J Manipulative Physiol Ther 2004 (Oct); 27 (8): 509–514 ~ FULL TEXT
Martin Descarreaux, Jean-Sébastien Blouin, Marc Drolet,
Stanislas Papadimitriou, Normand Teasdale
Martin Descarreaux, DC,
Universite du Quebec a Trois-Rivières,
Department de chiropractique,
Bureau 3613, 3351 Boul.
Des Forges C.P. 500,
Trois-Rivières, Quebec G9A 5H7, Canada
Very persuasive pro-maintenance data comes from this study of 29 patients with chronic low back pain. They were divided into two groups, one receiving 12 treatments within a single month, and the other adding to that regimen one additional treatment every 3 weeks for an extended 9 months (12-14 additional visits). Both groups improved with chiropractic care and maintained that improvement during the tenth month study.
In terms of disability (as indicated by a modified Oswestry questionnaire), the group receiving the supplementary maintenance treatments continued to improve throughout the entire 10 month period, while the cohort lacking the additional visits reverted to baseline levels within that same period. This is clearly depicted in the Oswestry scores over a 10-month period as indicated in Figure 1. The authors of this study speculate that repeated chiropractic visits may have been the direct cause for the improvement of disability scores due to (a) improved trunk mobility, (b) facilitated release of entrapped synovial folds or relaxation of hypertonic muscle by sudden stretching, or (c) the disruption of articular or periarticular lesions.
This study appears to confirm previous reports showing that low back pain and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and a reduction in the amount and intensity of pain episodes after an acute phase of treatment.
OBJECTIVE: To document the potential role of maintenance chiropractic spinal manipulation to reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments.
METHODS: Thirty patients with chronic nonspecific low-back pain were separated into 2 groups. The first group received 12 treatments in an intensive 1-month period but received no treatment in a subsequent 9-month period. For this group, a 4-week period preceding the initial phase of treatment was used as a control period to examine the sole effect of time on pain and disability levels. The second group received 12 treatments in an intensive 1-month period and also received maintenance spinal manipulation every 3 weeks for a 9-month follow-up period. Pain and disability levels were evaluated with a visual analog scale and a modified Oswestry questionnaire, respectively.
RESULTS: The 1-month control period did not modify the pain and disability levels. For both groups, the pain and disability levels decreased after the intensive phase of treatments. Both groups maintained their pain scores at levels similar to the postintensive treatments throughout the follow-up period. For the disability scores, however, only the group that was given spinal manipulations during the follow-up period maintained their postintensive treatment scores. The disability scores of the other group went back to their pretreatment levels.
CONCLUSIONS: Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.
From the Full-Text Article:
Low-back pain (LBP) is one of the most common musculoskeletal injuries in Western societies. Epidemiologic studies have shown that 50% to 80% of the population is affected by LBP at least once in a lifetime. [1, 2] This LBP “epidemic” generates important costs. In the United States only, annual direct and indirect costs for low-back disorders have been estimated to be $100 billion.  One factor explaining these enormous costs is the high rate of recurrence and chronic disability related to low-back disorders. As reported by Croft et al,  the majority of LBP patients are still symptomatic after 1 year, with only 21% of patients being pain free and 25% of patients completely recovering from disabilities associated with their low-back problems. It has been suggested that only 10% of LBP patients generate more than 80% of the total costs related to LBP.  During the past decades, many strategies have been developed to reduce the incidence of LBP. Unfortunately, primary prevention (preventing the first LBP episode) appears to be an unattainable goal, because too many factors are related to the development of LBP. [5, 6] As we learn more about the pathophysiology of LBP, researchers now consider secondary and tertiary prevention to be the most efficient ways to reduce the costs related to low-back conditions. 
Spinal manipulation is the most common treatment used by chiropractors. The exact mechanisms by which spinal manipulation can reduce LBP are still uncertain, but many models have been suggested.  Numerous clinical trials have attempted to evaluate the efficacy of spinal manipulation for acute and chronic LBP patients. In 1997, van Tulder et al  reviewed 25 randomized clinical trials concerning the efficacy of spinal manipulation in the treatment of acute and chronic LBP. For chronic LBP, they concluded that there is “strong evidence that manipulation is more effective than a placebo treatment” and that “there is moderate evidence that manipulation is more effective for chronic LBP than usual care by the general practitioner, bed-rest, analgesics, massages.” With respect to “short-term effects,” controversies and conflicting results about the superiority of spinal manipulation in the treatment of chronic LBP are still present in the scientific community, but there is growing evidence that spinal manipulation is more efficient than a placebo treatment. [9–11]
Tertiary preventive care (maintenance care) is commonly prescribed by chiropractors. A recent survey of American chiropractors showed that 95.4% of chiropractors believe that maintenance chiropractic care is used to minimize recurrence or exacerbation of pain and symptoms.  More than 9 of 10 chiropractors use spinal manipulation therapy (SMT) as a maintenance treatment for musculoskeletal conditions and general symptoms.  The majority of chiropractors agree that adequate research on this topic is lacking. [12, 13] To our knowledge, no one has studied the possible role of SMT as a tertiary prevention procedure in a clinical randomized trial.
The goal of this study was to explore the common assertion that maintenance SMT can help reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments and to determine the efficacy of maintenance chiropractic SMT. We conducted a 10-month study in which 2 groups of chronic LBP patients initially received 12 chiropractic treatments. After the initial phase of treatment, only 1 group received maintenance care during the second phase of the study. We hypothesized that both groups would reduce their pain and disability scores after the initial phase of treatment but that only patients receiving maintenance care would maintain their initial benefits during the next 9 months.
The present results show that no improvement in pain or disability scores was achieved through a 1-month control period where no intervention was provided. Moreover, this study confirms previous reports showing that pain and disability scores related to chronic LBP conditions are reduced after SMTs.  Stig et al  showed that 75% of the chronic LBP patients receiving chiropractic treatments reported improvements (pain and global improvement) after 12 visits. Meade et al  showed significant decrease of Oswestry scores after 10 chiropractic treatments (mainly manipulative treatment) in patients with chronic and severe LBP.
The main objective of this study was to evaluate the effects of preventive chiropractic treatments in maintaining functional capacities and levels of pain after an acute phase of treatment. Although the VAS pain scores remained at posttreatment levels for both groups, disability scores returned to their pretreatment levels for the LBP-1 group (no maintenance treatment), whereas they stayed at their posttreatment levels for the LBP-2 group (maintenance treatment group). The disability score difference (more than 15 points) observed between the 2 groups is not only statistically significant but also clinically important. Fritz and Irrgang  showed that a 6-point difference in the Modified Oswerstry Questionnaire was the minimal clinically important difference. This difference is defined as the amount of change that best distinguishes between patients who have improved and those who remained stable. Even if disabilities can be a consequence of chronic LBP, the relationship between pain and disability levels is not straightforward. [20, 21] There are at least 2 possible explanations for the discrepancies observed between pain and disability scores in the LBP-1 group. Patients from this group did use the ice significantly more often than the LBP-2 group. Even if the average pain scores were similar in both groups, it seems that patients from the LBP-1 group experienced a greater number of acute pain episodes. In a study aimed at defining the relation between pain intensity, disability, and episodic nature of chronic LBP, McGorry et al  showed that disability and medication use were strongly correlated to acute pain episodes. They concluded that “whereas pain intensity can have a profound effect on disability, the episodic nature of LBP also affects the patient's ability to function in both work and personal life.” It is possible that the patients from this group (LBP-1 patients who presumably had more acute pain episodes) suffered from higher levels of disabilities, even if their average pain scores were still at a low level. On the other hand, the LBP-2 group could have experienced fewer acute pain episodes because of the maintenance SMT. Other factors like psychologic and social status could influence the evolution of pain and disability and should be included in further investigations.
Because of different factors, it is possible that the patients in the LBP-1 group overestimated their level of disabilities. In 2000, Al-Obaidi et al  proposed the hypothesis that spinal physical capacity in chronic LBP patients is not explained solely by the sensory perception of pain. They found that cognitive perception of pain, anticipation of pain, and fear-avoidance belief about physical activities were the strongest predictors of the isometric strength deficit in chronic LBP patients. In their experiment, the intensity of true pain experienced during the isometric strength test and the self-reported disability belief were not related to the spinal strength deficit. Because the LBP-1 group had more acute pain episodes during the 9 months after the first phase of treatment, it is a possibility that they perceived themselves more disabled than they really were. Future study will be needed to include a “fear avoidance belief questionnaire” to clarify this question.
Alternatively, it is plausible that, as frequently encountered in practice, the patients from the LBP-2 group did benefit from the maintenance treatments. Many chiropractors believe that periodic patient visits permit the detection and early treatment of joint dysfunction, thus preventing future episodes of LBP. Physical improvements such as improved trunk mobility  or prevention through the proposed mechanisms of SMT-like release of entrapped synovial folds or plica, relaxation of hypertonic muscle by sudden stretching, or disruption of articular or periarticular adhesions may explain the observed differences between the 2 groups. 
This study appears to confirm previous reports showing that LBP and disability scores are reduced after spinal manipulation.  It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment. Maintenance chiropractic care involving spinal manipulation combined with other treatment modalities (exercises, pain management program) should be investigated. Such combined interventions may have a critical influence on pain, disability, and return to work.
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
FrymoyerJW, Ducker TB.
The adult spine: principles and practice. 2nd ed.
Philadelphia: Lippincott-Raven; 1997. p. xxviii, 2443, 42.
Occupational low back disorder causation and control.
Ergonomics. 2000; 43: 880–902
Croft, PR, Macfarlane, GJ, Papageorgiou, AC, Thomas, E, and Silman, AJ.
Outcome of low back pain in general practice: a prospective study.
BMJ. 1998; 316: 1356–1359
Fransen, M, Woodward, M, Norton, R, Coggan, C, Dawe, M, and Sheridan, N.
Risk factors associated with the transition from acute to chronic occupational back pain.
Spine. 2002; 27: 92–98
Burton, AK and Erg, E.
Back injury and work loss. Biomechanical and psychosocial influences.
Spine. 1997; 22: 2575–2580
Haldeman, SHP and Phillips, RB.
Spinal manipulative therapy.
in: JW Frymoyer (Ed.) The adult spine. 2nd ed.
Lippincott-Raven, Philadelphia; 1997: 1837–1861
van Tulder, MW, Koes, BW, and Bouter, LM.
Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions.
Spine. 1997; 22: 2128–2156
Triano JJ, McGregor M, Hondras MA, Brennan PC.
Manipulative Therapy Versus Education Programs in Chronic Low Back Pain
Spine (Phila Pa 1976). 1995 (Apr 15); 20 (8): 948–955
Shekelle, PG, Adams, AH, Chassin, MR, Hurwitz, EL, and Brook, RH.
Spinal manipulation for low-back pain.
Ann Intern Med. 1992; 117: 590–598
Skargren, EI, Oberg, BE, Carlsson, PG, and Gade, M.
Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain Six-month follow-up.
Spine. 1997; 22: 2167–2177
A Survey of Practice Patterns and the Health Promotion
and Prevention Attitudes
of US Chiropractors Maintenance Care: Part I
J Manipulative Physiol Ther 2000 (Jan); 23 (1): 1–9
Holistic health care in primary practice: chiropractic contributing to a sustainable health care system.
J Manipulative Physiol Ther. 1992; 15: 604–608
Fairbank, JC and Pynsent, PB.
The Oswestry Disability Index
Spine (Phila Pa 1976) 2000 (Nov 15); 25 (22): 2940–2952
Hestbaek L, Leboeuf-Yde C, Manniche C.
Low Back Pain: What Is The Long-term Course?
A Review of Studies of General Patient Populations
European Spine Journal 2003 (Apr); 12 (2): 149–165
Deyo, RA, Battie, M, Beurskens, AJ, Bombardier, C, Croft, P, Koes, B et al.
Outcome measures for low back pain research. A proposal for standardized use.
Spine. 1998; 23: 2003–2013
Stig, LC, Nilsson, O, and Leboeuf-Yde, C.
Recovery pattern of patients treated with chiropractic spinal manipulative therapy for long-lasting or recurrent low back pain.
J Manipulative Physiol Ther. 2001; 24: 288–291
Meade TW, Dyer S, Browne W, et al.
Low Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment
British Medical Journal 1990 (Jun 2); 300 (6737): 1431–1437
Fritz, JM and Irrgang, JJ.
A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale.
Phys Ther. 2001; 81: 776–788
Perception of disability in chronic back pain patients: a long-term follow-up.
Pain. 1989; 37: 67–75
Cooper, JE, Tate, RB, Yassi, A, and Khokhar, J.
Effect of an early intervention program on the relationship between subjective pain and disability measures in nurses with low back injury.
Spine. 1996; 21: 2329–2336
McGorry, RW, Webster, BS, Snook, SH, and Hsiang, SM.
The relation between pain intensity, disability, and the episodic nature of chronic and recurrent low back pain.
Spine. 2000; 25: 834–841
Al-Obaidi, SM, Nelson, RM, Al-Awadhi, S, and Al-Shuwaie, N.
The role of anticipation and fear of pain in the persistence of avoidance behavior in patients with chronic low back pain.
Spine. 2000; 25: 1126–1131
Aure, OF, Nilsen, JH, and Vasseljen, O.
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
Mechanisms and Effects of Spinal High-velocity,
Low-amplitude Thrust Manipulation:
J Manipulative Physiol Ther 2002 (May); 25 (4): 251–262
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