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What Does Best Practice Care for Musculoskeletal Pain
Adverse Impacts of Chronic Pain on Health-related
Quality of Life, Work Productivity, Depression
and Anxiety in a Community-based Study
Family Practice 2017 (Nov 16); 34 (6): 656–661 ~ FULL TEXT
We assessed the burden of chronic pain from patients’ perspective in multiple domains of physical, psychological, and social functioning and well-being. Chronic pain, particularly multisite pain and neuropathic pain, significantly affected physical and psychological health. In addition to the negative impacts on the psychological and physical of the individual, chronic pain places a significant burden on society through lost work productivity and reduced performance at work. Our study emphasizes the importance of understanding chronic pain as a multifaceted health condition that requires a multidisciplinary treatment approach.
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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.
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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.
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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
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Looking Ahead: Chronic Spinal Pain Management
J 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]
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Posterior, Lateral, and Anterior Hip Pain Due to
Musculoskeletal Origin: A Narrative Literature
Review of History, Physical Examination, and
Diagnostic Imaging
J 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.
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What Do Patients Value About Spinal Manipulation
and 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.
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A Narrative Review of Lumbar Fusion Surgery
with Relevance to Chiropractic Practice
J 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.
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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.
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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.
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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.
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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).
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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.
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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.
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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," and
"low back pain."
Significant change in certainty ceased after six questions at 80% (P < .05).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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%.
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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]
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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.
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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.
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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)
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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.
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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.
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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.
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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.
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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.”
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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.
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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.
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Regional Supply of Chiropractic Care and Visits
to Primary Care Physicians for Back and Neck Pain
J American Board of Family Medicine 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).
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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.
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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.
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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]
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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.]
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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.
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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.
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Cut-off Points for Mild, Moderate, and Severe Pain
on the Visual Analogue Scale for Pain in Patients
with Chronic Musculoskeletal Pain
Pain 2014 (Dec); 155 (12): 2545–2550 ~ FULL TEXT
The aim of this study was to find the cut-off points on the visual analogue scale (VAS) to distinguish among mild, moderate, and severe pain, in relation to the following: pain-related interference with functioning; verbal description of the VAS scores; and latent class analysis for patients with chronic musculoskeletal pain. A total of 456 patients were included. Pain was assessed using the VAS and verbal rating scale; functioning was assessed using the domains of the Short Form (36) Health Survey (SF-36). Eight cut-off point schemes were tested using multivariate analysis of variance (MANOVA), ordinal logistic regression, and latent class analysis. The study results showed that VAS scores ≤ 3.4 corresponded to mild interference with functioning, whereas 3.5 to 6.4 implied moderate interference, and ≥ 6.5 implied severe interference.
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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]
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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.
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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.
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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.
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Spinal Manipulation and Home Exercise with
Advice for Subacute and Chronic Back-related
Leg Pain: A Trial With Adaptive Allocation NCT00494065
Annals of Internal Medicine 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.
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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).
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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.
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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.
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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
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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.
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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
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.
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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.
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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.
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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.
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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.
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Outcomes of Acute and Chronic Patients wth
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.
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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.
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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.
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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
NCT00376350
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.
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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].
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Low Back Pain Across the Life Course
Best Pract Res Clin Rheumatol 2013 (Oct); 27 (5): 591-600 ~ FULL TEXT
Back pain episodes are traditionally regarded as individual events, but this model is currently being challenged in favour of treating back pain as a long-term or lifelong condition. Back pain can be present throughout life, from childhood to older age, and evidence is mounting that pain experience is maintained over long periods: for example, people with pain continue to have it on and off for years, and people without pain do not suddenly develop long-term pain. A number of factors predict back pain presence in epidemiological studies, and these are often present, and predictive, at different life stages. There are also factors present at particular life stages, such as childhood or adolescence, which predict back pain in adulthood. However, there are little published data on long-term pain patterns or predictors over the life course. Such studies could improve our understanding of the development and fluctuations in back pain, and therefore influence treatment approaches.
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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.
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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]
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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.
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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.
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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.
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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.
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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.
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Adding Chiropractic Manipulative Therapy to
Standard Medical Care for Patients with
Acute Back Pain: Results of a Pragmatic
Randomized Comparative
Effectiveness Study
NCT00632060
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.
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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.
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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.
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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]
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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
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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.
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The Treatment Experience of Patients With Low
Back Pain During Pregnancy and Their Chiropractors:
A Qualitative Study
Chiropractic & Manual Therapies 2012 (Oct 9); 20 (1): 32 ~ FULL TEXT
Chiropractors approach pregnant patients with low back pain from a patient-centered standpoint, and the pregnant patients interviewed in this study who sought chiropractic care appeared to find this approach helpful for managing their back pain symptoms.
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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.
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New Oregon LBP Guidelines:
Try Chiropractic First
Dynamic Chiropractic (January 1, 2013( ~ FULL TEXT
The 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.
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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.
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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.
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Clinical Presentation of a Patient with Thoracic
Myelopathy at a Chiropractic Clinic
J 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.
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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.
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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.
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Pulmonary Embolism in a Female Collegiate
Cross-country Runner Presenting
as Nonspecific Back Pain
J 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.
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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.
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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.
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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.
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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.
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Will Shared Decision Making Between Patients with
Chronic Musculoskeletal Pain and Physiotherapists,
Osteopaths and Chiropractors Improve Patient Care?
Family Practice 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.
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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.
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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.
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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.
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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.
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The McKenzie Method Compared with Manipulation
When Used Adjunctive to Information and Advice
in Low Back Pain Patients Presenting with
Centralization or Peripheralization: A
Randomized Controlled Trial
Spine (Phila Pa 1976) 2011 (Nov 15); 36 (24): 1999-2010 ~ FULL TEXT
Given the promising preliminary results in the literature
and the improvement rate achieved in both our treatment
groups, a future research area would be to explore clinical
findings that identify which patients respond better to the
McKenzie method or manipulation in patients with acute,
subacute, or chronic LBP. Furthermore it seems worthwhile
to test the effects of a combination of the two treatments as
suggested by the results of a series of case reports. [44]
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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].
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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).
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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.
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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]).
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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].
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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.
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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.
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Supervised Exercise, Spinal Manipulation, and
Home Exercise for Chronic Low Back Pain:
A Randomized Clinical Trial NCT00269347
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.
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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.
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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
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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.
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Chiropractic and Self-care for Back-related Leg Pain:
Design of a Randomized Clinical Trial
NCT00494065
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.
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Psychosocial Risk Factors For Chronic Low Back
Pain in Primary Care — A Systematic Review
Family Practice 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.
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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.
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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.
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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.
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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.
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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.
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The Chiropractic Hospital-Based Interventions
Research Outcomes Study: Consistency of
Outcomes Between Doctors of Chiropractic
Treating Patients With Acute
Lower 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.
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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.
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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.
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Integrative Care for the Management of Low Back
Pain: Use of a Clinical Care Pathway
NCT00567333
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.
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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.
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Synthesis of Recommendations for the Assessmen
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.
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Editorial:
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.
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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.
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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.
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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.
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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?
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Musculoskeletal Knowledge:
How Do You Stack Up?
Physician and Sportsmedicine 2002 (Aug); 30 (8)
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.
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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.
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Adequacy of Education in
Musculoskeletal Medicine
Journal of Bone and Joint Surgery 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.
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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.
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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.
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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".
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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.
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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.
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REFERENCES:
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 (Nov 14); 81: 646–656
3.
Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov); 32 (11)
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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?
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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.
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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.
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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.
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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.
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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.
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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
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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%.
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Locating and Treating Low Back Pain of
Myofascial Origin by Ischemic Compression
J 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.
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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
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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.
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Locating and Treating Low Back Pain of Myofascial
Origin by Ischemic Compression
J Can Chiropr Assoc 2002; 46 (4): 257–264 ~ FULL TEXT
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.
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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.
You may also enjoy this
32-page 1997 PDF version of this same guideline.
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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.
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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.
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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.
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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.
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Patient Characteristics and Physicians' Practice
Activities for Patients with Chronic Low Back Pain:
A Practice-based Study of Primary Care
and Chiropractic Physicians
J Manipulative Physiol Ther 2001 (Feb); 24 (2): 92–100
Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.
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A Case Study of Misrepresentation of the
Scientific Literature: Recent Reviews
of Chiropractic
J Altern Complement Med 2001 (Feb); 7 (1): 65-78 ~ FULL TEXT
Accurate use of published data and references is a cornerstone of the peer-review process. Statements, inferences, and conclusions based upon these references should logically ensue from the data they contain. When journal articles and textbook chapters summarizing the safety and efficacy of particular therapies or interventions use references inaccurately or with apparent intent to mislead, the integrity of scientific reporting is fundamentally compromised. Ernst et al.'s publication on chiropractic include repeated misuse of references, misleading statements, highly selective use of certain published papers, failure to refer to relevant literature, inaccurate reporting of the contents of published work, and errors in citation. Meticulous analysis of some influential negative reviews has been carried out to determine the objectivity of the data reported. The misrepresentation that became evident deserves full debate and raises serious questions about the integrity of the peer-review process and the nature of academic misconduct.
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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.
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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.
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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.
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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!
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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 [Meade et. al BMJ 1990 (Jun 2)] 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.
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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.
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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”.
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Chiropractic Care for Common
Industrial Low Back Conditions
Chiropractic Technique 1993 (Aug); 5 (3): 119–125 ~ FULL TEXT
This is the first guideline I discovered that actually states the number of visits which may be appropriate for a variety of common low back conditions. I have used these "care plans" since the mid-1990s, 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. Our thanks to Dana and Bob!
You will find more information like this in our:
Guidelines Section.
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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.
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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.
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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.
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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.
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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).
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Vladimir Janda Citation Collection
Shortcuts are provided to the PubMed abstracts of all the articles which are available online.
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What is the Natural History for Lower Back Pain?
Am original article, donated by Dr. Craig Liebenson, D.C.
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.
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