Change in Young People's Spine Pain
Following Chiropractic Care at a
Publicly Funded Healthcare Facility in CanadaThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Complement Ther Clin Pract. 2019 (May); 35: 301–307 ~ FULL TEXT
OPEN ACCESS Christian Manansala, DC, MSc(c), Steven Passmore, DC, PhD, Katie Pohlman, DC, PhD(c), Audrey Toth, DC, Gerald Olin, BSc, DC, CDir
Faculty of Kinesiology and Recreation Management,
University of Manitoba, Canada.
BACKGROUND: The presence of spinal pain in young people has been established as a risk factor for spinal pain later in life. Recent clinical practice guidelines recommend spinal manipulation (SM), soft tissue therapy, acupuncture, and other modalities that are common treatments provided by chiropractors, as interventions for spine pain. Less is known specifically on the response to chiropractic management in young people with spinal pain. The purpose of this manuscript was to describe the impact, through pain measures, of a pragmatic course of chiropractic management in young people's spinal pain at a publicly funded healthcare facility for a low-income population.
METHODS: The study utilized a retrospective analysis of prospectively collected quality assurance data attained from the Mount Carmel Clinic (MCC) chiropractic program database. Formal permission to conduct the analysis of the database was acquired from the officer of records at the MCC. The University of Manitoba's Health Research Ethics Board approved all procedures.
RESULTS: Young people (defined as 10-24 years of age) demonstrated statistically and clinically significant improvement on the numeric rating scale (NRS) in all four spinal regions following chiropractic management.
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CHIROPRACTIC PEDIATRICS PageCONCLUSION: The findings of the present study provide evidence that a pragmatic course of chiropractic care, including SM, mobilization, soft tissue therapy, acupuncture, and other modalities within the chiropractic scope of practice are a viable conservative pain management treatment option for young people.
From the Full-Text Article:
Introduction
Spinal pain, including neck and back pain [1, 2], is a common health problem occurring in all age groups. [3] Cases of chronic non-cancerous spine pain are common in older Canadians with 60.2% reporting pain in the neck, thoracic, and lower back areas. [4] Costs associated with spine pain not only affects the health care system, but in addition, negatively impacts societal support systems. [3]
On average, patients suffering from spine pain will incur 73% higher health care costs [5] with much of this costs going towards improper management [6] such as emergency services. Neck [7] and back pain are among the most commonly encountered complaints in the emergency room, with back pain being the most common musculoskeletal complaint in emergency medicine. [8]
Recent clinical practice guidelines (CPGs) pertaining to management of patients suffering from spinal pain are encouraging non-pharmacological, non-surgical treatment options. [9–11] According to recent CPGs a trial of non-pharmacologic care should be considered as a first line treatment for those suffering from spine pain. Among the nonpharmacologic treatment suggestions is spinal manipulation (SM). [9–14] Spinal manipulation, when delivered manually, involves a high-velocity low amplitude (HVLA) thrust delivered with therapeutic intent to a targeted spinal region. It involves bringing a spinal joint to the limit of the patients’ elastic barrier and subsequently into the paraphysiologic space within the anatomical range of the joint. The goal of SM is restoration of normal range of motion and decreased pain. [15] Spinal manipulation is a cost-effective treatment option in the management of spinal pain. [16]
Recent CPGs have aimed to improve knowledge translation in the clinical setting for patients suffering with spinal pain. For young people specifically, more research is warranted to develop a CPG for spinal pain. According to the World Health Organization, young people are those from ages 10-24 years old. [17] At present, a comprehensive picture of knowledge related to the management of spinal pain in young people is difficult to portray due to the heterogeneity in which spinal pain data are collected and reported on. Heterogeneity is also found in broad prevalence ranges that include point, period, and lifetime from 1% to 89%. [18] Etiology of spinal pain in young people is also unclear with varying directions for physical, psychological, and social factor associations. [19] Most studies note an increased prevalence with females [18, 20–23], as well as increased prevalence as age increases. [18, 20, 24, 25]. Other spinal pain risk factors identified in both males and females were pubertal development and linear growth, which were found to be independent. [26] Spinal pain can limit physical activity for the aforementioned young populations, which has numerous long-term consequences; a focused effort is needed on the prevention and effective treatment strategies.
Currently, no “gold standard” exists for the treatment of spinal pain in young people. [19, 27, 28] A review on conservative interventions for low back pain in a young population only found 4 low-quality randomized clinical trials. [29] Of these, one included manual therapy, but the study may have had low statistical power having 45 participants, thus no conclusion for the intervention could be made. However, a recent high-quality randomized trial was conducted with individuals 12-18 years of age. This study found SM combined with exercise was more effective than exercise for chronic low back pain. [30] Spinal manipulation has been increasingly used for musculoskeletal pain, in spite of the lack of clear evidence that it is effective. [31, 32]
The present study utilizes prospective quality assurance data attained from a publicly funded, non-profit, community health care facility with integrated chiropractic services, including SM delivered on-site to investigate changes in spinal pain in young people following conservative care. We hypothesize that young people’s spinal pain will improve to an extent demarcated as both clinically, and statistically significant following a conservative trial of chiropractic care involving SM.
Discussion
Spine pain is common health problem [3] and afflicts many Canadians. [4] According to a cross-sectional survey performed in the province of Saskatchewan, patients suffering with spine pain commonly seek care from a medical doctor (31.6%), a chiropractor (28.8%), or both (7.9%). [36]
The present study provides evidence that young people with spinal pain responded favorably to chiropractic management. The course of care between acute and chronic cases was similar; 9.38 visits (SD = 7.94) and 8.31 visits (SD = 8.47), respectively. Throughout the course of chiropractic care patients demonstrated a point change of – 3.3 NRS reduction on average. These findings were statistically significant and clinically meaningful in all five regions and provides support that chiropractic management may be a useful treatment option for young people suffering with spinal pain of musculoskeletal etiology in socioeconomically disadvantaged communities.
The results revealed that young people responded more favorably to chiropractic management in acute cases as evidenced by the greater decrease in average numeric rating scale (NRS) point change. Patients experiencing “severe pain” experienced greater benefit (–50.0% NRS reduction) from chiropractic management when compared to patients experiencing “moderate pain” (–40.0% NRS reduction). A similar study investigating spinal pain in older adults was conducted at MCC by Passmore, Toth, Kanovsky, & Olin in 2015. The researchers found that the average course of care was 12.7 (SD = 14.3) visits, with an average NRS point reduction of – 2.04 or – 29.3% in patients who were on average 51 years old or older. [37] Patient were also found to have a BMI >30 on average categorizing patients as obese in the 2015 study. [37] Whereas, the current study on young people found the average BMI to be 28.1 categorizing patients as overweight. Psychosocial comorbidities, which were present in a modest number of the population tested included anxiety and depression, may be challenges to responding favorably to a course of care. A larger cohort of individuals specifically with psychosocial comorbidities would be an area requiring future study using a team approach including clinical psychologists. [11] Potentially addressing musculoskeletal complaints, such as spinal pain, at a younger age and lower BMI, prior to the development of other psychosocial comorbidities is an upstream solution.
Adverse events following SM, a treatment frequently delivered during a course of chiropractic management, in younger populations are rare. [38, 39] The practitioner should be cognizant of the patients’ age, and development of the spine in younger populations and the necessity to modulate SM force. [38] The safety profile of SM in the adult population is similar to that of younger populations and SM for adults is generally regarded as safe. The current evidence suggests that adverse events following SM in all populations are very rare. [38–44] From the inception of chiropractic integration into the MCC in January 2011 to the end of the study period August 2017, no minor or serious adverse event were reported as a result of SM or other chiropractic intervention on young people.
In the presence of limited evidence practitioners must remain vigilant and rely on the best available evidence to help guide their clinical decisions. The present findings provide support for chiropractic management for young people suffering with spinal pain of musculoskeletal etiology in socioeconomically disadvantaged communities as a viable treatment option.
Limitations
Several limitations should be considered based on the inherent nature of the retrospective study design. Data collected were limited to the patient demographic headings and outcome measures utilized in the database, and the sample size of young people was modest. The authors also acknowledge that treatment outcomes reflect a pragmatic course of chiropractic care, which inherently included variations in frequency of clinic visits. The pragmatic treatment approach is compliant with recent clinical practice guidelines, which are multimodal in nature. While certain instances of spinal pain may be self-limiting, there may be a risk of developing chronicity if spinal pain in young people is left untreated. [45] Without a control group we are not able to comment on whether the population in the present study would have had their symptoms spontaneously resolve if untreated, or if their symptoms would have become chronic if left untreated. Future clinical trials are warranted to resolve the aforementioned issue, in the present study we observed that young people responded favorably to a brief course of chiropractic management.
Data does not necessarily reflect the general population as the sample studied was from a socioeconomically disadvantaged, underserved community with complex comorbidities.
Conclusion
Young people from a socioeconomically disadvantaged, underserved community with spinal pain experienced both statistically and clinically significant improvements in pain severity. A pragmatic course of chiropractic management, that was multimodal in nature, was found to have a favorable outcome as a treatment option for young people suffering with spinal pain of musculoskeletal etiology from a socioeconomically disadvantaged community. Further prospective research is warranted to explore the response of young people with specific diagnoses as the etiology of their spinal pain, and the changes in their functionality and disability, in response to chiropractic management.
Acknowledgements
The authors wish to thank the administration, board and patients of the Mount Carmel Clinic and the University of XXXXX for their encouragement to pursue this project.
Conflicts of interest
The authors report no conflict of interest. The authors alone are responsible for the content and composition of the manuscript.
Acknowledgements
The authors wish to thank the administration, board and patients of the Mount Carmel Clinic and the University of XXXXX for their encouragement to pursue this project.
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