Low Back Pain and Chiropractic

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

Key findings from the 4 papers published in The Lancet:

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

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

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

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

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

Evidence-Based Nonpharmacologic Strategies for
Comprehensive Pain Care: The Consortium Pain
Task Force White Paper
Explore (NY). 2018 (May); 14 (3) 177–211 ~ FULL TEXT
Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain.

Spinal Manipulative Therapy and Other
Conservative Treatments for Low
Back Pain: A Guideline From the
Canadian Chiropractic
Guideline Initiative
J Manipulative Physiol Ther. 2018 (May); 41 (4): 265–293 FONT COLOR="#8B0000">~ FULL TEXT
For patients with acute (0–3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).   A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Manipulation and Mobilization for Treating
Chronic Low Back Pain: A Systematic
Review and Meta-analysis
Spine J 2018 (May); 18 (5): 866–879 ~ FULL TEXT
There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.

Manipulation and Mobilization for Treating
Chronic Low Back Pain: A Systematic
Review and Meta-analysis
Spine J 2018 (May); 18 (5): 866–879 ~ FULL TEXT
There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.

Primary Care Management of Non-specific Low
Back Pain: Key Messages from
Recent Clinical Guidelines
Medical J Australia 2018 (Apr 2); 208 (6): 272–275 ~ FULL TEXT
Changes in management as a result of the guidelines:

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

• encouraging non-pharmacological treatments over pharmacological treatments; and

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

Preferences for Web-Based Information Material
for Low Back Pain: Qualitative Interview Study
on People Consulting a General Practitioner
JMIR Rehabil Assist Technol. 2018 (Apr 2); 5 (1): e7 ~ FULL TEXT
Fifteen 45–min interviews were conducted. Participants had a median age of 40 years (range 22–68 years) and reported a median disability of 7 points (range 0–18) using the 23–item Roland Morris Disability Questionnaire. Participants reported that Web-based information should be easy to find and read, easily overviewed, and not be overloaded with information. Subjects found existing Web-based information confusing, often difficult to comprehend, and not relevant for them, and they questioned the motives driving most hosting companies or organizations. The Patient Handbook, a Danish government-funded website that provides information to Danes about health, was mentioned as a trustworthy and preferred site when searching for information and advice regarding LBP.

Patients' Perceived Needs of Health Care Providers for
Low Back Pain Management: A Systematic Scoping Review
Spine J 2018 (Apr); 18 (4): 691–711 ~ FULL TEXT
Patients with LBP want patient-centered care, to be actively involved, and they have identified characteristics of HCP that foster a good provider-patient relationship. They noted areas of dissatisfaction with HCP and perceived obstacles to care. Given limited health care resources, HCP and policy makers need to implement novel methods of health care delivery that address these issues to facilitate improved patient satisfaction and achieve better patient and health system outcomes.

Chiropractic Integrated Care Pathway for
Low Back Pain in Veterans: Results of
a Delphi Consensus Process
J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 137–148 ~ FULL TEXT
The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers.
There are more articles like this at our
Chiropractic Care For Veterans Page

Failure to Define Low Back Pain as a Disease
or an Episode Renders Research on Causality
Unsuitable: Results of a Systematic Review
Chiropractic & Manual Therapies 2018 (Jan 9); 21: 6~ FULL TEXT
Recent literature concerning the causality of LBP does not differentiate between the ‘disease’ of LBP and its recurring episodes mainly due to a lack of a clear definition of absence of LBP at baseline. Therefore, current research is not capable of providing a valid answer on this topic.

Uneven Intervertebral Motion Sharing is Related to
Disc Degeneration and is Greater in Patients with
Chronic, Non-Specific Low Back Pain: An in Vivo,
Cross-Sectional Cohort Comparison of Intervertebral
Dynamics Using Quantitative Fluoroscopy
European Spine Journal 2018 (Jan); 27 (1): 145–153 ~ FULL TEXT
Greater inequality and variability of motion sharing was found in patients with CNSLBP than in controls, confirming previous studies and suggesting a biomechanical marker for the disorder at intervertebral level. The relationship between disc degeneration and MSI was augmented in patients, but not in controls during passive motion and similarly for MSV during active motion, suggesting links between in vivo disc mechanics and pain generation.

Elevated Production of Nociceptive CC-chemokines
and sE-selectin in Patients with Low Back Pain
and the Effects of Spinal Manipulation:
A Non-randomized Clinical Trial
Clin J Pain. 2018 (Jan); 34 (1): 68–75 ~ FULL TEXT
The production of chemotactic cytokines is significantly and protractedly elevated in LBP patients. Changes in chemokine production levels, which might be related to SMT, differ in the acute and chronic LBP patient cohorts.

The Association Between a Lifetime History of Low
Back Injury in a Motor Vehicle Collision and
Future Low Back Pain: A Population-based Cohort Study
European Spine Journal 2018 (Jan); 27 (1): 136–144 ~ FULL TEXT
Our analysis suggests that a history of low back injury in a MVC is a risk factor for developing future troublesome LBP. The consequences of a low back injury in a MVC can predispose individuals to experience recurrent episodes of low back pain.

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

National Clinical Guidelines for Non-surgical
Treatment of Patients with Recent Onset Low Back
Pain or Lumbar Radiculopathy
European Spine Journal 2018 (Jan); 27 (1): 60–75 ~ ~ FULL TEXT
In 2012, the Danish Finance Act appropriated a total of €10.8 mio for the preparation of clinical guidelines. The Danish Health Authority (DHA) was subsequently commissioned to formulate 47 national clinical guidelines to support evidence-based decision making within health areas with a high burden of disease, a perceived large variation in practice, or uncertainty about which care was appropriate. [1] Two of these areas were low back pain (LBP) and lumbar radiculopathy (LR). Consequently in 2014, two working groups were formed with the aim of developing national clinical guidelines for non-surgical interventions for recent onset (<12 weeks) LBP and for recent onset (<12 weeks) LR. The primary target groups for these guidelines were primary sector healthcare providers, i.e., general practitioners, chiropractors, and physiotherapists, but also medical specialists or others in the primary or secondary healthcare sector handling patients with LBP or LR.

Guideline for Opioid Therapy
and Chronic Noncancer Pain
CMAJ. 2017 (May 8); 189 (18): E659–E666 ~ FULL TEXT
This new Canadian guideline published today (May 8, 2017) in the Canadian Medical Association Journal (CMAJ) strongly recommends doctors to consider non-pharmacologic therapy, including chiropractic, in preference to opioid therapy for chronic non-cancer pain. The guideline is the product of an extensive review of evidence involving input from medical, non-medical, regulatory, and patient stakeholders.

Association of Spinal Manipulative Therapy
with Clinical Benefit and Harm for Acute
Low Back Pain: Systematic Review
and Meta-analysis
JAMA. 2017 (Apr 11); 317 (14): 1451–1460 ~ FULL TEXT
For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1] On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain. The authors concluded: “Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

Systemic Pharmacologic Therapies for Low
Back Pain: A Systematic Review for an
American College of Physicians
Clinical Practice Guideline
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 480–492
The American College of Physicians (ACP) released updated guidelines this week that recommend the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation.

Nonpharmacologic Therapies for Low Back Pain:
A Systematic Review for an American College
of Physicians Clinical Practice Guideline
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 493–505 ~ FULL TEXT
This report updates and expands on the earlier ACP/APS review [105] with additional interventions and newer evidence. We found evidence that mind–body interventions not previously addressed — tai chi (SOE, low) and mindfulness-based stress reduction (SOE, moderate) [45–47] — are effective for chronic low back pain; the new evidence also strengthens previous conclusions regarding yoga effectiveness (SOE, moderate). For interventions recommended as treatment options in the 2007 ACP/APS guideline [2], our findings were generally consistent with the prior review. Specifically, exercise therapy, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture are supported with some evidence of effectiveness for chronic low back pain (SOE, low to moderate). Unlike our previous report, which stated that higher-intensity multidisciplinary rehabilitation seemed to be more effective than lower-intensity programs, a stratified analysis based on currently available evidence [54] did not find a clear intensity effect. Our findings generally are consistent with recent systematic reviews not included in our evidence synthesis [106–117]. Although harms were not well-reported, serious adverse events were not described.
You will also enjoy the introductory Editorial, titled:
Management of Low Back Pain: Getting From
Evidence-Based Recommendations to High-Value Care
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 533-534

Noninvasive Treatments for Acute, Subacute,
and Chronic Low Back Pain: A Clinical Practice
Guideline From the American
College of Physicians
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530 ~ FULL TEXT
Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).

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.

Management of Back Pain-related Disorders in a
Community with Limited Access to Health Care
Services: A Description of Integration of
Chiropractors as Service Providers
J Manipulative Physiol Ther 2017 (Nov); 40 (9): 635–642 ~ FULL TEXT
Questionnaire data were obtained from 93 patients. The mean age of the sample was 49.0 ± 16.27 years, and 66% were unemployed. More than three-quarters (77%) had had their back pain for more than a month, and 68% described it as constant. According to the Bournemouth Questionnaire, Bothersomeness, and global improvement scales, a majority (63%, 74%, and 93%, respectively) reported improvement at discharge, and most (82%) reported a significant reduction in pain medication. More than three-quarters (77%) did not visit their primary care provider while under chiropractic care, and almost all (93%) were satisfied with the service. According to the EuroQol 5 Domain questionnaire, more than one-third of patients (39%) also reported improvement in their general health state at discharge. Implementation of an integrated chiropractic service was associated with high levels of improvement and patient satisfaction in a sample of patients of low socioeconomic status with subacute and chronic back pain.

Patient-centered Professional Practice Models for
Managing Low Back Pain in Older Adults:
A Pilot Randomized Controlled Trial
BMC Geriatr. 2017 (Oct 13); 17 (1): 235 ~ FULL TEXT
Professional practice models that included primary care and chiropractic care led to modest improvements in low back pain intensity and disability for older adults, with chiropractic-inclusive models resulting in better perceived improvement and patient satisfaction over the primary care model alone.

Association Between the Type of First Healthcare
Provider and the Duration of Financial Compensation
for Occupational Back Pain
Journal of Occupational Rehabilitation 2017 (Sep); 27 (3): 382-392 ~ FULL TEXT
The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.
Refer to our extensive collection on: Workers' Compensation

Looking Ahead: Chronic Spinal Pain Management
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]

Feeling Stiffness in the Back: A Protective
Perceptual Inference in Chronic Back Pain
Sci Rep. 2017 (Aug 29); 7 (1): 9681 ~ FULL TEXT
Does feeling back stiffness actually reflect having a stiff back? This research interrogates the long-held question of what informs our subjective experiences of bodily state. We propose a new hypothesis: feelings of back stiffness are a protective perceptual construct, rather than reflecting biomechanical properties of the back. This has far-reaching implications for treatment of pain/stiffness but also for our understanding of bodily feelings. Over three experiments, we challenge the prevailing view by showing that feeling stiff does not relate to objective spinal measures of stiffness and objective back stiffness does not differ between those who report feeling stiff and those who do not. Rather, those who report feeling stiff exhibit self-protective responses: they significantly overestimate force applied to their spine, yet are better at detecting changes in this force than those who do not report feeling stiff. This perceptual error can be manipulated: providing auditory input in synchrony to forces applied to the spine modulates prediction accuracy in both groups, without altering actual stiffness, demonstrating that feeling stiff is a multisensory perceptual inference consistent with protection. Together, this presents a compelling argument against the prevailing view that feeling stiff is an isomorphic marker of the biomechanical characteristics of the back.

Effect of Radiofrequency Denervation on Pain
Intensity Among Patients With Chronic Low
Back Pain: The Mint Randomized Clinical Trials
JAMA. 2017 (Jul 4); 318 (1): 68–81 ~ FULL TEXT
In 3 randomized clinical trials of participants with chronic low back pain originating in the facet joints, sacroiliac joints, or a combination of facet joints, sacroiliac joints, or intervertebral disks, radiofrequency denervation combined with a standardized exercise program resulted in either no improvement or no clinically important improvement in chronic low back pain compared with a standardized exercise program alone. The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources.

An Observational Study on Recurrences of Low
Back Pain During the First 12 Months After
Chiropractic Treatment
J Manipulative Physiol Ther. 2017 (Jul); 40 (6): 427–433 ~ FULL TEXT
The recurrence rate of LBP using a stringent definition of recurrence was found to be low in this chiropractic LBP patient population. Nevertheless, the vast majority of patients were not pain free after 1 year. The recurrent course could be distinguished from the fast recovering and chronic patterns, but the differences with respect to the others subgroups were minor. The duration of complaint before treatment was the main predictor for recurrence. Of importance, a subacute duration, defined in the present study as longer than 14 days, significantly increased the odds for an unfavorable course of LBP, which is of clinical relevance.

Advice for Acute Low Back Pain: A Comparison
of What Research Supports and
What Guidelines Recommend
Spine J 2017 (Jul 13) [Epub ahead of print] ~ FULL TEXT
Completeness of reporting was less than ideal for RCTs and extremely poor for guidelines. As such both RCTs and guidelines need to ensure they report on all aspects of advice interventions for acute LBP in future publications. The recommendations made in guidelines of advice for acute LBP were often not concordant with the results of the research literature. Taken together these two findings mean that the potential clinical value of advice interventions for patients with acute LBP are probably not being realised.

Influences of Lumbar Disc Herniation on the
Kinematics in Multi-segmental Spine, Pelvis,
and Lower Extremities During Five
Activities of Daily Living
BMC Musculoskelet Disord. 2017 (May 25); 18 (1): 216 ~ FULL TEXT
Lumbar disc herniation (LDH) patients mainly restrict the motion of lower lumbar (LLx) and upper lumbar (ULx) in the spinal region during the five ADLs. Pelvic rotation is an important method to compensate for the limited lumbar motion. Furthermore, pelvic tilt and lower extremities' flexion increased when ADLs were quite difficult for LDH patients.

Do Older Adults with Chronic Low Back Pain Differ
from Younger Adults in Regards to Baseline
Characteristics and Prognosis?
European Journal of Pain 2017 (May); 21 (5): 866–873
A total of 14,479 participants were included in the study. Of these 3,087 (21%) patients were older adults, 6,071 (42%) were middle aged and 5,321 (37%) were young adults. At presentation older adults were statistically different to the middle aged and younger adults for most characteristics measured (e.g. less intense back pain, more leg pain and more depression); however, the differences were small. The change in pain and disability over 12 months did not differ between age groups.

Take the Clinical Compass Chiropractic
Guideline for Low Back Pain Challenge
ACA News ~ May 15, 2017 ~ FULL TEXT
In my last blog post, I talked about the unprecedented opportunity the chiropractic profession has to make a critical difference in areas of great public health impact, such as low back pain. I strongly believe that if we do the right thing right now, the chiropractic profession is uniquely positioned to significantly impact the quality of spine care delivery, increasing access to chiropractic care for millions of patients who desperately need conservative treatment for spine-related conditions. The flipside is that if we don't take right action now, chiropractic risks becoming a marginalized profession that's on the outside looking in as other health care providers take ownership of musculoskeletal conditions and spinal manipulation.

Clinical Classification in Low Back Pain:
Best-evidence Diagnostic Rules Based on
Systematic Reviews
BMC Musculoskelet Disord. 2017 (May 12); 18 (1): 188 ~ FULL TEXT
This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

The Impact of Pain-related Fear on Neural
Pathways of Pain Modulation in Chronic
Low Back Pain
Pain Rep. 2017 (Apr 11); 2 (3): e601 ~ FULL TEXT
Our results might indicate a maladaptive psychobiological interaction in chronic LBP characterized by an attenuation of amygdala-PAG-FC that is modulated by the degree of pain-related fear. Besides the established role of the PAG in the modulation of nociceptive inputs, our results add further evidence to the involvement of the PAG in negative emotional processing not directly related to nociception. [9, 28] Furthermore, while we have previously shown that pain-related fear is positively correlated with amygdala activity in chronic LBP, [16] enhanced pain-related fear seems to simultaneously dampen the neural cross-talk between the amygdala and the PAG. This decreased informaion exchange between 2 key pain modulatory structures might ultimately tip the balance of PAG function to facilitation, ie, increased pronociception. [11] Thus, the decreased cross-talk between the amygdala and the PAG, in conjunction with increased amygdala activity, might be the neurobiological basis of how pain-related fear contributes to pain and its chronification.

Cost-Effectiveness of Non-Invasive and Non-
Pharmacological Interventions for Low Back
Pain: A Systematic Literature Review
Applied Health Economics and Health Policy 2017 (Apr); 15 (2): 173–201 ~ FULL TEXT
Thirty-three studies were identified. Study interventions were categorised as: (1) combined physical exercise and psychological therapy, (2) physical exercise therapy only, (3) information and education, and (4) manual therapy. Interventions assessed within each category varied in terms of their components and delivery. In general, combined physical and psychological treatments, information and education interventions, and manual therapies appeared to be cost effective when compared with the study-specific comparators. There is inconsistent evidence around the cost effectiveness of physical exercise programmes as a whole, with yoga, but not group exercise, being cost effective.

Contemporary Biopsychosocial Exercise Prescription
for Chronic Low Back Pain: Questioning Core
Stability Programs and Considering Context
J Can Chiropr Assoc. 2017 (Mar); 61 (1): 6–17 ~ FULL TEXT
Evidence keeps building about the multi-system benefits of exercise [109]; this includes therapeutic exercise for chronic low back pain (CLBP). As suggested throughout this commentary, a focus on gross biological changes alone (muscle strength, endurance etc.) has limited value. Instead, more research is needed to examine the interplay between biological, psychological, and social factors - as this may have novel exercise prescription implications for patients with CLBP. This commentary provided an overview of some of the contextual factors that have biopsychosocial implications. It was described how these contextual factors can facilitate placebo or nocebo effects, impacting patients’ behaviors and outcomes.

Individual Courses of Low Back Pain in Adult
Danes: A Cohort Study with 4-Year and
8-Year Follow-up
BMC Musculoskelet Disord. 2017 (Jan 21); 18 (1): 28 ~ FULL TEXT
In this study, it was evident that when applying the more ‘severe’ definitions of LBP (‘>30 days’, ‘seeking care’, and ‘non-trivial’) as risk factors for future LBP of the same definitions, the associations were stronger than for ‘year’ and ‘month’. We therefore suggest that composite measures of LBP outcomes should be further explored in future epidemiologic studies of risk factors and less attention should be paid to the LBP definitions ‘year’ and ‘month’, which may include both slight LBP with low clinical impact and severe disabling LBP.

Tissue Loading Created During Spinal
Manipulation in Comparison to Loading
Created by Passive Spinal Movements
Sci Rep. 2016 (Dec 1); 6: 38107 ~ FULL TEXT
Spinal manipulative therapy (SMT) creates health benefits for some while for others, no benefit or even adverse events. Understanding these differential responses is important to optimize patient care and safety. Toward this, characterizing how loads created by SMT relate to those created by typical motions is fundamental. Overall, SMT created both significantly greater and smaller loads compared to passive motions, with SMT generating greater anterioposterior peak force (the direction of force application) compared to all passive motions. In some comparisons, SMT did not create significantly different loads in the intact specimen, but did so in specific spinal tissues. Despite methodological differences between studies, SMT forces and loading rates fell below published injury values. Future studies are warranted to understand if loading scenarios unique to SMT confer its differential therapeutic effects.

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

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.

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.

Epidemiology of Chronic Low Back Pain in US
Adults: Data From the 2009-2010 National
Health and Nutrition Examination
Arthritis Care Res (Hoboken) 2016 (Nov); 68 (11): 1688–1694 ~ FULL TEXT
In conclusion, US adults with cLBP in 2009–2010 were less educated, less wealthy, and more likely to smoke, have depression, sleep disturbances, and other medical comorbidities than those without cLBP. They made more frequent healthcare visits and more often carried government-sponsored health insurance to cover the costs. Frequent healthcare visits in the cLBP group were strongly associated with depression and sleep disturbances. While causal inference cannot be established from a cross-sectional study design, the clustering of behavioral, psychosocial, and medical issues should be considered in the care and rehabilitation of Americans with cLBP.

Clinical Practice Guidelines for the Noninvasive
Management of Low Back Pain: A Systematic Review
by the Ontario Protocol for Traffic Injury
Management (OPTIMa) Collaboration
European Journal of Pain 2016 (Oct 6) ~ FULL TEXT
We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed.

Interdisciplinary Practice Models for Older
Adults With Back Pain: A Qualitative Evaluation
Arthritis Res Ther. 2016 (Oct 13); 18 (1): 237
Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups.

Identification of Subgroups of Inflammatory and
Degenerative MRI Findings in the Spine and
Sacroiliac Joints: A Latent Class Analysis
of 1037 Patients with Persistent
Low Back Pain
Arthritis Res Ther. 2016 (Oct 13); 18 (1): 237 ~ FULL TEXT
In general terms, the profile of each subgroup can be described in the following way.

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

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

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

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

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

Mechanisms of Low Back Pain:
A Guide for Diagnosis and Therapy
Version 2. F1000Res. 2016 (Oct 11); 5. pii: F1000 ~ FULL TEXT
Low back pain (LBP) is the most common musculoskeletal condition affecting the adult population, with a prevalence of up to 84%. [1] Chronic LBP (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 12 weeks. [2] Many authors suggest defining chronic pain as pain that lasts beyond the expected period of healing, avoiding this close time criterion. This definition is very important, as it underlines the concept that CLBP has well-defined underlying pathological causes and that it is a disease, not a symptom. CLBP represents the leading cause of disability worldwide and is a major welfare and economic problem. [1] Given this complexity, the diagnostic evaluation of patients with LBP can be very challenging and requires complex clinical decision-making. Answering the question, “what is the pain generator?” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a diagnosis not based on specific pain generator can lead to therapeutic mistakes. This article aims to provide a brief clinical guide that could help in the identification of pain generators through a careful anatomical description, thereby directing clinicians towards the correct diagnosis and therapeutic approach.

Effectiveness and Economic Evaluation of
Chiropractic Care for the Treatment of
Low Back Pain: A Systematic Review
of Pragmatic Studies
PLoS One. 2016 (Aug 3); 11 (8): e0160037 ~ FULL TEXT
Moderate evidence suggests that chiropractic care for LBP appears to be equally effective as physical therapy. Limited evidence suggests the same conclusion when chiropractic care is compared to exercise therapy and medical care although no firm conclusion can be reached at this time. No serious adverse events were reported for any type of care. Our review was also unable to clarify whether chiropractic or medical care is more cost-effective. Given the limited available evidence, the decision to seek or to refer patients for chiropractic care should be based on patient preference and values. Future studies are likely to have an important impact on our estimates as these were based on only a few admissible studies.

Consensus on the Clinical Diagnosis of Lumbar
Spinal Stenosis: Results of an
International Delphi Study
Spine (Phila Pa 1976). 2016 (Aug 1); 41 (15): 1239–1246 ~ FULL TEXT
A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated.

The six top items were

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

Neural Correlates of Fear of Movement in Patients
with Chronic Low Back Pain vs.
Pain-Free Individuals
Front Hum Neurosci. 2016 (Jul 26); 10: 386 ~ FULL TEXT
In the current fMRI study, we applied a novel approach encompassing: (1) video clips of potentially harmful activities for the back as fear of movement (FOM) inducing stimuli; and (2) the assessment of FOM in both, chronic low back pain (cLBP) patients (N = 20) and age- and gender-matched pain-free subjects (N = 20). Derived from the fear avoidance (FA) model, we hypothesized that FOM differentially affects brain regions involved in fear processing in patients with cLBP compared to pain-free individuals due to the recurrent pain and subsequent avoidance behavior.

Implementation Interventions to Improve the
Management of Non-specific Low Back Pain:
A Systematic Review
BMC Musculoskelet Disord. 2016 (Jun 10); 17: 258 ~ FULL TEXT
The results of this review indicate that the most successful interventions to support implementation of best available evidence into clinical practice for NSLBP are those that occur more frequently and are ongoing. Other factors such as intervention type, complexity or target healthcare practitioner or behaviour did not appear to determine the success of the implementation intervention tested. These results must be interpreted with some caution given that many included papers were at high risk of bias. Further high quality studies are needed to robustly test the effectiveness of implementation interventions in this field. The investigators of future implementation studies in this area should develop a strong rationale for the implementation intervention(s) chosen by identifying barriers and facilitators to implementation of best available evidence, select relevant implementation interventions to overcome these barriers and enhance the facilitators and follow best practice guidelines in design, conduct and reporting of their studies. In particular future studies need to give careful consideration to the frequency and duration of their implementation intervention and evaluate cost-effectiveness.

Identifying Patients With Chronic Low Back Pain
Who Respond Best to Mechanical Diagnosis and
Therapy: Secondary Analysis of a
Randomized Controlled Trial
Phys Ther. 2016 (May); 96 (5): 623–630 ~ FULL TEXT
Being older met our criteria for being a potentially important effect modifier; however, the effect occurred in the opposite direction to our hypothesis. Older people had 1.27 points more benefit in pain reduction from MDT (compared with Back School) than younger participants after 1 month of treatment.

Estimating the Risk of Chronic Pain: Development
and Validation of a Prognostic Model (PICKUP)
for Patients with Acute Low Back Pain
PLoS Med. 2016 (May 17); 13 (5): e1002019 ~ FULL TEXT
At 3 mo, 30% of the patients in the development sample were classified as having chronic LBP. Table 4 shows predictors and regression coefficients for the primary model (PICKUP) and the two secondary models that were fitted in this sample. PICKUP contained five predictors. We did not detect significant non-linearity in any continuous predictor variables.

Variations in Patterns of Utilization and Charges
for the Care of Low Back Pain in North Carolina,
2000 to 2009: A Statewide Claims'
Data Analysis
J Manipulative Physiol Ther. 2016 (May); 39 (4): 252–262 ~ FULL TEXT
A major strength of the study was the large amount of low back pain claims made available to us for analysis. The data were from 3,159,362 claims generated by approximately 66,0000 persons over the 2000–2009 decade in North Carolina, in several different pathways of healthcare services. This study and the series of papers it has generated on the treatment of low back pain, neck pain [25] and headache, [26] provides unique economic examination for healthcare policy makers and legislators. When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population. This is an opportunity to view costs laterally versus a confined, vertical analysis.
This is one of 3 of the
Cost-Effectiveness Triumvirate articles.

Importance of the Type of Provider Seen to Begin
Health Care for a New Episode Low Back Pain:
Associations with Future Utilization
and Costs
J Eval Clin Pract. 2016 (Apr); 22 (2): 247–252 ~ FULL TEXT
The RESULTS portion of this Abstract only partially discusses the findings, comparing 3 different professions' treatment, costs, and outcomes for low back pain. In it they only mention the costs associated with medical management, while in reviewing chiropractic care vs. physical thereapy portions, they choose to emphasize:

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

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

Symptomatic, MRI Confirmed, Lumbar Disc
Herniations: A Comparison of Outcomes
Depending on the Type and Anatomical
Axial Location of the Hernia in
Patients Treated With High-Velocity,
Low-Amplitude Spinal Manipulation
J Manipulative Physiol Ther. 2016 (Mar); 39 (3): 192–199 ~ FULL TEXT
The majority of patients in this study had either extruded or sequestered disc herniations. Patients with sequestered herniations treated with SMT to the level of herniation reported significantly higher levels of leg pain reduction at 1 month and a higher proportion reported improvement at all data collection time points compared to patients with extruded disc herniations but this did not reach statistical significance. Further investigation is needed to determine mechanisms for this finding. This also calls into question the seriousness of disc sequestration in determining appropriate treatment.

Prediction of Outcome in Patients with Low Back
Pain -- A Prospective Cohort Study Comparing
Clinicians' Predictions with those of
the Start Back Tool
Manual Therapy 2016 (Feb); 21: 120–127 ~ FULL TEXT
The accuracies of predictions made by clinicians (AUC .58-.63) and the STarT Back Screening Tool (SBT) (AUC .50-.61) were comparable and low. No substantial increase in the predictive capability was achieved by combining clinicians' expectations and the SBT. In conclusion, chiropractors' predictions were associated with well-established prognostic factors but not simply a product of these. Chiropractors were able to predict differences in outcome on a group level, but prediction of individual patients' outcomes were inaccurate and not substantially improved by the SBT.

Absence of Low Back Pain to Demarcate an Episode:
A Prospective Multicentre Study in Primary Care
Chiropractic & Manual Therapies 2016 (Feb 18); 24: 3 ~ FULL TEXT
A logical relationship exists between the prevalence of four consecutive pain free weeks and the study population, it being most common in the general population, followed by the primary care population and least common in the secondary care sector Further, absence of LBP is less common in patients from the primary care sector with a previous long duration of pain than in those with previous shorter pain duration. Therefore, a period of four consecutive pain free weeks may be applied both for research purposes and in clinical practice to demarcate a LBP episode.

Assessment of Chiropractic Treatment for Active
Duty, U.S. Military Personnel with Low Back
Pain: Study Protocol for a Randomized
Controlled Trial
Trials. 2016 (Feb 9); 17: 70 ~ FULL TEXT
Because low back pain is one of the leading causes of disability among U.S. military personnel, it is important to find pragmatic and conservative treatments that will treat low back pain and preserve low back function so that military readiness is maintained. Thus, it is important to evaluate the effects of the addition of chiropractic care to usual medical care on low back pain and disability.

The Association Between Use of Chiropractic Care
and Costs of Care Among Older Medicare Patients
With Chronic Low Back Pain and
Multiple Comorbidities
J Manipulative Physiol Ther. 2016 (Feb); 39 (2): 63–75 ~ FULL TEXT
After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided.

Workers' Compensation, Return to Work,
and Lumbar Fusion for Spondylolisthesis
Orthopedics. 2016 (Jan); 39 (1): e1–8 ~ FULL TEXT
In this study, researchers reviewed the files of 686 workers who underwent fusion surgery for spondylolisthesis between 1993 and 2013, revealing that only 29.9% of them ever returned to work (for at least 6 months). The failure rate (meaning return-to-work) was 70.1%.

Clinical Practice Guideline:
Chiropractic Care for Low Back Pain
J Manipulative Physiol Ther. 2016 (Jan); 39 (1): 1–22 ~ FULL TEXT
To facilitate best practices specific to the chiropractic management of patients with common, primarily musculoskeletal disorders, the profession established the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) in 1995. [6] The organization sponsored and/or participated in the development of a number of “best practices” recommendations on various conditions. [21–32] With respect to chiropractic management of LBP, a CCGPP team produced a literature synthesis [8] which formed the basis of the first iteration of this guideline in 2008. [9] In 2010, a new guideline focused on chronic spine-related pain was published, [12] with a companion publication to both the 2008 and 2010 guidelines published in 2012, providing algorithms for chiropractic management of both acute and chronic pain. [10] Guidelines should be updated regularly. [33, 34] Therefore, this article provides the clinical practice guideline (CPG) based on an updated systematic literature review and extensive and robust consensus process. [9–12]

Characteristics of Patients with Low Back
and Leg Pain Seeking Treatment in Primary
Care: Line Results from the ATLAS Cohort Study
BMC Musculoskelet Disord. 2015 (Nov 4); 16: 332 ~ FULL TEXT
In summary, in this unselected primary care cohort of patients seeking care for back and leg pain, disability levels are higher as compared with cohorts including mixed populations of LBP patients with and without pain in the leg(s) and similar for both sciatica and referred leg pain presentations. Nearly three quarters of the participants were clinically diagnosed as having sciatica. Approximately half of this cohort was likely to have pain of neuropathic nature as measured with self-reported scales. In contrast to non-specific LBP, minimal treatment was applicable to only a very small number of patients in this cohort. MRI findings of nerve root compression were present in just over half of the participants. There were differences between the sciatica and referred leg pain groups in terms of leg pain levels, neuropathic pain, bothersomeness due to the sciatic symptoms and MRI findings. Follow-up of this cohort will investigate the prognostic value of their baseline characteristics and explore the clinical relevance of the differences between those with sciatica and referred leg pain for the course of the low back and leg pain episode.

Low Back Pain Patients in Sweden, Denmark and
the UK Share Similar Characteristics and
Outcomes: A Cross-National Comparison
of Prospective Cohort Studies
BMC Musculoskelet Disord. 2015 (Nov 26); 16 (1): 367 ~ FULL TEXT
Chiropractic patients with low back pain had similar characteristics and clinical course across three Northern European countries. It is unlikely that culture have substantially different impacts on the course of LBP in these countries and the results support knowledge transfer between the investigated countries.

A Tailored Exercise Program Versus General
Exercise for a Subgroup of Patients with
Low Back Pain and Movement Control
Impairment: A Randomised Controlled Trial
with One-year Follow-up
Manual Therapy 2015 (Oct); 20 (5): 672–679 ~ FULL TEXT
Patient Specific Function Scale (PSFS) showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year. This study found no additional benefit of specific exercises targeting movement control impairment (MCI)

Prognosis and Course of Pain in Patients with
Chronic Non-Specific Low Back Pain: A 1-year
Follow-Up Cohort Study
European Journal of Pain 2015 (Sep); 19 (8): 1101–1110 ~ FULL TEXT
Patient-reported intensity of back pain decreased from 55.5 (SD 23.0) at baseline to 37.0 (SD 23.8), 35.3 (SD 26.1) and 32.3 (SD 26.9) at 2-, 5- and 12-month follow-up, respectively. Younger age, back pain at baseline, no psychological/physical dysfunction (Symptom Check List-90, item 9), and higher baseline scores on the physical component scale and mental component scale of quality of life (Short Form-36) were positively associated with recovery at 5 and 12 months. At 5-month follow-up, higher work participation at baseline was also a prognostic factor for both definitions of recovery. At 12-month follow-up, having co-morbidity was predictive for both definitions.

Interview with Michael Schneider, DC, PhD,
on a Non-surgical Approach to Spinal Stenosis
Topics in Integrative Health Care 2015 (Sep 29); 6 (2) ~ FULL TEXT
Michael Schneider, DC, PhD, is an Associate Professor at the School of Health and Rehabilitation Sciences at the University of Pittsburgh. Schneider was the only chiropractor to receive a grant as part of the Patient Centered Outcomes Research Institute’s (PCORI) first wave of 25 grants, in late 2012. PCORI was created as an independent entity by the Patient Protection and Affordable Care Act, with a mission to fund high-quality comparative effectiveness research. The topic of Dr. Schneider’s research is A Comparison of Nonsurgical Treatment Methods for Patients with Lumbar Spinal Stenosis.

Collaborative Care for a Patient with Complex
Low Back Pain and Long-term Tobacco Use:
A Case Report
J Can Chiropr Assoc. 2015 (Sep); 59 (3): 216–225 ~ FULL TEXT
Few examples of interprofessional collaboration by chiropractors and other healthcare professionals are available. This case report describes an older adult with complex low back pain and longstanding tobacco use who received collaborative healthcare while enrolled in a clinical trial. A doctor of chiropractic and a doctor of osteopathy provided collaborative care based on patient goal setting and supported by structured interdisciplinary communication, including record sharing and telephone consultations. Collaborative care facilitated active involvement of the patient and resulted in decreased radicular symptoms, improvements in activities of daily living, and tobacco use reduction.

Do Participants with Low Back Pain who Respond
to Spinal Manipulative Therapy Differ
Biomechanically From Nonresponders,
Untreated Controls or
Asymptomatic Controls?
Spine (Phila Pa 1976). 2015 (Sep 1); 40 (17): 1329–1337 ~ FULL TEXT
After the first SMT, SMT responders displayed statistically significant decreases in spinal stiffness and increases in multifidus thickness ratio sustained for more than 7 days; these findings were not observed in other groups. Similarly, only SMT responders displayed significant post-SMT improvement in apparent diffusion coefficients. Those reporting post-SMT improvement in disability demonstrated simultaneous changes between self-reported and objective measures of spinal function. This coherence did not exist for asymptomatic controls or no-treatment controls. These data imply that SMT impacts biomechanical characteristics within SMT responders not present in all patients with LBP. This work provides a foundation to investigate the heterogeneous nature of LBP, mechanisms underlying differential therapeutic response, and the biomechanical and imaging characteristics defining responders at baseline.

First-Contact Care With a Medical vs Chiropractic
Provider After Consultation With a Swiss
Telemedicine Provider: Comparison of
Outcomes, Patient Satisfaction, and
Health Care Costs in Spinal, Hip, and
Shoulder Pain Patients
J Manipulative Physiol Ther. 2015 (Sep); 38 (7): 477–483 ~ FULL TEXT
JMPT's Editor-in-Chief Claire Johnson, DC, MEd, emphasized the importance of the latest findings:
“Comparative studies – in other words, research that compares the outcomes between two different providers or modalities – are rare for chiropractic care,” she said. “Thus, this study by Houweling, et al., is especially important if payers and policy-makers are to better understand the 'triple aim' as it relates to chiropractic. Specifically, this study helps us better understand what type of care provides better patient satisfaction, is more cost effective, and improves population health.”

Association of Worker Characteristics and Early
Reimbursement for Physical Therapy, Chiropractic
and Opioid Prescriptions With Workers'
Compensation Claim Duration, For Cases of
Acute Low Back Pain: An Observational
Cohort Study
BMJ Open. 2015 (Aug 26); 5 (8): e007836
Our analysis found that early WSIB reimbursement for physiotherapy or chiropractic care, in claimants fully off work for more than 4 weeks, was not associated with claim duration, and that early reimbursement for opioids predicted prolonged claim duration. Well-designed randomised controlled trials are needed to verify our findings and establish causality between these variables and claim duration.

Prediction of Pain Outcomes in a Randomized
Controlled Trial of Dose-response of Spinal
Manipulation for the Care of
Chronic Low Back Pain
BMC Musculoskelet Disord. 2015 (Aug 19); 16: 205 ~ FULL TEXT
Internal validation of prediction models showed that participant characteristics preceding the start of care were poor predictors of at least 50% improvement and the individual's future pain intensity. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best.

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

Clinical Decision Rule for Primary Care Patient
with Acute Low Back Pain at Risk of
Developing Chronic Pain
Spine J 2015 (Jul 1); 15 (7): 1577–1586 ~ FULL TEXT
Despite these limitations, we conclude that our study provides a clinical decision rule that is urgently needed for one of the most frequent and most costly conditions in primary care. [50] It contains 8 items for the 6–month and 8 items for the 2–year risk classification (5 are common to both) into 3 levels of risk for developing chronic pain in patients presenting in primary care with a new-onset episode of strictly defined acute low back pain. The next step is to prospectively validate this tool in an independent population.

The Chiropractic Hospital-Based Interventions
Research Outcomes Study: Consistency of
Outcomes Between Doctors of Chiropractic
Treating Patients with
Acute Lower Back Pain
J Manipulative Physiol Ther. 2015 (Jun); 38 (5): 311–323 ~ FULL TEXT
The findings of this study show that regardless of the treating DC, most patients with acute LBP without radiculopathy appear to experience consistent levels of improvement in terms of back pain and general physical functioning (PF) after receiving guidelines-based treatment that includes a component of standardized HVLA SMT.

Low Back Pain: Guidelines for the Clinical
Classification of Predominant Neuropathic,
Nociceptive, or Central Sensitization Pain
Pain Physician. 2015 (May); 18 (3): E333–346 ~ FULL TEXT
Modern pain neuroscience has advanced our understanding about pain, including the role of central sensitization (CS) in amplifying pain experiences. CS is defined as “an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” [11], “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input” [3], or “an augmentation of responsiveness of central neurons to input from unimodal and polymodal receptors”. [12] Although one might say that these definitions differ substantially, they all point to the same underlying neurophysiological mechanism of increased neuronal response to stimuli in the central nervous system (i.e., central hyperexcitability). The definitions originate from laboratory research, but the awareness that the concept of CS should be translated to the clinic is growing. [13, 14]

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

Edirorial Comment: This is a fascinating series of articles. NOTE: However, they ignore all the widely accepted guidelines that we have grown accustomed to over the last 10 years, and are solely allopathic in their treatment pattern (drugs, and more drugs) with virtually no mention of spinal manipulation as an option. Even so, they are spot-on in their assessment and diagnosis sections, and it comes as no surprise that they only recommend what they were trained to provide, and ignore (mostly) all the *alternative* forms of care, unless they directly control them (like physical therapy). They are listed here for their contribution to our current understanding of the allopathic approach for managing *Chronic Low Back Pain in the Older Adult*.

A Qualitative Study of Changes in Expectations
Over Time Among Patients with Chronic Low Back
Pain Seeking Four CAM Therapies
BMC Complement Altern Med. 2015 (Feb 5); 15: 12 ~ FULL TEXT
These findings suggest the value of further research into the potential of the CAM therapeutic process to assist patients in taking control of their health management and wellness. Sointu [58] argues that CAM use is becoming increasingly common because the “discourse of well-being” (9) embedded in CAM interactions (see also [24, 25]) resonates with how people understand their bodies and selves. Our data support the finding that CAM participants report greater awareness of the need for ongoing engagement in their own care, an increased sense of control or empowerment, and motivation to seek effective coping strategies. [ Editorial Comment: These are all things that conventional medicine struggles with.]

Clinical Examination Findings as Prognostic
Factors in Low Back Pain: A Systematic
Review of the Literature
Chiropractic & Manual Therapies 2015 (Mar 23); 23: 13 ~ FULL TEXT
A total of 5,332 citations were retrieved and screened for eligibility, 342 articles were assessed as full text and 49 met the inclusion criteria. Due to clinical and statistical heterogeneity, qualitative synthesis rather than meta-analysis was performed. Associations between clinical tests and outcomes were often inconsistent between studies. In more than one third of the tests, there was no evidence of the tests being associated with outcome. Only two clinical tests demonstrated a consistent association with at least one of the outcomes: centralization and non-organic signs.

Pain Location Matters: The Impact of Leg Pain on
Health Care Use, Disability and Quality of Life
in Patients with Low Back Pain
European Spine Journal 2015 (Mar); 24 (3): 444–451 ~ FULL TEXT
Patients with self-reported leg pain below the knee utilise more health care are more likely to be unemployed and have poorer quality of life than those with LBP only 12 months following primary care consultation. The presence of leg pain warrants early identification in primary care to explore if targeted interventions can reduce the impact and consequences of leg pain.

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.

Evaluation of a Modified Clinical Prediction Rule
For Use With Spinal Manipulative Therapy in
Patients With Chronic Low Back Pain:
A Randomized Clinical Trial
Chiropractic & Manual Therapies 2014 (Nov 18); 22 (1): 41 ~ FULL TEXT
Recent literature has highlighted the lack of definitive data to emerge from RCTs evaluating Chronic Lower Back Pain (CLBP), with no treatment producing consistently superior outcomes. [29-32] In keeping with this previous literature and supporting our first hypothesis, we found clinically and statistically significant improvements in outcomes from baseline to follow up in the groups receiving Spinal Manipulative Therapy (SMT) and Active Exercise Therapy (AET), which are both recognized as evidence based interventions for CLBP. [10, 31]

What Are Patient Beliefs and Perceptions About
Exercise for Nonspecific Chronic Low Back Pain?
A Systematic Review of Qualitative Studies
Clin J Pain. 2014 (Nov); 30 (11): 995–1005 ~ FULL TEXT
Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue. People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

Occupational Low Back Pain in Primary and
High School Teachers: Prevalence and
Associated Factors
J Manipulative Physiol Ther. 2014 (Nov); 37 (9): 702–708 ~ FULL TEXT
The prevalence of low back pain (LBP) in teachers appears to be high. High school teachers were more likely to experience LBP than primary school teachers. Factors such as age, body mass index, length of employment, job satisfaction, and work-related activities were significant factors associated with LBP in this teacher population.

Low Back Pain in Primary Care: A Description of
1250 Patients with Low Back Pain in Danish
General and Chiropractic Practice
Int J Family Med. 2014 (Nov 4); 2014: 106102 ~ FULL TEXT
Four out of five patients had had previous episodes, one-fourth were on sick leave, and the LBP considerably limited daily activities. The general practice patients were slightly older and less educated, more often females, and generally worse on all disease-related parameters than chiropractic patients. All differences were statistically significant.

Spinal Manipulation and Home Exercise with
Advice for Subacute and Chronic Back-related
Leg Pain: A Trial With Adaptive Allocation   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.

Dose-response and Efficacy of Spinal Manipulation
for Care of Chronic Low Back Pain:
A Randomized Controlled Trial
Spine J 2014 (Jul 1); 14 (7): 1106–1116 ~ FULL TEXT
For the primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks and sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per six manipulation sessions at 12 and 52 weeks for both variables (p<.025). At 12 weeks, the greatest differences from the no-manipulation control were found for 12 sessions (8.6 pain and 7.6 disability points, p<.025); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points, p<.025).

Report of the NIH Task Force on Research Standards
for Chronic Low Back Pain
Journal of Pain 2014 (Jun); 15 (6): 569–585 ~ FULL TEXT
Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The NIH Pain Consortium therefore charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination.

Cost Analysis Related to Dose-response of Spinal
Manipulative Therapy for Chronic Low Back
Pain: Outcomes from a Randomized
Controlled Trial
J Manipulative Physiol Ther. 2014 (Jun); 37 (5): 300–311 ~ FULL TEXT
Lost productivity accounts for most societal costs of chronic LBP. Cost of treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were greater age (P = .03), greater disability (P = .01), lower quality-adjusted life year scores (P = .01), and higher costs in the period preceding enrollment (P < .01). Pain-free and disability-free days were greater for all SMT doses compared with control, but only SMT 12 yielded a statistically significant benefit of 22.9 pain-free days (P = .03) and 19.8 disability-free days (P = .04). No statistically significant group differences in quality-adjusted life years were noted.

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

The Global Burden of Low Back Pain: Estimates
from the Global Burden of Disease 2010 study
Ann Rheum Dis. 2014 (Jun); 73 (6): 968–974 ~ FULL TEXT
Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden disability-adjusted life years (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age.
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Global Burden of Disease Section

Tracking Low Back Problems in a Major Self-
Insured Workforce: Toward Improvement
in the Patient's Journey
J Occup Environ Med. 2014 (Jun); 56 (6): 604–620 ~ FULL TEXT
This comprehensive new study from the Journal of Occupational and Environmental Medicine reveals that chiropractic care costs significantly less than other forms of low back care, and appears to comply with guideline recommendations more closely than than any of the other 4 comparison groups.

Short Term Treatment Versus Long Term Management
of Neck and Back Disability in Older Adults
Utilizing Spinal Manipulative Therapy and
Supervised Exercise: A Parallel-group
Randomized Clinical Trial
Relative Effectiveness and Harms
Chiropractic & Manual Therapies 2014 (May 23); 22: 21 ~ FULL TEXT
This is one of the first full-scale randomized clinical trials to compare short term treatment and long term management using SMT and exercise to treat spine-related disability in older adults. It builds on previous research by the investigative team showing improvement with three months of SMT and exercise in similar populations, which regressed to baseline values in long term follow up without further intervention 88. As back and neck pain in older adults are often chronic and among several co-morbidities [6, 8], we theorized that long term management may result in sustained improvement compared to short term treatment. Identifying the most favorable duration of treatment is a pragmatic question common to patients, clinicians, policy makers, and third-party payers alike. [25, 89] This is especially important to address in an older population, whose long term functional ability is essential to maintaining vitality and independence.

A Modern Neuroscience Approach to Chronic
Spinal Pain: Combining Pain Neuroscience
Education with Cognition-targeted Motor
Control Training
Phys Ther. 2014 (May); 94 (5): 730–738 ~ FULL TEXT
Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed.

The Efficacy of Manual Therapy and Exercise
for Different Stages of Non-specific Low Back
Pain: An Update of Systematic Reviews
J Man Manip Ther. 2014 (May); 22 (2): 59–74 ~ FULL TEXT
This SR, based on low-risk of bias studies, has provided a comprehensive review of different MT approaches in patients with different stages of LBP, informing evidence-based-practice. Based on the results of this SR, a variety of manual procedures combined or not with other interventions, including exercise, may improve patient management. The summary findings of this review are both comprehensive and novel and may be used to guide clinical practice and future studies of this topic.

Predictors of Response to Exercise Therapy for
Chronic Low Back Pain: Result of a Prospective
Study With One Year Follow-up
Eur J Phys Rehabil Med. 2014 (Apr); 50 (2): 143–151 ~ FULL TEXT
The individually designed exercise therapy program for chronic LBP was associated to clinically significant functional improvement both on discharge and at 1 year. Only severe pain intensity predicted poor treatment response on discharge. At one year, younger age and better mental health predicted improved outcome, while use of drugs and previous LBP treatments were associated with worse response. Adherence to the exercise program almost doubled the probability of a favorable outcome.

Health Care Utilization and Costs Associated with
Adherence to Clinical Practice Guidelines for
Early Magnetic Resonance Imaging Among Workers
with Acute Occupational Low Back Pain
Health Serv Res. 2014 (Apr); 49 (2): 645–665 ~ FULL TEXT
Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.

Outcomes of Acute and Chronic Patients 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.

Patient with Low Back Pain and Somatic Referred
Pain Concomitant with Intermittent Claudication
in a Chiropractic Practice
Topics in Integrative Health Care 2014 (Mar 27); 5 (1) ~ FULL TEXT
Chiropractic care was provided and the low back pain improved. The patient developed leg weakness. Radiographic evaluation showed calcification of abdominal aorta and common iliac arteries. The patient was referred for medical evaluation and diagnostic ultrasound findings of arterial occlusion lead to surgical referral. The surgeon reported a “significant amount” of blockage of the left external iliac artery. Leg weakness resolved following placement of surgical stents.

Spinal Manipulative Therapy-specific Changes in
Pain Sensitivity in Individuals with Low Back Pain
Journal of Pain 2014 (Feb); 15 (2): 136–148 ~ FULL TEXT
Participants receiving the SMT and placebo SMT received their assigned intervention 6 times over 2 weeks. Pain sensitivity was assessed prior to and immediately following the assigned intervention during the first session. Clinical outcomes were assessed at baseline and following 2 weeks of participation in the study. Immediate attenuation of suprathreshold heat response was greatest following SMT (P = .05, partial η² = .07). Group-dependent differences were not observed for changes in pain intensity and disability at 2 weeks. Participant satisfaction was greatest following the enhanced placebo SMT.

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

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].

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.

Worsening Trends in the Management
and Treatment of Back Pain
JAMA Internal Medicine 2013 (Sep 23); 173 (17): 1573–1581 ~ FULL TEXT
We identified 23,918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P< .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P< .001). In contrast, narcotic use increased from 19.3% to 29.1% (P< .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P< .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P< .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location. Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.

Perspectives of Older Adults on Co-management
of Low Back Pain by Doctors of Chiropractic
and Family Medicine Physicians:
A Focus Group Study
BMC Complement Altern Med. 2013 (Sep 16); 13: 225 ~ FULL TEXT
Low back pain (LBP) is a leading cause of disability and disease burden. [1, 2] People age 65 years and older report a 25% monthly LBP prevalence rate [3, 4] with recurrent or debilitating LBP common in older populations. [4–6] Chronic LBP is linked to difficulties with activities of daily living (ADLs) [7, 8], depression [4, 7, 9, 10], sleep problems [7, 9], and decreased performance on physical function [7, 11] and neuropsychological tests. [11] An estimated 2.3% of annual physician visits in the U.S. are for LBP. [3] Persons with LBP and other spine conditions have increased healthcare expenditures for medications, spinal imaging, injections and surgery [3, 4, 9, 12–14]. Medicare charges among older adults with back disorders have demonstrated significant increases for patient visits, imaging and spinal injections [12, 15] without translation to better health outcomes for LBP patients. [13–15]

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

An Evidence-based Diagnostic
Classification System For Low Back Pain
J Can Chiropr Assoc. 2013 (Sep); 57 (3): 189–204 ~ FULL TEXT
This article describes and discusses the strength of evidence surrounding diagnostic categories for an in-office, clinical exam and checklist tool for LBP diagnosis. The use of a standardized tool for diagnosing low back pain in clinical and research settings is encouraged.

Evidence-based Classification Of Low Back Pain
In the General Population: One-year Data
Collected With SMS Track
Chiropractic & Manual Therapies 2013 (Sep 2); 21: 30 ~ FULL TEXT
In all, 261 study subjects were included in the analyses, for which 7 distinct LBP subsets could be identified. These could be grouped into three major clusters; those mainly without LBP (35%), those with episodic LBP (30%) and those with persistent LBP (35%). There was a positive association between number of episodes and their duration.

The Collateral Benefits Of Having Chiropractic
Available In a Public Central Hospital
Journal of Hospital Administration 2013 (Aug 8); 2 (4): 138–143 ~ FULL TEXT
Following previous reports on the co-operation between a chiropractor and a central hospital, experiences from the past five years are presented. The objective of this paper is to show that improved management of muscular and skeletal problems within a hospital setting depends on the availability of chiropractic health care as a treatment option.

Early Predictors of Lumbar Spine Surgery After
Occupational Back Injury: Results From a
Prospective Study of Workers
in Washington State
Spine (Phila Pa 1976). 2013 (May 15); 38 (11): 953-964 ~ FULL TEXT
Significant worker baseline variables in a multivariate model predicting one or more lumbar spine surgeries within 3 years of claim submission included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and first seeing a surgeon for the injury. Participants younger than 35 years, females, Hispanics, and participants whose first visit for the injury was to a chiropractor had lower odds of surgery.

Adding Chiropractic Manipulative Therapy to
Standard Medical Care for Patients with
Acute Back Pain: Results of a Pragmatic
Randomized Comparative
Effectiveness Study   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.

Clinical Course of Non-specific Low Back Pain:
A Systematic Review of Prospective Cohort
Studies Set in Primary Care
European Journal of Pain 2013 (Jan); 17 (1): 5–15 ~ FULL TEXT
This systematic review shows that spontaneous recovery from non-specific LBP occurs in the first 3 months after onset of LBP in about one-third of patients, but the majority of patients (65%) still experience pain 1 year after onset of LBP. These findings indicate that the assumption underlying current guidelines that spontaneous recovery occurs in a large majority of patients is not justified. There should be more focus on intensive follow-up and monitoring of patients who have not recovered within the first 3 months. Future research should be directed at improvement of classification of non-specific LBP in more specific groups.

Aging Baby Boomers and the Rising Cost of
Chronic Back Pain: Secular Trend Analysis
of Longitudinal Medical Expenditures
Panel Survey Data for Years 2000 to 2007
J Manipulative Physiol Ther. 2013 (Jan); 36 (1): 2–11 ~ FULL TEXT
The prevalence of back pain, especially chronic back pain, is increasing. To the extent that the growth in chronic back pain is caused, in part, by an aging population, the growth will likely continue or accelerate. With relatively high cost per adult with chronic back pain, total expenditures associated with back pain will correspondingly accelerate under existing treatment patterns. This carries implications for prioritizing health policy, clinical practice, and research efforts to improve care outcomes, costs, and cost-effectiveness and for health workforce planning.

Algorithms for the Chiropractic Management of
Acute and Chronic Spine-Related Pain
Topics in Integrative Health Care 2012 (Dec 31); 3 (4) ID: 3.4007 ~ FULL TEXT
The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1–3]

Years Lived with Disability (YLDs) for 1160
Sequelae of 289 Diseases and Injuries 1990-2010:
A Systematic Analysis for the Global Burden
of Disease Study 2010
Lancet. 2012 (Dec 15); 380 (9859): 2163–2196 ~ FULL TEXT
Rates of years lived with disability (YLD) per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world.
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Global Burden of Disease Section

Patients with Low Back Pain Differ From Those
Who Also Have Leg Pain or Signs of Nerve Root
Involvement - A Cross-sectional Study
BMC Musculoskelet Disord. 2012 (Nov 28); 13: 236 ~ FULL TEXT
LBP patients with pain referral to the legs were more severely affected than those with local LBP, and patients with signs of nerve root involvement were the ones most severily affected. These findings underpin the concurrent validity of the Quebec Task Force Classification. However, the small size of many between-subgroup differences amid the large variability in this sample of cross-sectional data also underlines that the heterogeneity of patients with LBP is more complex than that which can be explained by leg pain patterns alone. The implications of the observed differences also require investigation in longitudinal studies.

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.

Use of Chiropractic Spinal Manipulation in Older
Adults is Strongly Correlated with Supply
Spine (Phila Pa 1976). 2012 (Sep 15); 37 (20): 1771–1777
The supply of US chiropractors and utilization of CSM by older US adults varied widely by region. The variations cannot be entirely explained by basic patient characteristics or clinical indication, and there is insufficient evidence to explain the variation by patient preferences. Increased chiropractic supply was associated with increased CSM use, but not with increased CSM utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference. To better inform the most advantageous allocation and patient-centered utilization of chiropractic resources, more research is needed on how and why patients do or do not choose chiropractic care.

New Oregon LBP Guidelines:
Try Chiropractic First
Dynamic Chiropractic (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.

Stabilizing The Pelvis, Using the Modified Kemps
and Straight Leg Raise Tests And PIR
By Frank M. Painter, D.C.
Dr. Leonard Faye reminds us in Chapter 6 of Schafer's text “Motion Palpation” that: “In all low-back pain cases, it is essential to test for hamstring, quadriceps, and psoas length.”. Let's review those tests together right now.

Predictors of Functional Outcome in Patients with
Chronic Low Back Pain Undergoing Back School,
Individual Physiotherapy or Spinal Manipulation
Eur J Phys Rehabil Med. 2012 (Sep); 48 (3): 371–378
Of the 205 patients who completed treatment (140/205 women, age 58+14 years), non-responders were 72 (34.2%). SM showed the highest functional improvement and the lowest non-response rate. In a multivariable logistic regression, lower baseline RM score (OR 0.82, 95% CI 0.76–0.89, P<0.001) and received treatment (OR 0.32, 95% CI 0.21–0.50, P<0.001) were independent predictors of non-response. Being in the lowest tertile of baseline RM score (<6) predicted non response to treatment for back school (BS) and individual physiotherapy (IP), but not for spinal manipulation (SM) (same risk for all tertiles). In our patients with cLBP lower baseline pain-related disability predicted non-response to physiotherapy, but not to spinal manipulation.

Clinical Presentation of a Patient with Thoracic
Myelopathy at a Chiropractic Clinic
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.

Where the United States Spends its Spine Dollars:
Expenditures on Different Ambulatory Services
for the Management of Back and Neck Conditions
Spine (Phila Pa 1976). 2012 (Sep 1); 37 (19): 1693–1701 ~ FULL TEXT
Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008).

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

• Over the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable;

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

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

Predictors of Improvement in Patients With Acute
and Chronic Low Back Pain Undergoing
Chiropractic Treatment
J Manipulative Physiol Ther. 2012 (Sep); 35 (7): 525–533 ~ FULL TEXT
An important and unique finding in this current study is that although 123 (23%) of the patients with acute LBP and 71 (24%) of the patients with chronic LBP were diagnosed by their chiropractors as having radiculopathy, this finding was not a negative predictor of improvement. Radiculopathy was not simply defined as leg pain but required clinical signs of nerve root compression as determined by the examining chiropractor. Previous studies investigating outcomes from patients with LBP undergoing spinal manipulation have purposely excluded patients with radiculopathy, [2, 10, 29] and others have found that the presence of leg pain is a negative predictor of improvement. [12, 24, 30] This study purposely included these patients to evaluate this subgroup. It is quite common for patients with LBP experiencing radiculopathy to seek chiropractic care in Switzerland and to receive spinal manipulative therapy as one of the treatment options.

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

Conservative Management of a 31 Year Old Male
With Left Sided Low Back and Leg Pain:
A Case Report
J Can Chiropr Assoc. 2012 (Sep); 56 (3): 225–232 ~ FULL TEXT
This case demonstrates positive results for the treatment of a sub-acute lumbar disc injury with conservative care. It should be noted that results cannot be extrapolated to other cases, since this is only a single case report and the rapid resolution of this patient’s symptoms could be due to the natural history of the condition or the use of multiple interventions. Sitting and slouching have been shown to aggravate low back pain, especially when a disc injury is involved. Standing and extension exercises have been shown to help combat this. There are many reports of asymptomatic disc herniations and spontaneous resolutions, as well as muscular atrophy associated with this type of injury. The prognosis of disc herniation related low back pain relates to the extent of radiation, duration of pain and other psychosocial factors. Recommended conservative care includes spinal stabilization exercises, McKenzie assessment and treatment, neural mobilizations and chiropractic modalities, including spinal manipulative therapy. Conservative management may decrease pain and increase function for the treatment of lumbar disc injuries. Active patient participation in rehabilitative care is recommended before surgical referral.

Manual Therapy Followed by Specific Active Exercises
Versus a Placebo Followed by Specific Active
Exercises on the Improvement of Functional
Disability in Patients with Chronic Non
Specific Low Back Pain: A
Randomized Controlled Trial
BMC Musculoskelet Disord. 2012 (Aug 28); 13: 162 ~ FULL TEXT
This study confirmed the immediate analgesic effect of manual therapy (MT) over sham therapy (ST). Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic mechanisms at cortical level should be investigated more thoroughly.

A Model of Integrative Care for Low-back Pain
J Altern Complement Med. 2012 (Apr); 18 (4): 354–362 ~ FULL TEXT
Historically, federal agencies including the National Institutes of Health, the Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid, the Department of Defense, and the Veterans Administration have not sponsored research aimed at evaluating the cost effectiveness — or lack thereof — of emerging models of multidisciplinary, “integrative care” in the treatment of common medical conditions. This study argues that such comparative effectiveness research in this area is feasible, promising, and warranted, at least with regard to adults with persistent LBP.

New Study Reveals That Back Surgery
Fails 74% of the Time
Chiro.org Editorial Commentary:
Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses. After two years, just 26 percent of those who had surgery had actually returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.

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

Pain in the Three Spinal Regions: The Same
Disorder? Data From a Population-based
Sample of 34,902 Danish Adults
Chiropractic & Manual Therapies 2012 (Apr 5); 20: 11 ~ FULL TEXT
In all, 34,902 (74%) twin individuals representative of the general Danish population, aged 20 to 71, participated in a cross-sectional nation-wide survey. Identical questions from the Standardised Nordic Questionnaire for each of the three spinal regions were used for lumbar, mid-back and neck pain respectively: Pain past year, pain ever, radiating pain, and consequences of back pain (care-seeking, reduced physical activities, sick-leave, change of work/work duties and disability pension). The relative prevalence estimates of these variables were compared for the three spinal regions.

The Relationships Between Measures of Stature
Recovery, Muscle Activity and Psychological
Factors in Patients with
Chronic Low Back Pain
Manual Therapy 2012 (Feb); 17 (1): 27–33 ~ FULL TEXT
Patients who demonstrated higher paraspinal muscle activity were those with more severe CLBP and the mediational analysis also indicated that muscle activity may affect disability via its influence on pain. The results therefore support the clinical relevance of this measure and suggest that treatments that reduce muscle activity may improve outcome. In addition, muscle activity was significantly correlated with a number of psychological factors and was found to act as a partial mediator between self-efficacy and pain, confirming the link between psychological and biomechanical factors in CLBP. Furthermore, it suggests that there may be particular benefit in reducing muscle activity in those with low self-efficacy.

Prevalence of Pain-free Weeks in Chiropractic
Subjects With Low Back Pain - A Longitudinal
Study Using Data Gathered With Text Messages
Chiropractic & Manual Therapies 2011 (Dec 14); 19: 28 ~ FULL TEXT
It was uncommon that chiropractic subjects with non-specific LBP experienced an entire week without bothersome LBP during a course of 18 weeks. When this occurred, it was most commonly reported for brief periods only. Hence, recovery in the short term, in the sense that patients become absolutely pain free for longer periods, is rare, even in a primary care population.

Brief Psychosocial Education, Not Core
Stabilization, Reduced Incidence of Low
Back Pain: Results from the Prevention
of Low Back Pain in the Military
(POLM) Cluster Randomized Trial
BMC Medicine 2011 (Nov 29); 9: 128 ~ FULL TEXT
The European Guidelines for Prevention of Low Back Pain [6] indicated a high priority for rigorous randomized clinical trials that investigate primary prevention of LBP. Completion of the POLM trial meets this priority and has provided additional data for those interested in primary prevention of LBP. Specifically, our results suggest that exercise programs that target core lumbar musculature may offer no additional preventative benefit when compared to traditional lumbar exercise programs. Also, brief psychosocial education may be an important adjunct to exercise programs as they may prevent the seeking of health care when experiencing LBP. These are novel findings and, since this study was done in a military setting, future research is necessary to determine whether these education programs could be implemented in civilian populations with similar efficacy. In addition, future studies should consider the cost-benefit of education programs that reduce LBP incidence resulting in the seeking of health care.

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]

Application of a Diagnosis-Based Clinical
Decision Guide in Patients with Low Back Pain
Chiropractic & Manual Therapies 2011 (Oct 22); 19: 26 ~ FULL TEXT
Low back pain (LBP) affects approximately 80% of adults at some time in life [1] and occurs in all ages [2, 3]. Despite billions being spent on various diagnostic and treatment approaches, the prevalence and disability related to LBP has continued to increase [4]. There has been a recent movement toward comparative effectiveness research [5], i.e., research that determines which treatment approaches are most effective for a given patient population. In addition, there is increased recognition of the importance of practice-based research which generates data in a “real world” environment as a tool for conducting comparative effectiveness research [6, 7]. This movement calls for greater participation of private practice environments in clinical research [7].

Does Maintained Spinal Manipulation Therapy
for Chronic Non-specific Low Back Pain Result
in Better Long Term Outcome?
Spine (Phila Pa 1976) 2011 (Aug 15); 36 (18): 1427–1437
This new, single blinded placebo controlled study, conducted by Mansoura Faculty of Medicine at Mansoura University, conclusively demonstrates that maintenance care (aka Preventive Care) provides significant benefits for those with chronic low back pain.
This study re-confirms the findings of a virtually identical study by Descarreaux (JMPT 2004)
and the ground-breaking article: Rupert (JMPT 2000).

Cost-Effectiveness of General Practice Care
for Low Back Pain: A Systematic Review
European Spine Journal 2011 (Jul); 20 (7): 1012–1023 ~ FULL TEXT
Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual general practitioner (GP) care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone.

The Trials of Evidence: Interpreting Research
and the Case for Chiropractic
The Chiropractic Report (July 2011) ~ FULL TEXT
For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources – whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. [1]), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society [2]) or interdisciplinary (the European Back Pain Guidelines [3]).

Neurophysiologic Effects of Spinal Manipulation
in Patients with Chronic Low Back Pain
BMC Musculoskelet Disord. 2011 (Jul 22); 12: 170 ~ FULL TEXT
Low back pain (LBP) is one of the most common reasons for seeking medical care and accounts for over 3.7 million physician visits per year in the United States alone. Ninety percent of adults will experience LBP in their lifetime, 50% will experience recurrent back pain, and 10% will develop chronic pain and related disability [1–4]. According to the most recent national survey more than 18 million Americans over the age of 18 years received manipulative therapies in 2007 at a total annual out of pocket cost of $3.9 billion with back pain being the most common clinical complaint of these individuals [5].

Cost-effectiveness of Guideline-endorsed
Treatments for Low Back Pain:
A Systematic Review
European Spine Journal 2011 (Jul); 20 (7): 1024–1038 ~ FULL TEXT
This systematic review of the cost-effectiveness of treatments endorsed in the APS–ACP guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, as were other methods usually within the chiropractor’s scope of practice (interdisciplinary rehabilitation, exercise, and acupuncture). For acute low back pain, this review found insufficient evidence for reaching a conclusion about the cost-effectiveness of spinal manipulation. It also found no evidence at all on the cost-effectiveness of medication for low back pain.

Chiropractic Management of Postsurgical Lumbar
Spine Pain: A Retrospective Study of 32 Cases
J Manipulative Physiol Ther 2011 (Jul); 34 (6): 408–412 ~ FULL TEXT
Little has been published on the effects of Cox flexion distraction manipulation (Fig 1) on pain experienced in patients who previously underwent lumbar spinal surgery. The results of this study demonstrate that postsurgical patients with subsequent low back pain seem to respond positively to Cox flexion distraction manipulation treatments. These results are similar to previous case reports in terms of their positive outcomes; however, the data included in this article stratify treatment results based on surgical type and include a much larger sample size than previously documented.

Supervised Exercise, Spinal Manipulation, and
Home Exercise for Chronic Low Back Pain:
A Randomized Clinical Trial   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.

Clustering Patients on the Basis of Their Individual
Course of Low Back Pain Over a Six Month Period
BMC Musculoskelet Disord. 2011 (May 17); 12: 99 ~ FULL TEXT
Four clusters with distinctly different clinical courses were described and further validated against clinical baseline variables and outcomes. Cluster 1, a "stable" cluster, where the course was relatively unchanged over time, contained young patients with good self- rated health. Cluster 2, a group of "fast improvers" who were very bothered initially but rapidly improved, consisted of patients who rated their health as relatively poor but experienced the fewest number of days with bothersome pain of all the clusters. Cluster 3 was the "typical patient" group, with medium bothersomeness at baseline and an average improvement over the first 4–5 weeks. Finally, cluster 4 contained the "slow improvers", a group of patients who improved over 12 weeks. This group contained older individuals who had more LBP the previous year and who also experienced most days with bothersome pain of all the clusters.

Neck and Back Pain in Children:
Prevalence and Progression Over Time
Musculoskelet Disord. 2011 (May 16); 12: 98 ~ FULL TEXT
The following article appears to be the first study to track and review the progression of back pain in the same group of children, over a prolonged period, to see how (or if) it is a contributor to those same complains in adulthood. Of particular interest is Table 2, because it breaks down and tracks complaints of either neck, mid back, or low back pain in the same group of children at 3 different time periods: ages 9, 13 and 15 years old.
There are more articles like this at our Pediatrics Section

Health Maintenance Care in Work-Related Low Back
Pain and Its Association With Disability Recurrence
J Occupational and Environmental Medicine 2011 (Apr); 53 (4): 396–404 ~ FULL TEXT
In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than with chiropractic services or no treatment.

Chiropractic and Self-care for Back-related Leg Pain:
Design of a Randomized Clinical Trial   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.

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.

Cortical Changes in Chronic Low Back Pain:
Current State of the Art and Implications
for Clinical Practice
Man Ther. 2011 (Feb); 16 (1): 15–20 ~ FULL TEXT
There is increasing evidence that chronic pain problems are characterised by alterations in brain structure and function. Chronic back pain is no exception. There is a growing sentiment, with accompanying theory, that these brain changes contribute to chronic back pain, although empirical support is lacking. This paper reviews the structural and functional changes of the brain that have been observed in people with chronic back pain. We cast light on the clinical implications of these changes and the possibilities for new treatments but we also advise caution against concluding their efficacy in the absence of solid evidence to this effect.

A Hospital-Based Standardized Spine Care
Pathway: Report of a Multidisciplinary,
Evidence-Based Process
J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106 ~ FULL TEXT
A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as "excellent.

Long-term Outcomes of Lumbar Fusion Among
Workers' Compensation Subjects: An
Historical Cohort Study
Spine (Phila Pa 1976) 2011 (Feb 15); 36 (4): 320–331
Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses. After two years, just 26 percent of those who had surgery returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.

Consequences of Spinal Pain: Do Age and Gender
Matter? A Danish Cross-sectional Population-based
Study of 34,902 Individuals 20–71 Years of Age
BMC Musculoskelet Disord. 2011 (Feb 8); 12: 39 ~ FULL TEXT
Almost two-thirds of individuals with spinal pain did not report any consequence. Generally, consequences due to LBP were more frequently reported than those due to NP or MBP. Regardless of area of complaint, care seeking and reduced physical activities were the most commonly reported consequences, followed by sick-leave, change of work, and disability pension. There was a small mid-life peak for care-seeking and a slow general increase in reduced activities with increasing age. Increasing age was not associated with a higher reporting of sick-leave but the duration of the sick-leave increased somewhat with age. Disability pension due to spinal pain was reported exceedingly rare before the age of 50. Typically, women slightly more often than men reported some kind of consequences due to spinal pain.

SPECT/CT Imaging of the Lumbar Spine in
Chronic Low Back Pain:
A Case Report
Chiropractic & Manual Therapies 2011 (Jan 11); 19: 2 ~ FULL TEXT
Formerly known as: “Chiropractic & Osteopathy”
Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localization to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies.

The Chiropractic Hospital-Based Interventions
Research Outcomes 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.

An Updated Overview of Clinical Guidelines
for the Management of Non-specific Low
Back Pain in Primary Care
European Spine Journal 2010 (Dec); 19 (12): 2075–2094 ~ FULL TEXT
This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain.

Cost of Care for Common Back Pain Conditions
Initiated With Chiropractic Doctor vs Medical
Doctor/Doctor of Osteopathy as First Physician:
Experience of One Tennessee-Based
General Health Insurer
J Manipulative Physiol Ther 2010 (Nov); 33 (9): 640–643 ~ FULL TEXT
Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient's costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. This clearly demonstrates the savings that are possible when a patient is permitted to choose a chiropractor, rather than an MD for their care.

Integrative Care for the Management of Low Back
Pain: Use of a Clinical Care Pathway   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.

NASS Contemporary Concepts in Spine Care:
Spinal Manipulation Therapy for
Acute Low Back Pain
Spine J 2010 (Oct); 10 (10): 918–40
Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.

Synthesis of Recommendations for the 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.

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

Perceived Benefit of Complementary and Alternative
Medicine (CAM) for Back Pain: A National Survey
Journal of the American Board of Family Medicine 2010 (May); 23 (3): 354–62 ~ FULL TEXT
This new reports on interviews with 31,044 individuals who used CAM for low back pain.
The results are quite fascinating:

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

Money and Spinal Surgery:
What Happened to the Patient?
J. American Medical Association 2010 (Apr 7); 303 (13): 1259–1265 ~ FULL TEXT
There is a lack of evidence-based support for the efficacy of complex fusion surgeries over conservative surgical decompression for elderly stenosis patients. There is, however, a significant financial incentive to both hospitals and surgeons to perform the complex fusions. Spinal stenosis is the most frequent cause for spinal surgery in the elderly. There has been a slight decrease in these surgeries between 2002 and 2007. However, there has also been an overall 15 fold increase in the more complex spinal fusions (360 degree spine fusions).

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

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

Individualized Chiropractic and Integrative Care
for Low Back Pain: The Design of a
Randomized Clinical Trial Using
a Mixed-methods Approach   NCT00567333
Trials. 2010 (Mar 8); 11: 24 ~ FULL TEXT
This mixed-methods randomized clinical trial assesses clinical effectiveness, cost-effectiveness, and patients' and providers' perceptions of care, in treating non-acute LBP through evidence-based individualized care delivered by monodisciplinary or multidisciplinary care teams.

Resolution of Low Back and Radicular Pain in a
40-year-old Male United States Navy Petty Officer
After Collaborative Medical and Chiropractic Care
J Chiropractic Medicine 2010 (Mar); 9 (1): 17–21 ~ FULL TEXT
This article has described the case management of an active duty United States Navy Petty Officer who presented to his PCM with LBP and right leg pain. Radiologic studies confirmed posterior disk extrusion at L4/L5, abutting the right L5 nerve root, and posterior bulging of the L5/S1 disk. The primary purpose of this case report was to describe the interdisciplinary collaboration of chiropractic and medical services in a military setting. This article does not go into detail of the chiropractic treatments rendered, as several studies and trials on the use of manipulation and other forms of conservative care to treat patients with acute lumbar radiculopathy may be found in a systematic review by Lawrence et al. [21] Rather, it hoped to depict the unique inclusion of chiropractic management as part of available treatments within a military treatment facility.

Effectiveness of Manual Therapies:
The UK Evidence Report
Chiropractic & Manual Therapies 2010 (Feb 25); 18 (1): 3 ~ FULL TEXT
Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.

Interventions to Improve Adherence to Exercise
for Chronic Musculoskeletal Pain in Adults
Cochrane Database Syst Rev 2010 (Jan 20); 2010 (1): CD005956 ~ FULL TEXT
Authors' conclusions:

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

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

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

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

Commentary on the United Kingdom Evidence
Report About the Effectiveness
of Manual Therapies
Chiropractic & Manual Therapies 2010 (Feb 25); 18 (1): 4 ~ FULL TEXT
Bronfort et al [1] are to be congratulated on the production of this review of the clinical studies and systematic reviews of the scientific literature that have been published on the efficacy of the manual therapies and other treatments commonly offered by chiropractors. Although there are multiple other more detailed systematic reviews on the management of specific disorders I am not aware of any publication that has addressed the broader scope of manual therapy and chiropractic. His document should be of value to all chiropractors, medical physicians who work closely with chiropractors, as well as payers and health care policy makers. Although it is possible to argue over specific wording and disagree on the quality of some of the quoted studies in this document it is not possible to question the depth and scientific integrity of this work.

Management of Chronic Low Back Pain
in Active Individuals
Curr Sports Med Rep 2010 (Jan); 9 (1): 60–66 ~ FULL TEXT
The best available evidence currently suggests that in the absence of serious spinal pathology, nonspinal causes, or progressive or severe neurologic deficits, the management of chronic LBP should focus on patient education, self-care, common analgesics, and back exercises. Short-term pain relief may be obtained from spinal manipulative therapy or acupuncture. For patients with psychological comorbidities, adjunctive analgesics, behavioral therapy, or multidisciplinary rehabilitation also may be appropriate. Given the importance of active participation in recovery, patient preference should be sought to help select from among the recommended treatment options.

Spinal Manipulation Compared with Back School
and with Individually Delivered Physiotherapy
for the Treatment of Chronic Low Back Pain:
A Randomized Trial with One-year Follow-up
Clin Rehabil 2010 (Jan); 24 (1): 26–36 ~ FULL TEXT
Researchers followed patients with lumbar radiculopathy secondary to disk herniation treated after a diagnosis-based clinical decision rule. A prospective observational cohort study was conducted at a multidisciplinary, integrated clinic that includes chiropractic and physical therapy health care services. Data on 49 consecutive patients were collected at baseline, at the end of conservative, nonsurgical treatment and a mean of 14.5 months after cessation of treatment. Disability was measured using the Bournemouth Disability Questionnaire (BDQ) and pain using the Numerical Rating Scale for pain. Fear beliefs were measured with the Fear-Avoidance Beliefs Questionnaire (FABQ). Patients also self-rated improvement. Mean duration of complaint was 60.5 weeks. Mean self-rated improvement at the end of treatment was 77.5%. Improvement was described as "good" or "excellent" in nearly 90% of patients.

A Nonsurgical Approach to the Management of
Patients With Lumbar Radiculopathy Secondary
to Herniated Disk: A Prospective Observational
Cohort StudyWith Follow-Up
J Manipulative Physiol Ther 2009 (Nov); 32 (9): 723–733 ~ FULL TEXT
A randomized trial by researchers at an outpatient rehabilitation department in Italy involving 210 patients with chronic, nonspecific low back pain compared the effects of spinal manipulation, physiotherapy and back school. The participants were 210 patients (140 women and 70 men) with chronic, non-specific low back pain, average age 59. Back school and individual physiotherapy were scheduled as 15 1–hour-sessions for 3 weeks. Back school included group exercise and education/ergonomics. Individual physiotherapy included exercise, passive mobilization and soft-tissue treatment. Spinal manipulation included 4–6 20–minute sessions once-a-week. Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

Outcome of Pregnancy-Related Lumbopelvic Pain
Treated According to a Diagnosis-Based
Decision Rule: A Prospective
Observational Cohort Study
J Manipulative Physiol Ther 2009 (Oct); 32 (8): 616–624 ~ FULL TEXT
Fifty-seven patients (73%) reported their improvement as either "excellent" or "good." The mean patient-rated improvement was 61.5%. The mean improvement in BDQ was 17.8 points. The mean percentage of improvement in BDQ was 39% and the median was 48%. Mean improvement in pain was 2.9 points. Fifty-one percent of the patients had experienced clinically significant improvement in disability and 67% patients had experienced clinically significant improvement in pain. Patients were seen an average 6.8 visits. Follow-up data for an average of 11 months after the end of treatment were collected on 61 patients. Upon follow-up, 85.5% of patients rated their improvement as either "excellent" or "good." The mean patient-rated improvement was 83.2%. The mean improvement in BDQ was 28.1 points. The mean percentage of improvement in BDQ was 68% and the median was 87.5%. Mean improvement in pain was 3.5 points. Seventy-three percent of the patients had experienced clinically significant improvement in disability and 82% patients had experienced clinically significant improvement in pain.
There are more articles like this at our
Pediatrics Section

Do Chiropractic Physician Services for Treatment
of Low-Back and Neck Pain Improve the
Value of Health Benefit Plans?
Mercer Health and Benefits LLC (October 12, 2009) ~ FULL TEXT
This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.

Interventional Therapies, Surgery, and
Interdisciplinary Rehabilitation for Low
Back Pain: An Evidence-based Clinical
Practice Guideline from the
American Pain Society
Spine (Phila Pa 1976). 2009 (May 1); 34 (10): 1066–1077
Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.
You will want to review the complete:
Guideline for the Evaluation and Management of Low Back Pain:
Evidence Review (482 page Adobe Acrobat file)

Nonsurgical Interventional Therapies for Low Back Pain:
A Review of the Evidence for an American Pain Society
Clinical Practice Guideline
Spine (Phila Pa 1976). 2009 (May 1); 34 (10): 1078–1093
Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
You will want to review the complete:
Guideline for the Evaluation and Management of Low Back Pain:
Evidence Review (482 page Adobe Acrobat file)

Consumer Reports:
Chiropractic Top Rated Treatment for Back Pain
Consumer Reports (May 2009)
A study in the May issue of Consumer Reports shows that hands-on therapies were tops among treatments for relief of back pain. The study, which surveyed more than 14,000 consumers, was conducted by the Consumer Reports Health Ratings Center. The report states that, “eighty-eight percent of those who tried chiropractic manipulation said it helped a lot, and 59 percent were ‘completely’ or ‘very’ satisfied with their chiropractor.”

Doctors Likely to Encounter Children with
Musculoskeletal Complaints Have Low
Confidence in Their Clinical Skills
The Journal of Pediatrics 2009 (Feb); 154 (2): 267–271
Questionnaires, filled out by a broad spectrum of medical providers in England [Primary Care (n = 75), Pediatrics (n = 39), Emergency (n = 39), Orthopedics (n = 40), and experienced doctors in Primary Care (n = 93), and Pediatrics (n = 60).], revealed that 74% of them scored their personal confidence in pediatric musculoskeletal clinical assessment as "no" to "low".

Overtreating Chronic Back Pain:
Time to Back Off?
J Am Board Fam Med. 2009 (Jan); 22 (1): 62–68
Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses.

Chiropractic Management of Low Back Disorders:
Report From a Consensus Process
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651–658 ~ FULL TEXT
A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

A Diagnosis-based Clinical Decision Rule For
Spinal Pain Part 2: Review Of The Literature
Chiropractic & Osteopathy 2008 (Aug 11); 16: 7 ~ FULL TEXT
Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.

Chiropractic Management of Low Back Pain and Low Back-
Related Leg Complaints: A Literature Synthesis
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659–674 ~ FULL TEXT
As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Chiropractic Treatment of Pregnancy-related Low
Back Pain: A Systematic Review of the Evidence
J Manipulative Physiol Ther 2008 (Jul); 31 (6): 447–454 ~ FULL TEXT
Results from the 6 included studies showed that chiropractic care is associated with improved outcomes in pregnancy-related LBP. However, the low-to-moderate quality of evidence of the included studies preclude any definitive statement as to the efficacy of such care because all studies lacked both randomization and control groups. Given the relatively common use of chiropractic care during pregnancy, there is need for higher quality observational studies and controlled trials to determine efficacy.

Prognosis in Patients with Recent Onset Low Back
Pain in Australian Primary Care:
Inception Cohort Study
British Medical Journal 2008 (Jul 7); 337: a171 ~ FULL TEXT
This BMJ study contradicts Clinical Practice Guidelines that suggest that recovery from an episode of recent onset low back pain is usually rapid and complete. Their findings with 973 consecutive primary care patients was that recovery was slow for most patients, and almost 1/3 of patients did not recover within one year (when following standard medical recommendations).

A Comparison Between Chiropractic Management
and Pain Clinic Management for Chronic
Low-back Pain in a National Health
Service Outpatient Clinic
J Alternative and Complementary Medicine 2008 (Jun); 14 (5): 465–473
At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group than for the pain-clinic group. Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group. This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a sub-population of patients with chronic low-back pain (CLBP).

Prospective Case Series on the Effects of
Lumbosacral Manipulation on Dysmenorrhea
J Manipulative Physiol Ther 2008 (Mar); 31 (3): 237–246 ~ FULL TEXT
This prospective case series suggests the possibility that menstrual pain associated with primary dysmenorrhea may be alleviated by treating motion segment restrictions of the lumbosacral spine with a drop table technique. The research team needs to conduct a well-designed feasibility trial to further evaluate the effectiveness of this specific spinal manipulative technique for primary dysmenorrhea.

A Supermarket Approach to the Evidence-informed
Management of Chronic Low Back Pain
Spine J 2008 (Jan); 8 (1): 1–7 ~ FULL TEXT
Patients with chronic low back pain (CLBP) are finding it increasingly difficult to make sense of the growing list of treatment approaches promoted as solutions to this widespread problem. Their confusion is compounded by the financial and emotional cost of previous failed attempts. This frustration is felt not only by patients, but by all interested stakeholders, including clinicians trying to offer accurate advice and provide the most effective treatment to their patients, and third-party payers responsible for providing access to reasonable and necessary care. All share a common goal and wish to use limited healthcare resources to support those interventions most likely to result in clinically meaningful improvements in symptoms and functional capacity. The current approach to the management of CLBP makes this goal virtually unobtainable.

What Have We Learned About the Evidence-informed
Management of Chronic Low Back Pain?
Spine J 2008 (Jan); 8 (1): 266-277 ~ FULL TEXT
As noted in the review of the economic burden of LBP in this special focus issue, the magnitude of this problem is likely increasing in the United States and the question that needs to be answered is whether any treatment should be offered and widely used before there being sufficient research evidence to establish its efficacy, safety, and cost effectiveness. It is a generally accepted principle in most fields of health care that a treatment should not be offered to the public until there is sufficient evidence supporting its safety and effectiveness and a consensus by clinicians of different backgrounds as to its most appropriate indications and contraindications. It should be evident to most readers that this is not the norm when dealing with CLBP and additional research is required to achieve this long-term goal. In the interim, patients, clinicians, third-party payers, and policy makers have a responsibility to become thoroughly familiar with, critically appraise, compare, and openly discuss the best available evidence presented in this special focus issue. In this supermarket of over 200 available treatment options for CLBP, we are still in the era of caveat emptor (buyer beware). The enthusiastic support by providers of any treatment should be considered when reviewing available research evidence that supports its use. It is hoped that this special focus issue will provide a starting point for stakeholders desiring quality information to make decisions about the evidenceinformed management of CLBP.

A Systematic Review of Low Back Pain Cost of
Illness Studies in the United States
and Internationally
Spine J 2008 (Jan); 8 (1): 8–20~ FULL TEXT
This review identified several studies that have previously attempted to estimate the direct, indirect, or total costs associated with LBP, both in the United States and internationally. Study methodology differed considerably, making direct cost comparisons across studies and between countries difficult. The largest components of direct medical costs were PT, inpatient services, pharmacy, and primary care. From studies conducted outside the United States, it appears that direct medical costs represent only a small portion of the total costs of LBP, suggesting that interventions that are able to reduce LOD may present the opportunity for cost savings from a societal perspective. Further studies are required in the United States to estimate the total costs of LBP and inform decision making for this complex and challenging condition.

Evidence-informed Management of Chronic Low Back
Pain with Spinal Manipulation and Mobilization
Spine J 2008 (Jan); 8 (1): 213–225 ~ FULL TEXT
For CLBP, there is moderate evidence that SMT with strengthening exercise is similar in effect to prescription nonsteroidal anti-inflammatory drugs with exercise in both the short term and long term. There is also moderate evidence that flexion-distraction MOB is superior to exercise in the short term and superior/similar in the long term. There is moderate evidence that a regimen of high-dose SMT is superior to low-dose SMT in the very short term. There is limited to moderate evidence that SMT is better than physical therapy and home exercise in both the short and long term. There is also limited evidence that SMT is as good or better than chemonucleolysis for disc herniation in the short and long term. There is limited evidence that MOB is inferior to back exercise after disc herniation surgery.

Diagnosis and Treatment of Low Back Pain: A Joint
Clinical Practice Guideline from the American
College of Physicians and the
American Pain Society
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491 ~ FULL TEXT
Low back pain is the fifth most common reason for all physician visits in the United States [1, 2]. Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months [2], and 7.6% reported at least 1 episode of severe acute low back pain (see Glossary) within a 1–year period [3]. Low back pain is also very costly: Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998 [4]. In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the U.S. work force compensated for back injuries each year [5]. You will enjoy these recommendations because their ONLY recommendation for active treatment of acute low back pain is spinal adjusting (manipulation).

Nonpharmacologic Therapies for Acute and Chronic
Low Back Pain: A Review of the Evidence for an
American Pain Society/American College of
Physicians Clinical Practice Guideline
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 492–504 ~ FULL TEXT
Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.

Medications for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain
Society/American College of Physicians
Clinical Practice Guideline
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 505–514 ~ FULL TEXT
Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications.

Chiropractic and Exercise for Seniors With Low
Back Pain or Neck Pain: The Design of Two
Randomized Clinical Trials   NCT00269308   and   NCT00269321
BMC Musculoskelet Disord. 2007 (Sep 18); 8: 94 ~ FULL TEXT
To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers. This article presents the rationale and design of two mixed methods clinical trials, each consisting of an RCT, with cost-effectiveness and qualitative studies conducted alongside the central trial. Both are anticipated to be completed in 2007, at which time the results will be made available.

Back and Pelvic Pain in an Underserved United
States Pregnant Population: A Preliminary
Descriptive Survey
J Manipulative Physiol Ther. 2007 (Feb); 30 (2): 130–134 ~ FULL TEXT
Low back pain (LBP) in the general population is recognized as a major health concern, and left untreated, this malady can lead to chronic, disabling morbidity. [1, 2] Accordingly, chronic pain is a major health care expense in the United States, and LBP is responsible for the majority of chronic musculoskeletal pain. [3] Low back pain and pelvic pain (PP) in pregnancy, however, are frequently viewed as transient conditions that are anticipated to subside after childbirth. In fact, recent studies have identified that women who do have LBP/PP during pregnancy receive little recommendations and/or treatment for their complaints. [4, 5]

A Theoretical Model For the Development of a
Diagnosis-based Clinical Decision Rule for
the Management of Patients With Spinal Pain
BMC Musculoskelet Disord. 2007 (Aug 3); 8: 75 ~ FULL TEXT
In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.

Pathophysiological Model for Chronic Low Back
Pain Integrating Connective Tissue and
Nervous System Mechanisms
Medical Hypotheses 2007 (Jan); 68 (1): 74–80 ~ FULL TEXT
Although chronic low back pain (cLBP) is increasingly recognized as a complex syndrome with multifactorial etiology, the pathogenic mechanisms leading to the development of chronic pain in this condition remain poorly understood. We hypothesize that pain-related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation, nervous system sensitization and further decreased mobility. In addition to providing a new, testable framework for future mechanistic studies of cLBP, the integration of connective tissue and nervous system plasticity into the model will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise).
You will also enjoy Dr. Dan Murphy's Key Points.

The UCLA Low Back Pain Study
A Unique Series of Articles

A Randomized Trial of Medical Care with and without Physical Therapy and Chiropractic Care with and without Physical Modalities for Patients with Low Back Pain: 6-month Follow-up Outcomes From the UCLA Low Back Pain Study Spine (Phila Pa 1976) 2002 (Oct 15); 27 (20): 2193–2204 ~ FULL TEXT Of 1,469 eligible patients, 681 were enrolled; 95.7% were followed through 6 months. The mean changes in low back pain intensity and disability of participants in the medical and chiropractic care-only groups were similar at each follow-up assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95% confidence interval, –0.32–0.86; average pain, 0.22, –0.25–0.69; and disability, 0.75, –0.29–1.79). Physical therapy yielded somewhat better 6–month disability outcomes than did medical care alone (1.26, 0.20–2.32). After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

A Randomized Trial of Chiropractic and Medical Care for Patients with Low Back Pain: Eighteen-month Follow-up Outcomes from the UCLA Low Back Pain Study Spine (Phila Pa 1976). 2006 (Mar 15); 31 (6): 611–621 ~ FULL TEXT Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18–month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80–2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08–2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62–1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months. Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.

Amount of Health Care and Self-care Following
a Randomized Clinical Trial Comparing Flexion-
distraction with Exercise Program for
Chronic Low Back Pain
Chiropractic & Osteopathy 2006 (Aug 24); 14: 19 ~ FULL TEXT
Based on one-year follow-up data imputed for complete analysis, participants who received physical therapy (exercise program) during a clinical trial attended a higher number of visits to any health care provider and to general practitioners during the year after care when compared to participants who received chiropractic care (flexion distraction) within the trial. Further studies are needed to verify these data.

Diagnosis and Treatment of Low Back Pain
British Medical Journal 2006 (Jun 17); 332 (7555): 1430–1434 ~ FULL TEXT
The accumulated evidence from randomised trials and systematic reviews regarding the value of diagnostic and therapeutic interventions has now been incorporated in clinical guidelines. A few initial surveys have shown that these guidelines are being followed to some extent, but there is still room for improvement, especially in those countries and settings in which a large discrepancy exists between recommendations in guidelines and actual management in clinical practice. Measures should be taken to minimise this gap. Simply developing and publishing evidence based guidelines and subsequently disseminating these guidelines may not be effective enough to change practice. Implementation seems essential in changing clinical practice. Several trials have evaluated implementation of guidelines and its effect on patient and process outcomes. [25] [w8] These trials show modest effects at best. More intensive multifaceted interventions might be needed to achieve further progress in this area.

Back and Neck Pain in Seniors-
Prevalence and Impact
European Spine Journal 2006 (Jun); 15 (6): 802–806~ FULL TEXT
Neck pain (NP) and back pain (BP) are common symptoms in old age and 10–20% of persons over 70 reports moderate or severe NP or BP on a monthly basis. Overall, older women report more BP and NP than older men. Altering or diminishing physical activities and seeking of treatment due to NP or BP are relatively common in the older age groups, again especially among women. 1–year prevalence estimates of NP and BP in seniors may suffer from recall bias.

Hormonal and Reproductive Factors Are
Associated with Chronic Low Back Pain
and Chronic Upper Extremity Pain in Women
-- The MORGEN Study
Spine (Phila Pa 1976) 2006 (Jun 1); 31 (13): 1496–1502
Although LBP is suggested to be linked to hormonal and reproductive factors in women, results from previous studies are inconclusive. For this reason, a cross-sectional study of 11,428 Dutch women aged 20–59 years was accomplished. Multivariate logistic regression models were used to examine associations between hormonal and reproductive factors (independent variables) and, respectively, chronic LBP, chronic UEP (upper extremity pain) and combined chronic LBP/UEP. Past pregnancy, young maternal age at first birth, duration of oral contraceptive use, and use of estrogens during menopause were associated with chronic LBP, while young age at menarche was associated with chronic UEP. Irregular or prolonged menstruation and hysterectomy were associated both with chronic LBP and chronic UEP. No positive associations were found for current pregnancy and number of children.

Chiropractic Manipulation in the Treatment of
Acute Back Pain and Sciatica with Disc
Protrusion: A Randomized Double-blind
Clinical Trial of Active and Simulated
Spinal Manipulations
Spine J 2006 (Mar); 6 (2): 131–137 ~ FULL TEXT
A total of 64 men and 38 women aged 19–63 years were randomized to manipulations (53) or simulated manipulations (49). Manipulations appeared more effective on the basis of the percentage of pain-free cases (local pain 28 vs. 6%; p<.005; radiating pain 55 vs. 20%; p<.0001), number of days with pain (23.6 vs. 27.4; p<.005), and number of days with moderate or severe pain (13.9 vs. 17.9; p<.05). Patients receiving manipulations had lower mean VAS1 (p<.0001) and VAS2 scores (p<.001). A significant interaction was found between therapeutic arm and time. There were no significant differences in quality of life and psychosocial scores. There were only two treatment failures (manipulation 1; simulated manipulation 1) and no adverse events.

Is Comorbidity in Adolescence a Predictor for
Adult Low Back Pain? A Prospective Study of
a Young Population
BMC Musculoskelet Disord 2006 (Mar 16); 7: 29 ~ FULL TEXT
Your chiropractic care may be working out “kinks” in your lower back that have been around a lot longer than you realize. This new study of 10,000 Danish residents shows a link between adolescent and adult low back pain (LBP). Researchers studied twins born between 1972 and 1982 by sending out questionnaires in 1994 and again in 2002. The outcomes showed that a high percentage of those who had LBP in 1994 still suffered from LBP in 2002. They also found that those with persistent LBP were 4.5 times more likely than the average person to have future LBP episodes!
There are more articles like this at our
Pediatrics Section

The Course of Low Back Pain from Adolescence
to Adulthood: Eight-year Follow-up of 9600 Twins
Spine 2006 (Feb 15); 31 (4): 468–472
High prevalence rates of low back pain among children and adolescents have been demonstrated in several studies, and it has been theorized that low back pain in childhood may have important consequences for future low back pain. Almost 10,000 Danish twins born between 1972 and 1982 were surveyed by means of postal questionnaires in 1994 and again in 2002. The questionnaires dealt with various aspects of general health, including the prevalence of low back pain, classified according to number of days affected (0, 1–7, 8–30, >30). Low back pain in adolescence was found to be a significant risk factor for low back pain in adulthood with odds ratios as high as four. We also demonstrated a dose-response association: the more days with low back pain at baseline, the higher the risk of future low back pain.
There are more articles like this at our
Pediatrics Section

Chiropractic Spinal Manipulation for Low Back
Pain of Pregnancy: A Retrospective Case Series
J Midwifery Womens Health 2006 (Jan); 51 (1): e7–10
Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0–13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1–5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.
There are more articles like this at our
Pediatrics Section

Estimating the Global Burden of Low Back Pain
Attributable to Combined Occupational Exposures
American J Industrial Medicine 2005 (Dec); 48 (6): 459–469 ~ FULL TEXT
Worldwide, 37% of LBP was attributed to occupation, with twofold variation across regions. The attributable proportion was higher for men than women, because of higher participation in the labor force and in occupations with heavy lifting or whole-body vibration. Work-related LBP was estimated to cause 818,000 disability-adjusted life years lost annually. Occupational exposures to ergonomic stressors represent a substantial source of preventable back pain. Specific research on children is needed to quantify the global burden of disease due to child labor.
There are more articles like this at our Global Burden of Disease Section

Effects of a Managed Chiropractic Benefit on the
Use of Specific Diagnostic and Therapeutic
Procedures in the Treatment of
Low Back and Neck Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 564–569 ~ FULL TEXT
For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Classification of Low Back Pain in Primary Care:
Using "Bothersomeness" to Identify
the Most Severe Cases
Spine (Phila Pa 1976) 2005 (Aug 15); 30 (16): 1887–1892 ~ FULL TEXT
This study has investigated the use of a single question on bothersomeness in primary care patients with LBP, and provided evidence of its construct and predictive validity as a measure of severity. Its potential for use in clinical practice has been established as a method to identify in a standard way the most severely affected patients and predict outcome 6 months later. However, its usefulness and practicality in a clinical setting has not been studied, and further work is needed to clarify this. In conclusion, a simple question on bothersomeness could be useful for classifying patients with LBP at primary care consultation, and for standardized reporting and audit in clinical practice.

Cost-effectiveness of Medical and Chiropractic
for Acute and Chronic Low Back Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 555–563 ~ FULL TEXT
Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain.
There are more articles like this at our
Cost-Effectiveness Section.

Pragmatic Application of a Clinical Prediction
Rule in Primary Care to Identify Patients
with Low Back Pain with a Good Prognosis
Following a Brief Spinal
Manipulation Intervention
BMC Family Practice 2005 (Jul 14); 6 (1): 29 ~ FULL TEXT
Individuals with "non-specific" LBP are not a homogenous group, and different sub-groups of patients are likely to preferentially respond to different therapeutic management strategies. One sub-group consists of those patients with a good prognosis following spinal manipulation intervention. The results of this study demonstrate an association between two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, and outcome of a manipulation intervention.

An Epidemiologic Study of MRI and Low
Back Pain in 13-year-old Children
Spine (Phila Pa 1976). 2005 (Apr 1); 30 (7): 798–806
In children, degenerative disc findings are relatively common, and some are associated with LBP. There appears to be a gender difference. Disc protrusions, endplate changes, and anterolisthesis in the lumbar spine were strongly associated with seeking care for LBP.
There are more articles like this at our Pediatrics Section

A Clinical Prediction Rule to Identify Patients
with Low Back Pain Most Likely to Benefit from
Spinal Manipulation: A Validation Study
Annals of Internal Medicine 2004 (Dec 21); 141 (12): 920–928 ~ FULL TEXT
Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7).

The medical "debate" has been going on for years...is spinal adjusting (a.k.a manipulation) effective for Low Back Pain? The original Meade study (British Medical Journal 1990) demonstrated that chiropractic was much more effective for LBP than conventional medical care.

In 1993 the province of Ontario, Canada hired the esteemed health care economist Pran Manga, PhD to examine the benefits of chiropractic care for low back pain (LBP) and to make a set of recommendations on how to contain and reduce health care costs.

His report
A Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain
cited research demonstrating that:

(1) chiropractic manipulation is safer than medical management for LBP;

(2) that spinal manipulation is less safe and effective when performed by non-chiropractic professionals;

(3) that there is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management; and

(4) that there would be highly significant cost savings if more management of LBP was transferred from medical physicians to chiropractors.

He also stated that "A very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the Workers' Compensation System in Ontario."

In 1994 Medicine was horrified when the Agency for Health Care Policy and Research (AHCPR) confirmed the untested, questionable or harmful nature of many current medical therapies for LBP , and also stated that, of all forms of management they reviewed, only chiropractic care could both reduce pain AND improve function.

In 1995, Meade did a follow-up to his 1990 BMJ article, again publishing in the British Medical Journal 1995. It demonstrated that those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals, especially for those who suffered from chronic (or long-term) low back pain!

A recent study in SPINE Journal 2004 reveals that health care expenditures for back pain sufferers was a staggering $90.7 billion in 1998, and that prescription drugs accounted for more than 15% of that figure! This is alarming, since muscle relaxants have been associated with slower recovery rates, and steroid injections offer minimal relief. One needs to ask why drug costs continue to climb with a track record like that? Even care by physical therapists has been shown to prolong recovery from low back pain.

A chronic pain study at the University of Washington School of Medicine recently compared which treatments were most effective at reducing pain for neuromuscular diseases and found that Chiropractic scored the highest pain relief rating (7.33 out of 10), scoring higher than the relief provided by either nerve blocks (6.75) or opioid analgesics (6.37). WOW!!!

A recent 4–year retrospective study of 700,000 health plan members revealed that offering chiropractic services within a managed-care environment could save insurers 27% in back pain episode-related costs! The Cost-effectiveness Page documents many other studies with similar findings.

In December 2004, the British Medical Research Council published 2 papers in the British Medical Journal demonstrating both the efficacy and cost-effectiveness of chiropractic compared with medical management.

These two papers revealed:

• Spinal Manipulation, with or without exercise, improved symptoms more than medical care did at both 3 and 12 months.
• The authors concluded: “We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice.”

The most recent in a long line of articles showing the clear superiority of chiropractic management was published in May of 2007. Clinical and cost utilization based on 70,274 member-months over a 7–year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% less hospital days, 62.0% less outpatient surgeries and procedures, and 83% less pharmaceutical costs when compared with conventional medicine IPA performance.

That is rather significant savings, is it not?

So...what's the holdup?

Spinal Manipulation, Epidural Injections, and
Self-care for Sciatica: A Pilot Study for a
Randomized Clinical Trial
J Manipulative Physiol Ther. 2004 (Oct); 27 (8): 503–508 ~ FULL TEXT
At week 12 (the end of the treatment phase), the outcome measures indicating the most improvement/change were the Oswestry disability score (mean, 22.9; SD, 19.9; effect size [ES], 1.8), leg pain severity (mean, 2.9; SD, 1.7; ES, 1.7), and if the symptoms were bothersome (mean, 25.2; SD, 16.0; ES, 1.6). Twenty-four patients were either "very satisfied" or "completely satisfied," and 22 of 32 patients reported 75% or 100% improvement. After 52 weeks, the outcome measure showing the most improvement/change was leg pain severity (mean, 2.3; SD, 2.6; ES, 1.35), followed by the Oswestry disability score (mean, 15.6; SD, 20; ES, 1.2) and if symptoms were bothersome (mean, 18.1; SD, 22.6; ES, 1.1). Eighteen patients were either "very satisfied" or "completely satisfied," and 15 of 32 patients reported 75% or 100% improvement.

Compliance with Clinical Practice Guidelines in
Family Physicians Managing Worker's Compensation
Board Patients with Acute Lower Back Pain
Spine J 2003 (Nov); 3 (6): 442–450 ~ FULL TEXT
Physicians demonstrated a high degree of compliance with the guideline-recommended history, examination procedures and medications, but low compliance with recommended imaging and many treatment recommendations. Recently published clinical practice guidelines regarding the management of patients with acute mechanical lower back pain have not been fully implemented into the patterns of practice of the family physicians.

The British Medical Research Council (MRC) Trial
Finds Adding Spinal Manipulation and Exercise to
GP Care Provides Relief for Back Pain
The British Medical Research Council (MRC)
A Medical Research Council (MRC) trial to assess the effectiveness of adding different treatments to “best care” in general practice for patients with lower back pain has found that spinal manipulation, in the form of chiropractic, osteopathy, or manipulative physiotherapy, followed by a programme of exercise, provides significant relief of symptoms and improvements in general health. The results of the trial are published online today, Friday 19 November, in the British Medical Journal.

Post Partum and Beyond:
Managing Back Pain in Women
Dr. Diane Benizzi DiMarco ~ FULL TEXT
The post partum patient retains a higher risk for potential injury as compared to the patient who has not endured pregnancy or has not been pregnant for an extended period of time. Fertilization propels the release of estrogen, progesterone and relaxin, hormones essential to the growth and development of the embryo and fetus. These hormones that are essential to the pregnancy cause global relaxation to the ligaments and muscles in the female pregnant patient. A conglomerate of anatomical changes created by the global laxity in muscles and ligaments compromises the stability of the spine.

Chiropractors pride themselves in their ability to diagnose and manage neuro-musculo-skeletal (NMS) complains. According to all the surveys, this is our bread and butter, and no one on the planet is better trained to diagnose (locate) and treat (correct) neck, low back, or peripheral joint (knee, elbow etc) complaints. But, don't just take my word for it. Read on.

Orthopedic surgeons are supposed to be the *gods* of medicine, the pinnacle of medical knowledge. First they become MDs, then rotate through a variety of specialties, and finally take residence in a highly competitive orthopedic program. You may want to review this interesting description of the requirements for the UCLA Orthopedic Surgery's Residency Program.

The following is a long and sad tale about the weakness of modern medical education. This series of articles were all mostly published in the prestigious Journal of Bone and Joint Surgery, the Number One journal for orthopedic surgeons.

In 1998, two medical doctors at the University of Pennsylvania School of Medicine in Philadelphia, contacted all 157 chairpersons of orthopedic residency programs in the United States. Together they developed and validated a basic-competency examination in musculoskeletal medicine to give to the first year residents.

The results were astounding, because 82% of the eighty-five medical school graduates failed this BASIC competency exam!

Four years later they redesigned the exam (or changed the scoting). Even though the passing grade was LOWERED from 74% to 70%, 78% of them again failed the exam, with a mean test score average of 59.9 percent.

Isn't that frightening?

To add insult to injury, this exact same test was given to a group of 51 chiropractic students during their last semester of schooling. The results? 70% of the students passed the test. This is in contrast to an 80% failure rate for the MDs.

For clarity sake, you need appreciate the difference between the chiropractic and the medical participants in these studies.

• The chiropractic group were still JUST STUDENTS in their last undergrad year

• The medical group had already graduated medical school, been awarded their MD degrees, completed all their hospital rotations, and finally been accepted into highly competitive orthopedic residencies.

One would expect that, during their 5 years of medical training, followed by endless hours of hospital rotations and residency programs, that all these doctors *might have* picked up a little more musculoskeletal knowledge along the way.

Evidently this is NOT the case.

These medical authors concluded that residents in orthopedic surgery programs are not provided with sufficient training in NMS analysis. The truth is, they are incompetent in musculoskeletal assessment or treatment. This situation was not corrected during the 4–year interim between the publication of the 1st and 2nd article, and still has not been corrected 11 years later.

Since that time there has been a storm brewing at medical schools, but in the 11 years since Dr. Freedman published his first paper, medical students still continue to fail on basic musculoskeletal exams, as documented by the following series of peer-reviewed studies. This is a huge problem because “conditions affecting the musculoskeletal system are the primary reason patients seek medical care from physicians, accounting for nearly 100 million office visits per year. [1] Furthermore, musculoskeletal conditions are the most common cause of long-term pain and physical disability.”[2], [3]

What's the best solution? If you have spinal pain, seek care from someone who is properly trained to assess and manage your care. That person is a chiropractor.

The following articles are listed from the oldest to the newest, so that you can follow the lack of progress in correcting this issue at medical schools.

	The Adequacy of Medical School Education in Musculoskeletal Medicine Journal of Bone and Joint Surgery 1998 (Oct); 80–A (10): 1421–1427 This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that "we therefore believe that medical school preparation in musculoskeletal medicine is inadequate" and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints.
	Educating Medical Students About Musculoskeletal Problems: Are Community Needs Reflected in the Curricula of Canadian Medical Schools? Journal of Bone and Joint Surgery 2001 (Sept); 83–A (9): 1317–1320 Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. (So they conclude:) There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.
	A Comparison of Chiropractic Student Knowledge Versus Medical Residents Proceedings of the World Federation of Chiropractic Congress 2001 Pgs. 255 A previously published knowledge questionnaire designed by chief orthopedic residents was given to a Chiropractic student group for comparison to the results of the medical resident group. Based on the marking scale determined by the chief residents, the Chiropractic group (n = 51) showed statistically significant higher average grade than the orthopedic residents. Expressed in other terms, 70% of chiropractic students passed the knowledge questionnaire, compared to an 80% failure rate for the residents.
	Educational Deficiencies in Musculoskeletal Medicine Journal of Bone and Joint Surgery 2002 (Apr); 84–A (4): 604–608 According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate. NOTE: This is a follow-up article to the study cited below, which demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. What would the headlines scream if, after 4 years, our profession had failed to improve it's skills in musculoskeletal assessment and management? Ask your self why medicine is shown more slack than?
	Musculoskeletal Knowledge: How Do You Stack Up? Physician and Sportsmedicine 2002 (Aug); 30 (8) One of every 4 or 5 primary care visits is for a musculoskeletal problem. Yet undergraduate and graduate training for this burden of illness continues to constitute typically less than 3% of the medical curriculum. This is an area of clear concern, but also one in which sports medicine practitioners can assume leadership.
	Musculoskeletal Curricula in Medical Education Physician and Sportsmedicine 2004 (Nov); 32 (11) It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5–year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment. This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.[ 1 ] While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.
	Adequacy of Education in Musculoskeletal Medicine 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.
	More Evidence of Educational Inadequacies in Musculoskeletal Medicine Clin Orthop Relat Res 2005 (Aug); (437): 251–259 A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.
	Why is the Bone and Joint Decade Important? Welcome to the United States Bone and Joint Decade The Bone and Joint Decade initiative is a global campaign to improve quality of life for people with musculoskeletal conditions and to advance understanding and treatment of these conditions through research, prevention, and education. [ 1 ] The Decade aims to raise the awareness of the increasing societal impact of musculoskeletal injuries and disorders; empower patients to participate in decisions about their care; increase funding for prevention activities and research; and promote cost-effective prevention and treatment of musculoskeletal injuries and disorders.
	Doctors Likely to Encounter Children with Musculoskeletal Complaints Have Low Confidence in Their Clinical Skills The Journal of Pediatrics 2009 (Feb); 154 (2): 267–271 Questionnaires, filled out by a broad spectrum of medical providers in England [Primary Care (n = 75), Pediatrics (n = 39), Emergency (n = 39), Orthopedics (n = 40), and experienced doctors in Primary Care (n = 93), and Pediatrics (n = 60).], revealed that 74% of them scored their personal confidence in pediatric musculoskeletal clinical assessment as "no" to "low".
	Orthopaedists' and Family Practitioners' Knowledge of Simple Low Back Pain Management Spine 2009 (Jul 1); 34 (15): 1600–1603 One hundred forty family practitioners and 253 orthopaedists responded to the questionnaire. The mean family practitioners' score (69.7) was significantly higher than the orthopaedists' score (44.3) (P < 0.0001). No relation was found between the results and physician demographic factors, including seniority. Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs.
	The Inadequacy of Musculoskeletal Knowledge After Foundation Training in the United Kingdom Journal of Bone and Joint Surgery Br 2009 (Nov); 91 (11): 1413–1418 The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment.