusing paper found that an "educational booklet" was as effective as either chiropractic or McKenzie protocol! I still can't figure out how they managed to charge $153.00 for each and every booklet...what idiot funded this project? Maybe selling $153. books will be medicine's next big "breakthrough" in managing low back pain. Nice work, if you can get it!

Research: New Challenges for Chiropractic
Response to the Low Back Pain study in the New England Journal of Medicine listed above.   Read these responses from the Research and Academic Community.

Predictive Factors for 1-year Outcome of Low-back and Neck Pain in Patients Treated in
Primary Care: Comparison Between the Treatment Strategies Chiropractic and Physiotherapy

Pain. 1998 (Aug);   77 (2):   201–207

The inability to predict outcome in patients with low back/neck pain leads to inappropriate or unnecessary treatment. The aims of the study were to identify prognostic factors for disability at 1-year follow-up in patients with back pain visiting primary care, and to compare the effect of these in two treatment strategies--chiropractic and physiotherapy. Data were taken from a randomised trial on patients with back/neck pain visiting the general practitioner, in which patients were allocated to chiropractic and physiotherapy as primary management. Three hundred and twenty-three patients, aged 18-60 years, who had no contraindications to manipulation and who had not been treated within the previous month were included in the study. Multiple regression analysis was used to identify prognostic factors. Dependent variables were mean Oswestry score and mean change in Oswestry score at 12-month follow-up. The multiple regression analysis revealed five significant (P < 0.001-0.01) prognostic factors; duration of current episode, Oswestry score at entry, expectations of treatment, number of localisations, and well-being. Besides, the regression coefficients for the significant factors were compared between the two treatment strategies.

Congruence between Decisions To Initiate Chiropractic Spinal Manipulation
for Low Back Pain and Appropriateness Criteria in North America

Annals of Internal Medicine 1998 (Jul 1);   129:   9–17 ~ FULL TEXT

The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.
Responses to the above AIM Article from our readers

Complementary Care: When Is It Appropriate? Who Will Provide It?
Annals of Internal Medicine 1998 (Jul );   129:   65–66 ~ FULL TEXT

The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low back pain. [1] The 1994 guidelines for acute low back pain developed by AHCPR concluded that spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidial anti-inflammatory drugs. [1] At the same time, AHCPR concluded that various traditional methods, such as bed rest, traction, and other physical and pharmaceutical therapies were less effective than spinal manipulation and cautioned against lumbar surgery except in the most severe cases. Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice.

Outcome of Low Back Pain in General Practice: A Prospective Study
British Medical Journal 1998 (May 2);   316 (7141):   1356–1359 ~ FULL TEXT

This FULL TEXT article investigated the generally accepted statistic that 90% of low back pain (LBP) goes away by itself. The discrepancy lies in the method of the data collection. Croft et al point out that the original study to publish the "90% recovery" results was based on patient consultation records, not follow up interviews. By comparison, this study takes into account consultation rates as well as follow-up interviews. In fact, Croft's consultation rates show a 90% drop-out rate after 3 months, not resolution of the complaint! The follow-up interviews, however, showed that most patients simply stopped consulting their doctors about low back pain, even though they still suffered pain and disability 12 months later! Clearly, the number of visits to general practitioners cannot be used as a measure of how quickly the pain and disability goes away.

MDs Employ Spinal Manipulation After a Short Training Course: Limited Benefit for Patients
The Back Letter 1998 (Nov): 13 (11): 121 ~ FULL TEXT

Results: Overall, the results do not support training primary care physicians in manipulative techniques. "The incremental effect of adding manual therapy to an approach involving enthusiastic physicians, special evaluation and patient educational skills, standard medication therapies, and exercise prescription appears to be minimal," said Carey. More intense manual therapy might hold promise, but for now the evidence for training physicians in manual therapy remains to be established, said Carey.

Magnetic Resonance Imaging and Clinical Follow-up: Study of
27 Patients Receiving Chiropractic Care for Cervical
and Lumbar Disc Herniations

J Manipulative Physiol Ther 1996 (Nov);   19 (9):   597–606

Clinically, 80% of the patients studied had a good clinical outcome with postcare visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p < .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their predisability occupations.

Randomised Comparison of Chiropractic and Hospital Outpatient Management
for Low Back Pain: Results from Extended Follow up

British Medical Journal 1995 (Aug 5);   311 (7001):   349–351 ~ FULL TEXT

At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.

Manipulative Therapy Versus Education Programs in Chronic Low Back Pain
Spine (Phila Pa 1976). 1995 (Apr 15);   20 (8):   948–955

Triano and colleagues studied treatment effects for patients with low back pain persisting longer than seven weeks. Subjects were randomly assigned to a back education program, high-velocity low-amplitude (HVLA) manipulation and sham/mimic treatment procedure groups for a series of 10 treatment sessions. Sessions were scripted to balance for physical contact, attention, and intervention frequency and duration. Sessions involved a consistent time commitment and direct one-on-one attention from the physician, either in the form of teaching about spine anatomy and function, or in assessment and delivery of the sham/HVLA procedures. Although all treatment groups showed improvement over time, the patients receiving thrusting procedures demonstrated significantly greater and more rapid rates of improvement from their symptoms and in their ability to function.

Effective Management of Low Back Pain: It’s Time to Accept the Evidence
J Can Chiropr Assoc. 1993 (Dec);   37 (4):   221–229 ~ FULL TEXT

Low back pain is a ubiquitous and economically costly problem. Unfortunately, the clinical management of low back pain is not yet well understood. Chiropractic management of back pain, long the black sheep of back care, has undergone a transition and is now a more respected and understood alternative to conservative medical care, itself under increased scrutiny due to unsatisfactory outcomes and unacceptable iatrogenic side effects. The substantial amount of clinical and related research on the effectiveness of manipulation for low back pain is summarized here from a larger study, divided into randomized control trials, case-control trials, meta-analyses and descriptive studies. The chiropractic management of low back pain is found to be a more effective way of dealing with this medical, social and economic problem. It is suggested that greater utilization of chiropractors be encouraged such that the “right people are doing the right things at the right time”.

Chiropractic Care for Common Industrial Low Back Conditions
Chiropractic Technique 1993 (Aug);   5 (3):   119–125 ~ FULL TEXT

This is the first guideline I have seen which actually states the number of visits which may be appropriate for a variety of common low back conditions.   I have used these "care plans" for years, presenting them to third party's as a "working diagnosis" care plan, which need ongoing "fine tuning" during patient care. Check out this Chiropractic Technique article, and the attached care plans, which have been released exclusively to Chiro.Org by the National College of Chiropractic. Thanks, Dana!
You will find more information like this in our: Guidelines Section.

Low Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic
and Hospital Outpatient Treatment

British Medical Journal 1990 (Jun 2);   300 (6737):   1431–1437

For patients with low back pain in whom manipulation is not contraindicated chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain.   Introducing chiropractic into NHS practice should be considered.

Patient Evaluations of Low Back Pain Care From Family Physicians and Chiropractors
Western Journal of Medicine 1989 (Mar); 150 (3): 351–355 ~ FULL TEXT

Patients of chiropractors were three times as likely as patients of family physicians to report that they were very satisfied with the care they received for low back pain (66% versus 22%, respectively). Compared with patients of family physicians, patients of chiropractors were three times more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem.

A New Clinical Model For The Treatment Of Low-back Pain
Winner of the 1987 Volvo Award In Clinical Sciences

Spine (Phila Pa 1976) 1987 (Sep);   12 (7):   632–644

Because there is increasing concern about low–back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low–back pain should be a benign, self–limiting condition, that low back–disability as opposed to pain is a relatively recent Western epidemic, and that the role of medicine in that epidemic must be critically examined. The traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low–back disorders.

Spinal Manipulation in the Treatment of Low–back Pain
Canadian Family Physician 1985 (Mar);   31:   535–540 ~ FULL TEXT

The truly spectacular results from chiropractic treatment (approximately 80 percent of patients 'totally disabled' for an average of 7 years back on the job and doing well after 3 weeks of daily adjustments) reflect, in my view, not only the positive value of low back adjustments but also the exceptional skill of the particular chiropractor.

How to Shift LBP Paradigms: The "Hinges" of Practice
Dynamic Chiropractic – March 26, 2001

Specialists in the management of spinal disorders have seen tremendous changes in the last decade. While the low back pain (LBP) problem has been acknowledged as an epidemic, a consensus has gradually emerged as to why this has happened and what can be done about it . An overemphasis on the simplistic biomedical approach of identifying and treating the structural cause of pain has led to excesses in diagnostic testing, bed rest, narcotic analgesics, and surgery (Waddell). Meanwhile, an underemphasis on illness behavior has led to an under–utilization of functional (re–activation advice, manipulation and exercise) and cognitive–behavorial approaches (Feuerstein).

Vladimir Janda Citation Collection
Shortcuts are provided to the PubMed abstracts of all the articles which are available online.

What is the Natural History for Lower Back Pain?
We have all heard the statistics that say 83% of patients are better in 6 weeks. Is this universally advertised short term outcome true? What do we mean by better? If our goal is to improve the quality of care for back pain patients then we first need to establish benchmark outcomes of recovery. If improvement is the goal then 90% of patients are improving after only 3 weeks. But, if asymptomatic is the goal then only 46% reached this goal after 7 weeks. If not having any activity limitations due to pain is the goal, as AHCPR suggests, then only 38% have achieved this goal by 7 weeks.


The Trajectories of Low Back Pain

The Natural Course of Low Back Pain From Childhood to Young Adulthood -
A Systematic Review

Chiropractic & Manual Therapies 2019 (Mar 20);   27:   10 ~ FULL TEXT

Although methodological heterogeneity, mainly due to different age ranges, an indication of a natural course of LBP was seen across studies. The majority of children and adolescents repeatedly reporting no or low probability of LBP. With recall periods between one week to three months and sampling rates ranging from one to four years, a very low rate repeatedly reported LBP, and approximately one-fifth to one-third of children and adolescents had fluctuating reports of LBP. A need of future research of LBP trajectories with short reporting period lengths and narrower sampling windows in a long-term perspective is emphasized in order to study childhood influences on the development of LBP throughout life.
There are more articles like this at our Pediatrics Section

Contrasting Real Time Quantitative Measures (Weekly SMS) to Patients’ Retrospective Appraisal
of Their One-year’s Course of Low Back Pain; A Probing Mixed-methods Study

Chiropractic & Manual Therapies 2019 (Feb 26);   27:   12 ~ FULL TEXT

This study shows that a real time quantitative measure (weekly SMS) and the patient's retrospective appraisal do not fundamentally differ in their reflection of the one-year course of LBP.As a first investigation into this area, these results are promising, as longitudinal quantitatively derived trajectories of LBP seem to reflect the lived experience of the patient to a large degree. Furthermore, the patient's ability to retrospectively recall their one-year course of LBP appears to be quite good. Future studies should focus on refining the categories of trajectories.

An Observational Study on Trajectories and Outcomes of Chronic Low Back Pain Patients
Referred From a Spine Surgery Division for Chiropractic Treatment

Chiropractic & Manual Therapies 2019 (Feb 5);   27:   6 ~ FULL TEXT

Chiropractic treatment is a valuable conservative treatment modality associated with clinically relevant improvement in approximately half of patients with chronic LBP. These findings provide an example of the importance of interdisciplinary collaboration in the treatment of chronic back pain patients.

Trajectories and Predictors of the Long-term Course of Low Back Pain:
Cohort Study with 5-year Follow-up

Pain 2018 (Feb);   159 (2):  252–260 ~ FULL TEXT

Low back pain (LBP) is a major health challenge globally. Research has identified common trajectories of pain over time. We aimed to investigate whether trajectories described in 1 primary care cohort can be confirmed in another, and to determine the prognostic value of factors collected 5 years prior to the identification of the trajectory. The study was conducted on 281 patients who had consulted primary care for LBP, at that point completed a baseline questionnaire, and then returned a questionnaire at 5-year follow-up plus at least 3 (of 6) subsequent monthly questionnaires.

How Can Latent Trajectories of Back Pain be Translated into Defined Subgroups?
BMC Musculoskelet Disord. 2017 (Jul 3);   18 (1):   285 ~ FULL TEXT

This study was the first to demonstrate that suggested definitions of LBP trajectory subgroups can be readily applied to individuals’ observed data resulting in subgroups that match well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with infrequent and mild LBP. Further, we suggest that minor fluctuations in pain intensity might be conceptualised as ‘ongoing LBP’. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP.

Leg Pain Location and Neurological Signs Relate to Outcomes in
Primary Care Patients with Low Back Pain

BMC Musculoskelet Disord. 2017 (Mar 31);   18 (1):   133 ~ FULL TEXT

The Quebec Task Force categories (QTFC) identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals' outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

What Have We Learned From Ten Years of Trajectory Research in Low Back Pain?
BMC Musculoskelet Disord. 2016 (May 21);   17 (1):   220 ~ FULL TEXT

Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals' course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management.

Trajectories of Acute Low Back Pain: A Latent Class Growth Analysis
Pain. 2016 (Jan);   157 (1):   225–234 ~ FULL TEXT

Characterising the clinical course of back pain by mean pain scores over time may not adequately reflect the complexity of the clinical course of acute low back pain. We analysed pain scores over 12 weeks for 1585 patients with acute low back pain presenting to primary care to identify distinct pain trajectory groups and baseline patient characteristics associated with membership of each cluster. This was a secondary analysis of the PACE trial that evaluated paracetamol for acute low back pain. Latent class growth analysis determined a 5 cluster model, which comprised:

567 (35.8%) patients who recovered by week 2   (cluster 1, rapid pain recovery)
543 (34.3%) patients who recovered by week 12   (cluster 2, pain recovery by week 12)
222 (14.0%) patients whose pain reduced but did not recover   (cluster 3, incomplete pain recovery)
167 (10.5%) patients whose pain initially decreased but then increased by week 12   (cluster 4, fluctuating pain); and
86   (5.4%) patients who experienced high-level pain for the whole 12 weeks   (cluster 5, persistent high pain).

Exploring the Definition of Acute Low Back Pain: A Prospective Observational Cohort Study
Comparing Outcomes of Chiropractic Patients With 0–2, 2–4, and 4–12 Weeks
of Symptoms and Multiple Comorbidities

J Manipulative Physiol Ther. 2016 (Mar);   39 (3):   141–149 ~ FULL TEXT

Patients with 0–2 weeks of symptoms were significantly more likely to "improve" at 1 week, 1 month, and 6 months compared with those with 2–4 weeks of symptoms (P < .015). Patients with 0–2 weeks of symptoms reported significantly higher NRS and Oswestry change scores at all data collection time points. Outcomes for patients with 2–4 weeks of symptoms were similar to patients having 4–12 weeks of symptoms.   The time period 0–4 weeks as the definition of "acute" should be challenged. Patients with 2–4 weeks of symptoms had outcomes similar to patients with subacute (4–12 weeks) symptoms and not with patients reporting 0–2 weeks of symptoms.

Patients With Low Back Pain Had Distinct Clinical Course Patterns That Were Typically
Neither Complete Recovery Nor Constant Pain. A Latent Class Analysis of Longitudinal Data

Spine J. 2015 (May 1);   15 (5): 885–894 ~ FULL TEXT

The clinical course of LBP is complex. Most primary care patients do not become pain-free within a year, but only a small proportion reports constant severe pain. Some distinct patterns exist which were identified independently of the way the outcome was modeled. These patterns would not be revealed by using the simple summary measures traditionally applied in LBP research or when describing a patient's pain history only in terms of duration. The appropriate number of subgroups will depend on the intended purpose of subgrouping.

Is Puberty a Risk Factor For Back Pain in the Young?
A Systematic Critical Literature Review

Chiropractic & Manual Therapies 2014 (Oct 15);   22 (1):   27 ~ FULL TEXT

It has previously been established that back pain starts during childhood. [1–4] According to two recent systematic literature reviews [1, 2], the lifetime prevalence increases between the ages of 7 and 12 (on average from 1% to 17%) to reach the adult level around the age of 20. [5] In relation to low back pain, it appears that puberty is the time for a rapid increase. Girls start puberty earlier than boys, which may explain why they report back pain earlier than boys. [5]
There are more articles like this at our Pediatrics Section

Long-term Trajectories of Back Pain: Cohort Study With 7-year Follow-up
BMJ Open. 2013 (Dec 11);   3 (12):   e003838 ~ FULL TEXT

Four clusters with different back pain trajectories at follow-up were identified:

(1)   no or occasional pain
(2)   persistent mild pain
(3)   fluctuating pain and
(4)   persistent severe pain.

Trajectory clusters differed significantly from each other in terms of disability, psychological status and other symptoms. Most participants remained in a similar trajectory as 7 years previously (weighted κ 0.54; 95% CI 0.42 to 0.65).

Trajectories of Low Back Pain
Best Pract Res Clin Rheumatol. 2013 (Oct);   27 (5):   601–612 ~ FULL TEXT

Low back pain is not a self-limiting problem, but rather a recurrent and sometimes persistent disorder. To understand the course over time, detailed investigation, preferably using repeated measurements over extended periods of time, is needed. New knowledge concerning short-term trajectories indicates that the low back pain 'episode' is short lived, at least in the primary care setting, with most patients improving. Nevertheless, in the long term, low back pain often runs a persistent course with around two-thirds of patients estimated to be in pain after 12 months. Some individuals never have low back pain, but most have it on and off or persistently. Thus, the low back pain 'condition' is usually a lifelong experience. However, subgroups of patients with different back pain trajectories have been identified and linked to clinical parameters. Further investigation is warranted to understand causality, treatment effect and prognostic factors and to study the possible association of trajectories with pathologies.

Trajectories of Pain in Adolescents: A Prospective Cohort Study
Pain. 2011 (Jan);   152 (1):   66–73 ~ FULL TEXT

Identification of different patterns of change in pain over time – trajectories – has the potential to provide new information on the course of pain. Describing trajectories among adolescents would improve understanding of how pain conditions can develop. This prospective cohort study identified distinct trajectories of pain among adolescents (11–14 years) in the general population (n=1,336). Latent class growth analysis was carried out on the self-reported frequency of back pain, headache, stomach pain and facial pain, which was collected every 3 months for 3 years. Forty four percent of adolescents had a 'painful' trajectory for at least one pain site, and 12% reported persistent pain at one or more pain site. Headache was the most common; 25% of subjects were in a 'painful' trajectory and 5% reported persistent pain. Back pain and stomach pain were also common, with 22% and 21% of subjects in painful trajectories, respectively. Facial pain was the least common, with only 10% in a painful trajectory, and 1% reporting persistent pain. Trajectory characteristics were similar at baseline across pain sites, with the more painful trajectories having significantly higher levels of depression and somatization, lower life satisfaction and more females.
There are more articles like this at our Pediatrics Section

Identifying Episodes of Back Pain Using Medical Expenditures Panel Survey Data:
Patient Experience, Use of Services, and Chronicity

J Manipulative Physiol Ther. 2010 (Oct);   33 (8):   562–575 ~ FULL TEXT

These findings suggest that other longitudinal studies based only on data that reflect service use, for example, claims data, may incorrectly infer the nature of back pain and back pain episodes. Many individuals report ongoing back pain that continues beyond their Episodes-of-Care, and many individuals with persistent back pain may use prescription drugs, medical services, and other health services only intermittently.

Characterizing the Course of Low Back Pain:   A Latent Class Analysis
American Journal of Epidemiology 2006 (Apr 15);   163 (8):   754–761 ~ FULL TEXT

Understanding the course of low back pain is important for clinicians and researchers because it provides information on the need for, and potential benefits of, treatment. [1, 2] It also helps patients learn what to expect in terms of symptoms, the impact of the problem on their life, and the interventions they may receive. Information on symptom course may enable patients with nonspecific low back pain to be classified into clinically meaningful subgroups. There are currently no accepted methods for classifying these patients, who constitute 85–95 percent of those seeking care for low back pain. [3] Thus, it is difficult to select clearly defined subgroups of patients for clinical trials, and the potential effectiveness of treatments may be masked by the heterogeneity of the patients studied.


What is Usual Care?

Primary Care for Low Back Pain: We Don't Know the Half of It
Pain. 2020 (Apr);   161 (4):   663–665 ~ FULL TEXT

In a new systematic review, Kamper et al. [What is Usual Care for Low Back Pain?] (See it directly below this article) tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, [17] and there is good evidence for what constitutes best first-contact treatment. [6] The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit). [2, 3, 16]
Refer to our extensive collection, titled: Initial Provider/First Contact

What is Usual Care for Low Back Pain? A Systematic Review of Health Care Provided
to Patients with Low Back Pain in Family Practice and Emergency Departments

Pain. 2020 (Apr);   161 (4):   694–702 ~ FULL TEXT

International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis. Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs.
Refer to our extensive collection, titled: Initial Provider/First Contact

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
JAMA Network Open. 2018 (May 18);   1 (1):   e180105 ~ FULL TEXT

Chiropractic care, when added to usual medical care (UMC), resulted in moderate short-term treatment benefits in both LBP intensity and disability, demonstrated a low risk of harms, and led to high patient satisfaction and perceived improvement in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for LBP, as currently recommended in existing guidelines. [21, 22, 37] However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses.
You will also enjoy this Invited Commentary, titled:
Innovating to Improve Care for Low Back Pain in the Military:
Chiropractic Care Passes Muster

You will also enjoy Medscape Medical News' review of this study, titled:
Chiropractic Care Improves Usual Management for Low Back Pain

Comparison of Spinal Manipulation Methods and Usual Medical Care
for Acute and Subacute Low Back Pain: A Randomized Clinical Trial

Spine (Phila Pa 1976). 2015 (Feb 15);   40 (4):   209–217 ~ FULL TEXT

Manual-Thrust Manipulation (MTM) provides greater short-term reductions in self-reported disability and pain scores compared with Usual Medical Care (UMC) or Mechanical-Assisted Manipulation (MAM).

A Comparison of Chiropractic Manipulation Methods and Usual Medical Care for
Low Back Pain: A Randomized Controlled Clinical Trial

J Altern Complement Med. 2014 (May);   20 (5):   A22–23

The primary aim of this study was to compare manual and mechanical methods of spinal manipulation (Activator) for patients with acute and sub-acute low back pain. These are the two most common methods of spinal manipulation used by chiropractors, but there is insufficient evidence regarding their comparative effectiveness against each other. Our secondary aim was to compare both methods with usual medical care.

The Burden of Chronic Low Back Pain: Clinical Comorbidities,
Treatment Patterns, and Health Care Costs in Usual Care Settings

Spine (Phila Pa 1976). 2012 (May 15);   37 (11):   E668–677

Relative to controls, patients with CLBP had a greater comorbidity burden including a significantly higher (P < 0.0001) frequency of musculoskeletal and neuropathic pain conditions and common sequelae of pain such as depression (13.0% vs. 6.1%), anxiety (8.0% vs. 3.4%), and sleep disorders (10.0% vs. 3.4%). Pain-related pharmacotherapy was significantly greater (P < 0.0001) among patients with CLBP including opioids (37.0% vs. 14.8%; P < 0.0001), nonsteroidal anti-inflammatory drugs (26.2% vs. 9.6%; P < 0.0001), and tramadol (8.2% vs. 1.2%; P < 0.0001). Prescribing of "adjunctive" medications for treating conditions associated with pain (i.e., depression, anxiety, and insomnia) was also significantly greater (P < 0.0001) among patients with CLBP; 36.3% of patients received combination therapy. Health care costs were significantly higher in the CLBP cohort (P < 0.0001), reflecting greater resource utilization. Total direct medical costs were estimated at $8386 ± $17,507 in the CLBP group and $3607 ± $10,845 in the control group; P < 0.0001).

A Structured Protocol of Evidence-based Conservative Care Compared with Usual Care
for Acute Nonspecific Low Back Pain: A Randomized Clinical Trial

Arch Phys Med Rehabil. 2012 (Jan);   93 (1):   11–20 ~ FULL TEXT

Overall, the 2 treatment groups were similar based on primary or secondary outcome measure scores for the full treatment period (4 weeks, with up to 7 treatments). However, there were statistically significant and clinically meaningful differences in both disability and pain scores at week 2 (midpoint) with 4 treatments, suggesting that the protocol of care had a more rapid effect than usual care. The results of this study offer guidance to musculoskeletal practitioners, who regularly use manual and manipulative therapy (MMT) for acute LBP, that an evidence-based, structured protocol of care may yield comparable results to usual care in a shorter period with less treatment.

A Systematic Review on the Effectiveness of Physical and Rehabilitation
Interventions for Chronic Non-specific Low Back Pain

European Spine Journal 2011 (Jan);   20 (1):   19–39 ~ FULL TEXT

In total 83 randomized controlled trials met the inclusion criteria: exercise therapy (n = 37), back school (n = 5), TENS (n = 6), low level laser therapy (n = 3), behavioural treatment (n = 21), patient education (n = 1), traction (n = 1), and multidisciplinary treatment (n = 6).   Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function.   Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no treatment/waiting list controls.   Finally, multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls.

Exercise Therapy for Chronic Nonspecific Low-back Pain
Best Pract Res Clin Rheumatol. 2010 (Apr);   24 (2):   193–204 ~ FULL TEXT

In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

Low Back Pain and Best Practice Care: A Survey of General Practice Physicians
Archives of Internal Medicine 2010 (Feb 8);   170 (3):   271–277~ FULL TEXT

It is clear from this study that the usual care provided by GPs does not align with best practice recommendations. The results indicate that in most cases, usual care is not evidence-based care and so is not likely to provide the best outcomes. Given that usual care is the control treatment in many trials38 evaluating new treatments for LBP, these trials may provide overly optimistic estimates of the effects of the new therapy. In our view, it would be more meaningful for future trials to use guideline-based care as the control treatment. This would have the advantage of being replicable and would provide an appropriate benchmark for comparison with new therapies. Moreover, while the focus in this study was the GP, it is unclear if other health care providers (eg, physiotherapists or chiropractors) who see patients with LBP are better in providing evidence-based care.

Cost Effectiveness of Physical Treatments for Back Pain in Primary Care
British Medical Journal 2004 (Dec 11);   329 (7479):   1381 ~ FULL TEXT

We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with "usual care" in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain. [1]
Read both British Medical Journal articles about the UK BEAM Trial now.


Return to Work

Workers' Compensation and Chiropractic
A Chiro.Org article collection

Studies going back to the 1980s reveal that chiropractic care gets workers back to work faster and cheaper than standard medical care. Drop by and enjoy this new topical collection.

Chiropractic Care For Veterans
A Chiro.Org article collection

Review this collection of studies detailing the slowly expanding use of chiropractic care for vererans and active military.

A Prospective Cohort Study of the Impact of Return-to-Work Coordinators
in Getting Injured Workers Back on the Job

J Occup Rehabil. 2018 (Jun);   28 (2):   298–306 ~ FULL TEXT

The findings suggest that workplace-based RTW Coordinators are an effective intervention for improving RTW outcomes among injured workers. Their functional activities appeared beneficial for shorter-duration claims, while interpersonal activities appeared beneficial for longer-duration claims. Therefore different Coordinator activities may be more effective depending on injured worker trajectory. However, a large proportion of participants had not been contacted by a Coordinator nor had RTW plans, despite requirements for both.

Effectiveness of Integration and Re-Integration into Work Strategies for
Persons with Chronic Conditions: A Systematic Review of European Strategies

Int J Environ Res Public Health. 2018 (Mar 19);   15 (3):   E552 ~ FULL TEXT

Due to low employment rates associated to chronic conditions in Europe, it is essential to foster effective integration and re-integration into work strategies. The objective of this systematic review is to summarize the evidence on the effectiveness of strategies for integration and re-integration to work for persons with chronic diseases or with musculoskeletal disorders, implemented in Europe in the past five years. A systematic search was conducted in MedLine, PsycINFO, CDR-HTA, CDR-DARE and Cochrane Systematic Reviews. Overall, 32 relevant publications were identified. Of these, 21 were considered eligible after a methodological assessment and included. Positive changes in employment status, return to work and sick leave outcomes were achieved with graded sickness-absence certificates, part-time sick leave, early ergonomic interventions for back pain, disability evaluation followed by information and advice, and with multidisciplinary, coordinated and tailored return to work interventions. Additionally, a positive association between the co-existence of active labour market policies to promote employment and passive support measures (e.g., pensions or benefits) and the probability of finding a job was observed. Research on the evaluation of the effectiveness of strategies targeting integration and re-integration into work for persons with chronic health conditions needs, however, to be improved and strengthened.

Effects of the New York State Workers Compensation Board Medical
Treatment Guidelines on Return to Work

J Occup Environ Med. 2017 (Dec 26) [Epub]

Guidelines use positively influenced return-to-work after acute occupational low back injuries. Inconsistencies in following Guidelines were observed for diagnostic tests, having a potential paradoxical effect on lost time. Further studies are necessary to test for additional hypotheses.

Who will have Sustainable Employment After a Back Injury?
The Development of a Clinical Prediction Model in a Cohort of Injured Workers

J Occup Rehabil. 2017 (Sep);   27 (3):   445–455

Our analysis suggests that using information gathered during the initial clinical encounter may assist health care practitioners to better predict an injured worker’s post-back injury employment pattern. We created a promising clinical prediction model to predict sustainable employment following a work-related back injury. Our models suggest that clinicians might gain insight about sustainable employment approximately 1 month after claim-initiation by measuring back pain intensity, mental health-related quality of life (SF-12), claim litigation and type of employer. Similarly, examining physical and mental health-related quality of life (SF-12), claim litigation, and type of employer are adequate for predicting those with a sustainable employment pattern approximately 6 months post-injury.

Factors Affecting Return To Work After Injury Or Illness:
Best Evidence Synthesis of Systematic Reviews

Chiropractic & Manual Therapies 2016 (Sep 8);   24 (1):   32 ~ FULL TEXT

Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations.

Workers' Compensation, Return to Work, and Lumbar Fusion for Spondylolisthesis
Orthopedics. 2016 (Jan);   39 (1):   e1–8 ~ FULL TEXT

In this study, researchers reviewed the files of 686 workers who underwent fusion surgery for spondylolisthesis between 1993 and 2013, revealing that only 29.9% of them ever returned to work (for at least 6 months).   The failure rate (meaning return-to-work) was 70.1%.

Association of Worker Characteristics and Early Reimbursement for Physical Therapy, Chiropractic
and Opioid Prescriptions With Workers' Compensation Claim Duration, For Cases of Acute
Low Back Pain: An Observational Cohort Study

BMJ Open. 2015 (Aug 26);   5 (8):   e007836

Our analysis found that early WSIB reimbursement for physiotherapy or chiropractic care, in claimants fully off work for more than 4 weeks, was not associated with claim duration, and that early reimbursement for opioids predicted prolonged claim duration. Well-designed randomised controlled trials are needed to verify our findings and establish causality between these variables and claim duration.

The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO)
Study: A Randomized Controlled Trial on the Effectiveness of Clinical Practice
Guidelines in the Medical and Chiropractic Management of Patients with Acute
Mechanical Low Back Pain

Spine J. 2010 (Dec);   10 (12):   1055–1064

This is the first reported randomized controlled trial comparing evidence-based clinical practice guideline treatment (CPGs) (which includes reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar chiropractic spinal manipulative care, and return to work within 8 weeks), to family physician-directed UC in the treatment of patients with AM–LBP. Compared to family physician-directed UC, full CPG–based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.

Nonspecific Low Back Pain and Return to Work
Am Fam Physician. 2007 (Nov 15);   76 (10):   1497–1502 ~ FULL TEXT

As many as 90 percent of persons with occupational nonspecific low back pain are able to return to work in a relatively short period of time. As long as no "red flags" exist, the patient should be encouraged to remain as active as possible, minimize bed rest, use ice or heat compresses, take anti-inflammatory or analgesic medications if desired, participate in home exercises, and return to work as soon as possible. Medical and surgical intervention should be minimized when abnormalities on physical examination are lacking and the patient is having difficulty returning to work after four to six weeks. Personal and occupational psychosocial factors should be addressed thoroughly, and a multidisciplinary rehabilitation program should be strongly considered to prevent delayed recovery and chronic disability. Patient advocacy should include preventing unnecessary and ineffective medical and surgical interventions, prolonged work loss, joblessness, and chronic disability.


Low Back Pain Resources

Low Back Pain Guidelines from Around the World
A Chiro.Org article collection

A new addition from the American College of Physicians (2017) recommends the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation. This section also includes recommendations from the California Industrial Medical Council, the Royal College of General Practitioners, the 1994 AHCPR guides, the "Mercy Conference Document", and the New Zealand "Psychosocial Yellow Flags" Page

Workers' Compensation and Chiropractic
A Chiro.Org article collection

Studies going back to the 1980s reveal that chiropractic care gets workers back to work faster and cheaper than standard medical care. Drop by and enjoy this new topical collection.

Chiropractic Care For Veterans
A Chiro.Org article collection

Review this collection of studies detailing the slowly expanding use of chiropractic care for vererans and active military.

Chiropractic and Pain Management
A Chiro.Org article collection

Start with conservative chiropractic care. It's cost-effective and yields higher levels of patient satisfaction.

Chiropractic and Scoliosis
A Chiro.Org article collection

Review a collection of articles that focus on the effectiveness of chiropractic for scoliosis

Pregnancy-related Spinal Pain and Chiropractic
A Chiro.Org article collection

Review this growing collection of studies detailing how effective chiropractic management is for pregancy-related low back and pelvic pain.

Chiropractic and Sciatica
A Chiro.Org article collection

Review the collected literature that supports chiropractic for sciatica.

Disc Derangement and Chiropractic
A Chiro.Org article collection

Review the collected literature that supports chiropractic for disc defangement.

The McKenzie Method Page
A Chiro.Org article collection

The McKenzie Method is grounded in finding a cause and effect relationship between the positions the patient usually assumes while sitting, standing, or moving, and the generation of pain as a result of those positions or activities. The therapeutic approach requires a patient to move through a series of activities and test movements to gauge the patient's pain response. The approach then uses that information to develop an exercise protocol designed to centralize or alleviate the pain.

Neck and Back Pain in Children
A Chiro.Org article collection

Review this growing collection of studies detailing the progression of neck and low back pain in children.

The Low Back Pain Bookshelf
A Chiro.Org book collection

Learn about chiropractic management of disc disruption.

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these learned articles about chiropractors as first-contact Spinal Health Care Experts.

Life-Threatening Lower Back Pain - Decoding the Mystery Step-By-Step
By David J Schimp DC, DACNB, DAAPM, FICCN and Stefanie Krupp DC, MS
Intra-abdominal bleed (e.g. aortic aneurysm), infection and tumor are the most dangerous causes of lower back pain and carry the potential for devastating consequences.   Table 1 identifies red flags that should raise suspicion of a serious disorder. [1]

Lower Back Trauma
Chapter 24 from:   The Rehabilitation Monograph Series

By Richard C. Schafer, D.C., FICC and the ACAPress
Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet. Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.

Joint Trauma
Chapter 8 from:   The Rehabilitation Monograph Series

By Richard C. Schafer, D.C., FICC and the ACAPress
The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur. The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.

Chiropractic Cost-Effectiveness Supplement
Provided by a Joint Task Force of the ACA, ICA, CAS and the ACC
The following is a collection of studies relating to the cost effectiveness and efficacy associated with chiropractic care and the procedures that doctors of chiropractic provide. The American Chiropractic Association, The International Chiropractic Association, The Congress of State Associations, and the Association of Chiropractic Colleges appreciate the opportunity to provide these materials for your review. This presentation is divided into several parts:

  • Background studies, detailing that LBP is much more complex than the literature leads us to believe;
  • Cost-Effectiveness Studies;
  • Worker's Compensation Studies (National studies) and
  • Worker's Compensation Studies (State specific studies)
  • Additional Research Studies

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