Exercise and Chiropractic Care

This section was compiled by Frank M. Painter, D.C.
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The Wolfe-Harris Center @ Northwestern Health Sciences University

Our usual Topical Pages list the newest studies first.   This page is different... for a reason.

By tracking the work of a specific research group over time, from their first to last, we can see the evolution of the question, along with their growing precision at revealing the facts. It's a different way of looking at research, and I hope you will find it as fascinating as I did.

Now meet the researchers of the The Wolfe-Harris Center for Clinical Studies
@ Northwestern Health Sciences University.

Trunk Exercise Combined with Spinal Manipulative or NSAID Therapy
for Chronic Low Back Pain: A Randomized, Observer-blinded Clinical Trial

J Manipulative Physiol Ther. 1996 (Nov);   19 (9):   570–582

Each of the three therapeutic regimens was associated with similar and clinically important improvement over time that was considered superior to the expected natural history of long-standing CLBP. For the management of CLBP, trunk exercise in combination with SMT or NSAID therapy seemed to be beneficial and worthwhile. The magnitude of nonspecific therapeutic (placebo) effects, cost-effectiveness and relative risks of side effects associated with these types of therapy need to be addressed in future studies.

A Randomized Clinical Trial of Exercise and Spinal Manipulation
for Patients with Chronic Neck Pain

Spine (Phila Pa 1976). 2001 (Apr 1);   26 (7):   788–797

For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone. The effect of low-technology exercise or spinal manipulative therapy alone, as compared with no treatment or placebo, and the optimal dose and relative cost effectiveness of these therapies, need to be evaluated in future studies.

Two-year Follow-up of a Randomized Clinical Trial of Spinal Manipulation
and Two Types of Exercise for Patients With Chronic Neck Pain

Spine (Phila Pa 1976). 2002 (Nov 1);   27 (21):   2383–2389 ~ FULL TEXT

The results of this study demonstrate an advantage of spinal manipulation combined with low-tech rehabilitative exercise and MedX rehabilitative exercise versus spinal manipulation alone over two years and are similar in magnitude to those observed after one-year follow-up. These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers. Further studies are needed to examine the cost effectiveness of these therapies and how spinal manipulation compares to no treatment or minimal intervention.

What Do Patients Think? Results of a Mixed Methods Pilot Study Assessing
Sciatica Patients' Interpretations of Satisfaction and Improvement

J Manipulative Physiol Ther. 2003 (Oct);   26 (8):   502–509 ~ FULL TEXT

This study demonstrated that a "mixed methods" approach using qualitative research methods within a clinical trial is not only feasible but can provide interesting and useful information for trial interpretation and future study design. By providing insight to the multidimensional nature of patients' beliefs and perceptions, this technique may not only shape but also redefine the focus of patient-oriented research and health care for low back pain conditions.

Exercises for Mechanical Neck Disorders
Cochrane Database Syst Rev. 2005 (Jul 20);   (3):   CD004250 ~ FULL TEXT

There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisation or manipulation for subacute and chronic MND with or without headache, in the short and long term. A program of eye fixation or proprioception exercises imbedded in a more complete program shows moderate evidence of benefit for pain [pooled SMD -0.72 (95% CI:-1.12 to -0.32)], function, and global perceived for chronic MND in the short term, and on pain and function for acute and subacute MND with headache or WAD in the long term. There is limited evidence of benefit on pain relief in the short term for a home mobilisation program with other physical modalities over a program of rest then gradual mobilisation for acute MND or WAD. There was evidence of no difference between the different exercise approaches.

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.

Individualized Chiropractic and Integrative Care for Low Back Pain:
The Design of a Randomized Clinical Trial Using a
Mixed-methods Approach
Trials. 2010 (Mar 8);   11:   24 ~ FULL TEXT

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

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

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

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

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

Spinal Manipulation, Medication, or Home Exercise With Advice
for Acute and Subacute Neck Pain: A Randomized Trial

Annals of Internal Medicine 2012 (Jan 3);   156 (1 Pt 1):   1–10 ~ FULL TEXT

For participants with acute and subacute neck pain, SMT was more effective than management with medication in both the short and long term; however, a few sessions of supervised instruction in HEA resulted in similar outcomes at most time points.

Supervised Exercise With And Without Spinal Manipulation Performs
Similarly And Better Than Home Exercise For Chronic Neck Pain:
A Randomized Controlled Trial

Spine (Phila Pa 1976). 2012 (May 15);   37 (11):   903–914 ~ FULL TEXT

Our study found that groups receiving high-dose supervised ET with and without spinal manipulation performed similarly, reporting less pain, greater global perceived effect, and more satisfaction than the low-dose home exercise group, particularly in the short term. The supervised exercise groups also demonstrated greater gains in blinded assessment of neck endurance and strength, supporting the patient-self report measures. The results of qualitative interviews suggest that personal attention played an important role in the supervised exercise groups. Various stakeholders’ perspectives should be considered carefully when making recommendations regarding these therapies for chronic neck pain patients, taking into account side effects, preferences, and costs.

"I Know It's Changed": A Mixed-methods Study of the Meaning of Global
Perceived Effect in Chronic Neck Pain Patients

Eur Spine J. 2014 (Apr);   23 (4):   888–897 ~ FULL TEXT

This work provides a better understanding of the meaning of GPE and influencing factors, than what was previously known. The GPE appears to capture chronic neck pain patient perceptions of change in different domains important to their individual pain experiences which may not be captured by other outcome instruments. Thus, the GPE scales are useful measurement tools for clinical practice and research.

Spinal Manipulation and Exercise for Low Back Pain in Adolescents:
Study Protocol for a Randomized Controlled Trial

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

This is the first randomized clinical trial assessing the effectiveness of combining spinal manipulative therapy with exercise for adolescents with low back pain. The results of this study will provide important evidence on the role of these conservative treatments for the management of low back pain in adolescents.

Short Term Treatment Versus Long Term Management of Neck and Back
Disability in Older Adults Utilizing Spinal Manipulative Therapy and
Supervised Exercise: A Parallel-group Randomized Clinical Trial
Evaluating Relative Effectiveness and Harms
Chiropractic & Manual Therapies 2014 (May 23);   22:   21 ~ FULL TEXT

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

Spinal Manipulative Therapy and Exercise For Seniors with Chronic Neck Pain
Spine J. 2014 (Sep 1);   14 (9):   1879–1889   NCT00269308

Spinal manipulative therapy (SMT) with home exercise resulted in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone. Supervised exercise sessions added little benefit to the HE-alone program.

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

Ann Intern Med. 2014 (Sep 16);   161 (6):   381—391 ~ FULL TEXT

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

Perceived Value of Spinal Manipulative Therapy and Exercise Among Seniors
With Chronic Neck Pain: A Mixed Methods Study

J Rehabil Med. 2014 (Nov);   46 (10):   1022–1028 ~ FULL TEXT

Participants placed high value on their relationships with health care team members, supervision, individualized care, and the exercises and information provided as treatment. Change in symptoms did not figure as prominently as social and process-related themes. Percpetions of age, activities, and co-morbities influenced some seniors' expectations of treatment results, and comorbidities impacted perceptions of their ability to participate in active care.   Relationship dynamics should be leveraged in clinical encounters to enhance patient satisfaction and perceived value of care.

Adverse Events Among Seniors Receiving Spinal Manipulation and Exercise
in a Randomized Clinical Trial

Man Ther. 2015 (Apr);   20 (2):   335–341 ~ FULL TEXT

Non-serious AE were reported by 130/194 participants. AE were reported by three times as many participants in supervised plus home exercise, and nearly twice as many as in SMT with home exercise, as in home exercise alone. The majority of AE were musculoskeletal in nature; several participants associated AE with specific exercises. One incapacitating AE occurred when a participant fell during supervised exercise session and fractured their arm. One serious adverse event of unknown relationship occurred to an individual who died from an aneurysm while at home. Eight serious, non-related AE also occurred. Musculoskeletal AE were common among elderly participants receiving SMT and exercise interventions for NP. As such, they should be expected and discussed when developing care plans.

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

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

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


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