Low Back Pain and Chiropractic

This section was compiled by Frank M. Painter, D.C.
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Low Back Pain Resources

Low Back Pain Guidelines from Around the World
A Chiro.Org article collection

A new addition is the Danish Institute's Low Back Pain Guidelines, available in HTML or Adobe Acrobat. This section also includes recommendations from the California Industrial Medical Council, the Royal College of General Practitioners, the 1994 AHCPR guides, the "Mercy Conference Document", and the New Zealand "Psychosocial Yellow Flags" Page

Pregnancy-related Spinal Pain and Chiropractic
A Chiro.Org article collection

Review this growing collection of studies detailing how effective chiropractic management is for pregancy-related low back and pelvic pain.

The Low Back Pain Bookshelf
A Chiro.Org book collection

Learn about chiropractic management of disc disruption.

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these learned articles about chiropractors as first-contact Spinal Health Care Experts.

Chiropractic and Pain Management
A Chiro.Org article collection

Start with conservative chiropractic care. It's cost-effective and yields higher levels of patient satisfaction.

Lower Back Trauma
Chapter 24 from:   The Rehabilitation Monograph Series

By Richard C. Schafer, D.C., FICC and the ACAPress
Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet. Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.

Joint Trauma
Chapter 8 from:   The Rehabilitation Monograph Series

By Richard C. Schafer, D.C., FICC and the ACAPress
The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur. The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.

Life-Threatening Lower Back Pain -
Decoding the Mystery Step-By-Step

By David J Schimp DC, DACNB, DAAPM, FICCN and Stefanie Krupp DC, MS
Intra-abdominal bleed (e.g. aortic aneurysm), infection and tumor are the most dangerous causes of lower back pain and carry the potential for devastating consequences.   Table 1 identifies red flags that should raise suspicion of a serious disorder. [1]

Chiropractic Cost-Effectiveness Supplement
Provided by a Joint Task Force of the ACA, ICA, CAS and the ACC
The following is a collection of studies relating to the cost effectiveness and efficacy associated with chiropractic care and the procedures that doctors of chiropractic provide. The American Chiropractic Association, The International Chiropractic Association, The Congress of State Associations, and the Association of Chiropractic Colleges appreciate the opportunity to provide these materials for your review. This presentation is divided into several parts:
  • Background studies, detailing that LBP is much more complex than the literature leads us to believe;
  • Cost-Effectiveness Studies;
  • Worker's Compensation Studies (National studies) and
  • Worker's Compensation Studies (State specific studies)
  • Additional Research Studies


Low Back Pain Research

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. 2017 (Apr 19) [Epub] ~ 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.

Noninvasive Treatments for Acute, Subacute, and Chronic
Low Back Pain: A Clinical Practice Guideline From
the American College of Physicians

Ann Intern Med. 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).

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

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.

Do Older Adults with Chronic Low Back Pain Differ from Younger Adults
Eur J Pain. 2017 (Mar 14) [Epub ahead of print]

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.

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.

Clinical Practice Guidelines for the Noninvasive Management
of Low Back Pain: A Systematic Review by the Ontario
Protocol for Traffic Injury Management
(OPTIMa) Collaboration

Eur J Pain. 2016 (Oct 6).   doi: 10.1002/ejp.931 ~ 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.

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.

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.

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]

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.

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.

Report of the NIH Task Force on Research Standards
for Chronic Low Back Pain

Int J Ther Massage Bodywork. 2015 (Sep 1);   8 (3):   16–33 ~ 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.

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.

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 ~ FULL TEXT

Regarding significant factors and treatment variables in our adjusted analysis, older age (eg, HR for age ≥55 vs <25=0.52; 99% CI 0.36 to 0.74) and WSIB reimbursement for opioid prescription in the first 4 weeks of a claim (HR=0.68; 99% CI 0.53 to 0.88) were associated with longer claim duration. Higher predisability income was associated with longer claim duration, but only among persistent claims (eg, HR for active claims at 1 year with a predisability income >$920 vs ≤$480/week=0.34; 99% CI 0.17 to 0.68).

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.

First-Contact Care With a Medical vs Chiropractic Provider
J Manipulative Physiol Ther. 2015 (Sep);   38 (7):   477–483 ~ FULL TEXT

Spinal, hip, and shoulder pain patients had clinically similar pain relief, greater satisfaction levels, and lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs.

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.

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

Deconstructing Chronic Low Back Pain in the Older Adult –
Shifting the Paradigm from the Spine to the Person
The Introduction to the Article Series

Pain Medicine 2015 (May);   16 (5):   881–885 ~ FULL TEXT

Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled [1], and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket. [1–3]   Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected.   This issue of Pain Medicine contains the first in a series of articles on how to systematically and comprehensively rethink our approach to evaluating and designing management for older adults with chronic low back pain (CLBP).

Deconstructing Chronic Low Back Pain in the Older Adult –
Part I:   Hip Osteoarthritis

Pain Medicine 2015 (May);   16 (5):   886–897 ~ FULL TEXT

An estimated one in two people with hip osteoarthritis (OA) has low back pain (LBP). [1] The Hip-Spine Syndrome (HSS) was first described by Offierski in 1983. [2] Three types of patients were described – those with “simple” HSS who had pathology of both the hip and lumbar spine, but disability related to only one source; those with “complex” HSS who had symptoms from both the hip and spine without a clear single source of disability, such as patients with low back and leg pain and who have clinical evidence of both lumbar spinal stenosis and hip OA [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part II:   Myofascial Pain

Pain Medicine 2015 (Jul);   16 (7):   1282–1289 ~ FULL TEXT

Myofascial pain (MP) as first described by Travell and Simons, is defined by a localized region of palpable tightness and tenderness within a muscle that is characterized by resistance to passive elongation, and reproduction of a predictable pattern of referred pain on palpation. [1] The pathogenesis of MP is not fully understood, but can be a local muscle response to underlying mechanical factors (postural abnormalities, biomechanical faults, chronic strain), or a response to altered neurotrophic factors secondary to spondylosis. [2–4]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part III:   Fibromyalgia Syndrome

Pain Medicine 2015 (Sep);   16 (9):   1709–1719 ~ FULL TEXT

Fibromyalgia syndrome (FMS) is a challenging diagnosis for many health care providers given the breadth of symptoms patients have on presentation and the paucity of specific objective findings. Twenty-five years ago, FMS was initially described as a syndrome characterized by widespread musculoskeletal pain that could not be explained by another diagnosis. [1] FMS has been increasingly recognized to encompass additional features such as fatigue and nonrestorative sleep, and these other symptoms are included in the updated 2010 American College of Rheumatology (ACR) criteria. [2] The prevalence of FMS increases with age, has a female preponderance, peaks in the seventh decade, and varies from <1% to 5%. [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part IV:  Depression

Pain Medicine 2015 (Nov);   16 (11):   2098–2108 ~ FULL TEXT

Major depressive disorder (MDD) has a reported 1-year prevalence of 6–12% in older adults in both Veterans Affairs and civilian settings. In addition to MDD, the prevalence of clinically significant subsyndromal depressive symptoms in late-life (generally defined as ≥65 years) is estimated to be even higher. This may be due to under-recognition in the context of complex comorbidities. [1, 2] Depression is often a recurrent illness, triggered, and exacerbated by both psychological stress and medical illnesses. High medical burden in older adults contributes to treatment response variability such as delayed response to antidepressant pharmacotherapy and increased likelihood of recurrence. [3]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part V:  Maladaptive Coping

Pain Medicine 2016 (Jan);   17 (1):   64–73 ~ FULL TEXT

Older adults who experience chronic low back pain (CLBP) develop behavioral and cognitive coping strategies to tolerate or reduce pain. These coping strategies have been shown to significantly predict pain, functional capacity, and chronification of LBP. For example, adaptive coping strategies are generally associated with reduced pain, positive affect, and better psychological adjustment [1], whereas maladaptive coping strategies have been linked with negative outcomes such as psychological distress, increased pain, and heightened disability. [2–4] Please see Table 1 for examples of maladaptive and adaptive coping strategies.

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VI:   Lumbar Spinal Stenosis

Pain Medicine 2016 (Mar);   17 (3):   501–510 ~ FULL TEXT

Lumbar spinal stenosis (LSS) is a common source of pain and diminished function among older adults with chronic low back pain (CLBP). Lumbar spinal stenosis results from narrowing of the lumbar spinal canal, and/or intervertebral foramina most often resulting from degenerative changes in the spine including facet joint arthrosis, loss of intervertebral disk height, degenerative spondylolisthesis, ligament thickening, post-surgical fibrosis, etc. [1] The prevalence of LSS based on imaging criteria is estimated to be almost 50% in individuals over age 60, but many older adults with imaging evidence of anatomical stenosis are asymptomatic. [2] Lumbar spinal stenosis is the most common indication for spinal surgery among Medicare recipients, [3, 4] occurring at a rate of 135.5 surgeries per 100,000 Medicare beneficiaries in 2007. [5]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VII:   Insomnia

Pain Med. 2016 (May);   17 (5):   851–863 ~ FULL TEXT

Sleep problems are a highly prevalent comorbidity and consequence of chronic low back pain (CLBP), impacting an estimated 50–80% of individuals with CLBP. [1–3] Insomnia – dissatisfaction with sleep quantity or quality related to difficulty initiating, maintaining, and/or early morning awakenings [4] – is the most common sleep disorder in the general population and among those with CLBP. [5] Insomnia also significantly increases the risk of developing CLBP, even after controlling for socioeconomic, self-reported health, lifestyle behaviors, and anthropometric variables. [6]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part VIII:   Lateral Hip and Thigh Pain

Pain Med. 2016 (May);   17 (5):   851–863 ~ FULL TEXT

Many physicians assume that an older adult with low back pain (LBP) and concomitant lateral hip/thigh pain has lumbar spinal stenosis. However, in reality there are myriad causes of lateral hip/thigh pain in older adults and the diagnosis of this pain can be challenging due to pain referral patterns. First, the hip and nearby lumbopelvic structures share innervation from common nerve roots, so pain referral patterns from pathology of these structures overlap. [1, 2] Second, faulty mechanics of the lumbar spine and/or hip can lead to compensatory movement patterns and eventually result in multiple pain generators. These challenges are illustrated in a study by Sembrano and colleagues. In a sample of 200 patients presenting for evaluation by a spine surgeon, only 65% had isolated spine pain, whereas 17.5% had a combination of hip, spine, and/or sacroiliac (SI) joint pain. [3] Lastly, diagnosing the etiology of hip and lumbopelvic pain in older adults is challenging in that many people have structural abnormalities on imaging studies that are asymptomatic. For instance, 93% of asymptomatic people 60–80 years old have MRI evidence of disc degeneration, 36% have a herniated disc, and 21% have spinal stenosis. [4] Additionally, only 46.5% of women ages 65 years and older who have radiographic evidence of hip osteoarthritis (OA) report hip pain “on most days for at least 1 month”. [5]

Deconstructing Chronic Low Back Pain in the Older Adult –
Part IX:   Anxiety

Pain Med. 2016 (Aug);   17 (8):   1423–1435 ~ FULL TEXT

Patients with chronic low-back pain (CLBP) commonly exhibit increased levels of emotional distress. [1]   For example, anxious mood and other symptoms of anxiety are commonly seen in patients with CLBP. [2]   Prevalence of anxiety disorders in CLBP patients (19–31%) has been found to be greater than that of the general population (10–25%). [3–5]   Polatin and colleagues (1993) also found that approximately 95% of adults with a lifetime history of anxiety disorders experienced these symptoms prior to the onset of low back pain, with only 5% reporting the development of anxiety after the onset of low-back pain. [3]   Additionally, symptoms of psychological distress (e.g., anxiety and somatization) have been found to predict subsequent onset of new episodes of low back pain. [6, 7]

Pain Location Matters: The Impact of Leg Pain on Health Care Use,
Disability and Quality of Life in Patients with Low Back Pain

Eur Spine J. 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.

Comparison of Spinal Manipulation Methods and Usual Medical Care
for Acute and Subacute Low Back Pain: A Randomized Clinical Trial

Spine (Phila Pa 1976). 2015 (Feb 15);   40 (4):   209–217 ~ FULL TEXT

Manual-Thrust Manipulation (MTM) provides greater short-term reductions in self-reported disability and pain scores compared with Usual Medical Care (UMC) or Mechanical-Assisted Manipulation (MAM).

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.

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

The number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.

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.

A Comparison of Chiropractic Manipulation Methods and Usual
Medical Care for Low Back Pain: A Randomized Controlled
Clinical Trial

J Altern Complement Med. 2014 (May);   20 (5):   A22–23

The primary aim of this study was to compare manual and mechanical methods of spinal manipulation (Activator) for patients with acute and sub-acute low back pain. These are the two most common methods of spinal manipulation used by chiropractors, but there is insufficient evidence regarding their comparative effectiveness against each other. Our secondary aim was to compare both methods with usual medical care.

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.

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].

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.

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

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.

Spinal High-velocity Low Amplitude Manipulation in Acute Nonspecific
Low Back Pain: A Double-blinded Randomized Controlled Trial
in Comparison With Diclofenac and Placebo

Spine 2013 (Apr 1);   38 (7):   540–548

A total of 101 patients with acute LBP (for <48 hr) were recruited from 5 outpatient practices, exclusion criteria were numerous and strict. Outcomes registered by a second and blinded investigator included self-rated physical disability, function (SF–12), off-work time, and rescue medication between baseline and 12 weeks after randomization. In a subgroup of patients with acute nonspecific LBP, spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo.

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]

New Oregon LBP Guidelines:   Try Chiropractic First
Dynamic Chiropractic ~ FULL TEXT

This 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 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.

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.

The Burden of Chronic Low Back Pain: Clinical Comorbidities,
Treatment Patterns, and Health Care Costs in Usual Care Settings

Spine (Phila Pa 1976). 2012 (May 15);   37 (11):   E668–677

Relative to controls, patients with CLBP had a greater comorbidity burden including a significantly higher (P < 0.0001) frequency of musculoskeletal and neuropathic pain conditions and common sequelae of pain such as depression (13.0% vs. 6.1%), anxiety (8.0% vs. 3.4%), and sleep disorders (10.0% vs. 3.4%). Pain-related pharmacotherapy was significantly greater (P < 0.0001) among patients with CLBP including opioids (37.0% vs. 14.8%; P < 0.0001), nonsteroidal anti-inflammatory drugs (26.2% vs. 9.6%; P < 0.0001), and tramadol (8.2% vs. 1.2%; P < 0.0001). Prescribing of "adjunctive" medications for treating conditions associated with pain (i.e., depression, anxiety, and insomnia) was also significantly greater (P < 0.0001) among patients with CLBP; 36.3% of patients received combination therapy. Health care costs were significantly higher in the CLBP cohort (P < 0.0001), reflecting greater resource utilization. Total direct medical costs were estimated at $8386 ± $17,507 in the CLBP group and $3607 ± $10,845 in the control group; P < 0.0001).

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.

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

In the Danish and the Swedish populations respectively, 93/110 (85%) and 233/262 (89%) of the subjects were eligible for analysis. In both groups, zero weeks were rather rare and were most commonly (in 40% of the zero weeks) reported as a single isolated week. The prevalence of pain free periods, i.e. reporting a maximum of 0, 1 or 2, or 3–6 zero weeks in a row, were similar in the two populations (20–31%). Smaller percentages were reported for ≥ 7 zero weeks in a row. There were no significant differences between the two study

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 Rupert's ground-breaking JMPT article, titled:   Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65 and Older, Part II.

Cost-Effectiveness of General Practice Care for Low Back Pain:
A Systematic Review

Eur Spine J. 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

Eur Spine J. 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

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.

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.

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.

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.

The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO)
Study: A Randomized Controlled Trial on the Effectiveness of Clinical Practice
Guidelines in the Medical and Chiropractic Management of Patients with Acute
Mechanical Low 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.

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.

An Updated Overview of Clinical Guidelines for the Management
of Non-specific Low Back Pain in Primary Care

Eur Spine J. 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.

Synthesis of Recommendations for the Assessment
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

     The Initial Study

Can Patient Reactions to the First Chiropractic Treatment Predict
Early Favorable Treatment Outcome in
Persistent Low Back Pain?

J Manipulative Physiol Ther. 2002 (Sep);   25 (7):   450–454 ~ FULL TEXT

Of the 115 patients in the most favorable prognostic group, 84% (95% confidence interval, 77–91) reported to be "definitely improved" by the 4th visit versus 63% (59–67) of the 384 patients in the intermediate prognostic group, and 30% (22–38) of the 116 patients in the least favorable prognostic group. No major interactions from the covariates could explain these results.   Among chiropractic patients with persistent low back pain, it is possible to predict which patients will report definite improvement early in the course of treatment.

     The Predictive Series

The Nordic Back Pain Subpopulation Program: Demographic and
Clinical Predictors for Outcome in Patients Receiving
Chiropractic Treatment for Persistent Low–Back Pain

J Manipulative Physiol Ther. 2004 (Oct);   27 (8):   493–502 ~ FULL TEXT

Treatment outcome at the fourth visit was best predicted by a model containing the following 5 variables: sex, social benefit, severity of pain, duration of continuous pain at first consultation, and additional neck pain (odds ratios between 2.2 and 4.3). A similar profile was found at 3 months, but 2 different variables (relating to disability) were the final variables in relation to the 12–month status. These final models were best at predicting absence of treatment success. Being low-back pain free at the fourth visit was a strong predictor for being low-back pain free both at 3 months and 12 months, with relative risks of 3.0 (2.2–4.8) and 3.1 (1.5–6.5), respectively.

The Nordic Back Pain Subpopulation Program: A 1-year Prospective
Multicenter Study of Outcomes of Persistent Low-back Pain
in Chiropractic Patients

J Manipulative Physiol Ther. 2005 (Feb);   28 (2):   90–96 ~ FULL TEXT

Considerable improvement was noted between baseline and the fourth visit both for mean values and in numbers of LBP-free patients. There was virtually no further mean improvement up to the third month, whereas the number of LBP-free individuals doubled. At 12 months, no additional improvement was noted, and 80% reported that they had experienced recurrent problems. Less than 1% reported considerable worsening. Severity of symptoms at baseline determined the subsequent outcome, mild symptoms tending to worsen, and severe symptoms tending to improve.   The outcome pattern is similar to that found in other clinical studies. Treatment outcome should be measured early with follow-up at 3 rather than at 12 months, because patients will improve or recover quickly but may experience recurring problems. Numbers "cured" appear to be a feasible outcome variable in this type of study population.

The Nordic Back Pain Subpopulation Program: Can Patient Reactions
to the First Chiropractic Treatment Predict Early Favorable Treatment
Outcome in Nonpersistent Low Back Pain?

J Manipulative Physiol Ther. 2005 (Mar);   28 (3):   153–158 ~ FULL TEXT

Information was provided on 708 patients, of which 674 questionnaires were valid. Of the 223 patients in the hypothesized best prognostic group, 91% (95% CI, 79–100) reported to be "definitely improved" by the fourth visit, vs 76% (72–80) of the 420 patients in the intermediate prognostic group, and 36% (19–53) of the 31 patients in the least favorable prognostic group. These results were not altered after controlling for the covariates.   For chiropractic patients with nonpersistent LBP, these findings show that it is possible to predict already by the second visit which patients may or may not report improvement at the fourth visit.

The Nordic Back Pain Subpopulation Program: Validation and Improvement
of a Predictive Model for Treatment Outcome in Patients With Low Back Pain
Receiving Chiropractic Treatment

J Manipulative Physiol Ther. 2005 (Jul);   28 (6):   381–385 ~ FULL TEXT

In this study, patients with LBP who also had leg pain and LBP occurring sufficiently frequently or having lasted sufficiently long to add up to at least 30 days in the past year, and who did not report definite general improvement by the second treatment were not good candidates for short-term recovery. It is suggested that patients who fit the criteria of potential nonresponders should be carefully monitored to allow a selective approach of care.

The Nordic Back Pain Subpopulation Program: The Long-term
Outcome Pattern in Patients With Low Back Pain
Treated by Chiropractors in Sweden

J Manipulative Physiol Ther. 2005 (Sep);   27 (7):   472–478 ~ FULL TEXT

Patients were spread in a U-shaped fashion from benign to severe with the 2 extreme groups being most prevalent. About half the participants reported "no LBP in the past week" at 3 months and somewhat fewer at 12 months. Almost 75% claimed to be definitely better at 3 months, and approximately 50% at 12 months. Specific predictive subgroups can be identified, mainly in relation to the past-year history of LBP. Improvement at the fourth visit is a predictor of long-term outcome.

The Nordic Back Pain Subpopulation Program: Predicting Outcome
Among Chiropractic Patients in Finland

Chiropractic & Osteopathy 2008 (Nov 7);   16:   13 ~ FULL TEXT

The Swedish model was reproduced in this study sample. An alternative model including leg pain (yes/no), improvement at 2nd visit (yes/no) and BMI (underweight/normal/overweight or obese) was also identified with similar predictive values. Common throughout the testing of various models was that improvement at the 2nd visit had an odds ratio of approximately 5. Additional analyses revealed a dose-response in that 84% of those patients who fulfilled none of these (bad) criteria were classified as "definitely better" at the 4th visit, vs. 75%, 60% and 34% of those who fulfilled 1, 2 or all 3 of the criteria, respectively.

The Nordic Back Pain Subpopulation Program: Individual Patterns
of Low Back Pain Established by Means of Text Messaging:
A Longitudinal Pilot Study

Chiropractic & Osteopathy 2009 (Nov 17);   17:   11 ~ FULL TEXT

A total of 110 patients were included from 5 chiropractic clinics, and the study sample consisted of the 78 patients who participated at least until week 12. Nine of the predefined patterns were identified within this population. The majority of patients improved within the first four weeks (63%), and such early improvement was associated with a generally favourable course. Patients with nonspecific LBP were shown to have a number of different course-patterns. The next step is to explore whether the identified patterns relate to different LBP diagnoses.

The Nordic Subpopulation Research Program: Prediction of Treatment
Outcome in Patients With Low Back Pain Treated By Chiropractors --
Does the Psychological Profile Matter?

Chiropractic & Osteopathy 2009 (Dec 30);   17:   14 ~ FULL TEXT

In all, 55 of 99 invited chiropractors collected information on 731 patients. At the 4(th )visit data were available on 626 patients and on 464 patients after 3 months. At the three months follow-up, duration of pain in the past year, and pain in other parts of the spine in the past year were independently associated with outcome. However, both the sensitivity and specificity were relatively low (60% and 50%). The addition of the psychological variables did not improve the models and none of the psychological variables remained significant in the final analyses. Psychological factors were not found to be relevant in the prediction of treatment outcome in Swedish chiropractic patients with LBP.

The Nordic Back Pain Subpopulation Program: Course Patterns
Established Through Weekly Follow-ups in Patients Treated
For Low Back Pain

Chiropractic & Osteopathy 2010 (Jan 15);   18:   2 ~ FULL TEXT

We suggest that follow-ups in studies concerning primary sector LBP care are conducted in week seven after treatment was initiated and at some later point which cannot be established from this study. In clinical practice we recommend that patients' LBP status is systematically followed for the first four weeks since lack of improvement during that period should cause watchfulness.

The Nordic Back Pain Subpopulation Program: Can Low Back Pain Patterns
Be Predicted From the First Consultation With a Chiropractor?
A Longitudinal Pilot Study

Chiropractic & Osteopathy 2010 (Apr 29);   18:   8 ~ FULL TEXT

A total of 110 patients were included and 76 (69%) completed follow-up. Thirty-five patients were examined by two chiropractors. The agreement regarding diagnostic classes was 83% (95% CI: 70 – 96). The diagnostic classes were associated with the pain course patterns and number of LBP days. Patients with disc pain had the highest number of LBP days and patients with muscular pain reported the fewest (35 vs. 12 days, p < 0.01). Men had better outcome than women (17 vs. 29 days, p < 0.01) and patients without leg pain tended to have fewer LBP days than those with leg pain (21 vs.31 days, p = 0.06). Duration of LBP at the first visit was not associated with outcome.

Other Key Studies For Predicting Candidates and Outcomes

A Clinical Model for the Diagnosis and Management of Patients
With Cervical Spine Syndromes

Australasian Chiropractic & Osteopathy 2004 (Nov);   12 (2):   57–71 ~ FULL TEXT

Neck pain and related disorders are a group of conditions that are common and often disabling. It can be argued that the importance of these disorders is under-appreciated. Because of the prevalence of low back pain and its great cost to society, much clinical attention and research dollars are focused on the low back. But epidemiological research suggests that cervical related disorders are as common and may be more costly to society than low back disorders. [1–4]

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.

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.

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].

Predictors of Outcome in Neck Pain Patients Undergoing
Chiropractic Care: Comparison of Acute and Chronic Patients

Chiropractic & Manual Therapies 2012 (Aug 24);   20 (1):   27 ~ FULL TEXT

The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients.
There are many similar articles at our Diagnosis and Management Page

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 “It is unclear why more complex operations are increasing. It seems implausible that the number of patients with the most complex spinal pathology increased 15–fold in just 6 years. The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications... financial incentives to hospitals and surgeons for more complex procedures may play a role...” 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.

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.

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 Study With 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.

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.

Spinal Manipulation for Low-Back Pain
National Center for Complementary and Alternative Medicine (NCCAM)

Low-back pain is a common condition that can be difficult to treat. Spinal manipulationThe application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems, including chiropractic medicine, massage, and naturopathy. is among the treatment options used by people with low-back pain in attempts to relieve pain and improve functioning. It is performed by chiropractors and other health care professionals such as physical therapists, osteopaths, and some conventional medical doctors. This fact sheet summarizes the current scientific knowledge about the effects of spinal manipulation on low-back pain.

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.

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.

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.

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.

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!

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.

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.

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.

Cost-effectiveness of Medical and Chiropractic Care 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 in the Cost-Effectiveness Page.

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.

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).

End Medical Mis-Management of LBP

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;   (4) and 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. 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 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?

Cost Effectiveness of Physical Treatments for Back Pain in Primary Care
British Medical Journal 2004 (Dec 11);   329 (7479):   1381 ~ FULL TEXT

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. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with "usual care" in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain. [1]
Read both British Medical Journal articles about the UK BEAM Trial now.

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.

End Medical Mis-Management of Musculoskeletal Complaints

Q.   Are medical doctors well trained to diagnose or treat musculoskeletal complaints?

A.   Read the unsettling answer in this series of articles

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

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

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

In 1998, two medical doctors at the University of Pennsylvania School of Medicine in Philadelphia, contacted all 157 chairpersons of orthopedic residency programs in the United States. Together they developed and validated a basic-competency examination in musculoskeletal medicine to give to the first year residents. The results were astounding, because 82% of the eighty-five medical school graduates failed this BASIC competency exam!

Four years later they redesigned the exam and again gave it to all the residents. 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) August

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
J Bone Joint Surg Am 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.


1.   Musculoskeletal conditions in the United States.
Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999

2.   Burden of major musculoskeletal conditions
Bull World Health Organ 2003;   81 (9):   646–656

3.   Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov);   32 (11)

Palmer Research Center Conducting Several Clinical Trials on Back Pain
The Palmer Center for Chiropractic Research is currently studying back pain through several groundbreaking clinical trials at its research clinic. About 500 people from throughout the Quad-City region who suffer from back pain are being recruited to participate in two separate clinical trials, expected to last up to 18 months. Both studies are funded through federal grants totaling $2.4 million.

Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain
and Related Disabilities: A Preliminary Study

J Manipulative Physiol Ther 2004 (Oct);   27 (8):   509–514 ~ FULL TEXT

This study demonstrated two important points: (1) Chiropractic is effective for chronic low back pain (LBP), and (2) that ongoing supportive care can reduce disability levels, as measured by the Oswestry Low Back Pain Disability questionnaire.

Dose-response for Chiropractic Care of Chronic Low Back Pain
Spine J 2004 (Sep);   4 (5):   574–583 ~ FULL TEXT

There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.

A Randomized Clinical Trial Comparing Chiropractic Adjustments to
Muscle Relaxants for Subacute Low Back Pain

J Manipulative Physiol Ther 2004 (Jul);   27 (6):   388–398 ~ FULL TEXT

Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing Global Impression of Severity Scale (GIS).

Complementary and Alternative Medical Therapies for Chronic
Low Back Pain: What Treatments Are Patients Willing To Try?

BMC Complement Altern Med. 2004 (Jul 19);   4:   9 ~ FULL TEXT

Most patients with chronic back pain in our sample were interested in trying therapeutic options that lie outside the conventional medical spectrum. This highlights the need for additional studies evaluating their effectiveness and suggests that researchers conducting clinical trials of these therapies may not have difficulties recruiting patients.

Efficacy of Spinal Manipulation and Mobilization for Low Back Pain
and Neck Pain: A Systematic Review and Best Evidence Synthesis

Spine Journal (of the North American Spine Society) 2004 (May);   4 (3):   335–356

Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and neck pain. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.

A Practice-Based Study of Patients With Acute and Chronic
Low Back Pain Attending Primary Care and Chiropractic
Physicians: Two-Week to 48-Month Follow-up

J Manipulative Physiol Ther 2004 (Mar);   27 (3):   160–169 ~ FULL TEXT

This study found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients' first year of symptoms.

Safety of Spinal Manipulation in the Treatment of Lumbar
Disk Herniations: A Systematic Review
and Risk Assessment

J Manipulative Physiol Ther 2004 (Mar);   27 (3):   197–210 ~ FULL TEXT

An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million. The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.

Biomechanical and Neurophysiological Responses to Spinal Manipulation
in Patients With Lumbar Radiculopathy

J Manipulative Physiol Ther. 2004 (Jan);   27 (1):   1–15 ~ FULL TEXT

Because spinal manipulation (SM) is a mechanical intervention, it is inherently logical to assume that its mechanisms of therapeutic benefit may lie in the mechanical properties of the applied force (mechanical mechanisms), the body's response to such force (mechanical or physiologic mechanisms), or a combination of these and other factors. Basic science research, including biomechanical and neurophysiological investigations of the body's response to SM, therefore, should assist researchers, educators, and clinicians to understand the mechanisms of SM, to more fully develop SM techniques, to better train clinicians, and ultimately attempt to minimize risks while achieving better results with patients.

FCER Critiques 2 LBP Articles in Annals of Internal Medicine
The June 3, 2003 issue of Annals of Internal Medicine featured two studies which questioned the clinical and cost-effectiveness of spinal manipulation. The first is titled Spinal Manipulative Therapy for Low Back Pain: A Meta-Analysis of Effectiveness Relative to Other Therapies. The second study is titled A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain.   After careful review of these articles, Anthony L. Rosner, Ph.D., Director of Research for the Foundation for Chiropractic Education and Research (FCER), authored critical responses on behalf of the chiropractic profession.   In addition to sharing his understanding of what constitutes research of clinical utility, Dr. Rosner has been able to apply his knowledge of the better research offering significant support for spinalmanipulation, helping the chiropractic profession and the public recognize potentially flawed conclusions.

The Course of Low Back Pain in a General Population.
Results From a 5-year Prospective Study

J Manipulative Physiol Ther. 2003 (May);   26 (4):   213–219 ~ FULL TEXT

Low back pain should not be considered transient and therefore neglected, since the condition rarely seems to be self-limiting but merely presents with periodic attacks and temporary remissions. On the other hand, chronicity as defined solely by the duration of symptoms should not be considered chronic.

Low Back Pain: What Is The Long-term Course?
A Review of Studies of General Patient Populations

Eur Spine J 2003 (Apr);   12 (2):   149–165

The results of the review showed that the reported proportion of patients who still experienced pain after 12 months was 62% on average (range 42–73%)...the percentage who experienced relapses of pain was 60% (range 44–78%), and the percentage who had relapses of work absence was 33% (range 26–37%)...The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.

Manual Therapy and Exercise Therapy in Patients With
Chronic Low Back Pain: A Randomized, Controlled Trial
With 1-Year Follow-Up

SPINE (Phila Pa 1976) 2003 (Mar 15);   28 (6):   525–531

Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. Immediately after the 2–month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work (P < 0.01), a relative difference that was maintained throughout the follow-up period.

Evaluation of Chiropractic Management of Pediatric Patients
with Low Back Pain: A Prospective Cohort Study

J Manipulative Physiol Ther 2003 (Jan);   26 (1):   1–8 ~ FULL TEXT

Fifteen chiropractors provided data on 54 consecutive pediatric patients with LBP. The average age of the patients was 13.1 years, 57% were male, 61% were acute, with 47% attributing onset to a traumatic event (most commonly sports-related); 24% reported an episode duration of greater than 3 months. Almost 90% of cases presented with uncomplicated mechanical LBP, most frequently diagnosed as lumbar facet dysfunction or subluxation.

Locating and Treating Low Back Pain of Myofascial Origin
by Ischemic Compression

Journal of the Canadian Chiropractic Assoc 2002 (Dec);   46 (4)

The purpose of this article is to describe a method to identify and treat trigger points of myofascial origin by ischemic compression among patients with low back pain. In addition to a review of the literature, the author draws upon his own clinical experience to accomplish this goal. In general, thumb pressure is used for the identification, localization and treatment of trigger points and tender spots within the muscles of the lumbar, pelvic, femoral and gluteal areas. The management of low back pain of myofascial origin by ischemic compression can be used in any setting, without the need of specialized equipment. In addition to clinical effectiveness within a wide range of safety, this approach is easy on the practitioner and well tolerated by the patient.

Back, Neck, and Shoulder Pain in Finnish Adolescents:
National Cross Sectional Surveys

British Medical Journal 2002 (Oct 5);   325 (7367):   743–745 ~ FULL TEXT

To study changes in the prevalence of pain in the back or neck in adolescents between the years 1985 and 2001, the authors compared biennial nationwide postal surveys, between 1985–2001, and annual classroom surveys, from 1996–2001. They found that pain in the neck, shoulder, and lower back is becoming more common in Finnish adolescents. This pain suggests a new disease burden of degenerative musculoskeletal disorders for future adults. Prevalence of pain in the back and neck was greater in the 1990s than in the 1980s and increased steadily from 1993 to 1997. Pain of the neck and shoulder and pain of the lower back was much more common in 1999 than in 1991 and in 2001 than in 1999. Pain was more common among girls and older groups: pain of the neck and shoulder affected 24% of girls and 12% of boys in 14 year olds, 38% of girls and 16% of boys in 16 year olds, and 43% of girls and 19% of boys in 18 year olds; pain in the lower back affected 8% of girls and 7% of boys in 14 year olds, 14% of girls and 11% of boys in 16 year olds, and 17% of boys and 13% of girls in 18 year olds.

A Randomized Trial of Medical Care with and without
Physical Therapy and Chiropractic Care with and without
Physical Modalities for Patients with Low Back Pain:
6-month Follow-up Outcomes From the UCLA Low Back Pain Study

Spine (Phila Pa 1976) 2002 (Oct 15);   27 (20):   2193–2204 ~ FULL TEXT

After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

The Not-So-Hidden Costs of Back Pain
Some "experts" – ironically, those outside the chiropractic profession – have attempted to describe back pain as a harmless, self–limiting condition that requires only rest and time for resolution, despite evidence to the contrary. If that's the case, how do these experts explain the results of a study published in the Jan. 1, 2004 issue of Spine?

Appropriate ICD–9 Diagnostic Coding in the Low Back Pain Case
The "pecking order" in which you place your diagnoses in box 21 of the CMS–1500 claim plays a role in the way insurance companies interpret the severity of a patient's condition and ultimately, how much they'll pay. The diagnoses you choose represent your patient's condition to the insurance company and must be extremely accurate. If a patient presents to your office with severe low back pain, severe leg pain, constant leg numbness and foot drop, don't automatically assume and report disc involvement without a diagnostic test to substantiate it. A table with specific codes is supplied. You will enjoy this free online ICD–9 coding tool to help you create the most specific coding possible at FlashCode.

Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain:
Risk Factors for Long–Term Disability and Work Loss

New Zealand Guidelines Group ~ FULL TEXT

This guide is to be used in conjunction with the New Zealand Acute Low Back Pain Guide. It provides an overview of risk factors for long–term disability and work loss, and an outline of methods to assess these at risk. Identification should lead to appropriate early management targeted towards the prevention of chronic pain and disability.

Clinical Guidelines for the Management of Low Back Pain in Primary Care:
An International Comparison

SPINE (Phila Pa 1976) 2001 (Nov 15);   26 (22):   2504–2513

Clinical guidelines from 11 different countries published from 1994 until 2000 were included in this review. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions.
You may review more articles like this in the: LOWBACK GUIDELINES Page.

Pain, Disability, and Satisfaction Outcomes and Predictors of Outcomes:
A Practice-based Study of Chronic Low Back Pain Patients Attending
Primary Care and Chiropractic Physicians

J Manipulative Physiol Ther. 2001 (Sep);   24 (7):   433–439

Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study.

A Prospective Study of Back Belts for Prevention of Back Pain and Injury
Jou. American Medical Association 2000 (Dec 6);   284 (21):  2727–2732 ~ FULL TEXT

In the largest prospective cohort study of back belt use, adjusted for multiple individual risk factors, neither frequent back belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain.

A Comparison of Physical Therapy, Chiropractic Manipulation,
and Provision of an Educational Booklet for the Treatment
of Patients with Low Back Pain

New England Journal of Medicine 1998 (Oct 8);   339 (15):   1013–1029

This amusing paper found that an "educational booklet" was as effective as either chiropractic or McKenzie protocol! I still can't figure out how they managed to charge $153.00 for each and every booklet...what idiot funded this project? Maybe selling $153. books will be medicine's next big "breakthrough" in managing low back pain. Nice work, if you can get it!

Research:   New Challenges for Chiropractic
Response to the Low Back Pain study in the New England Journal of Medicine listed above.   Read these responses from the Research and Academic Community.

Congruence between Decisions To Initiate Chiropractic
Spinal Manipulation for Low Back Pain and
Appropriateness Criteria in North America

Annals of Internal Medicine 1998 (Jul 1);   129:   9–17 ~ FULL TEXT

The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.
Responses to the above AIM Article from our Viewers

Complementary Care:
When Is It Appropriate? Who Will Provide It?

Annals of Internal Medicine 1998 (Jul );   129:   65–66 ~ FULL TEXT

The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low back pain [1]. The 1994 guidelines for acute low back pain developed by AHCPR concluded that spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidial anti-inflammatory drugs [1]. At the same time, AHCPR concluded that various traditional methods, such as bed rest, traction, and other physical and pharmaceutical therapies were less effective than spinal manipulation and cautioned against lumbar surgery except in the most severe cases. Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice.

Outcome of Low Back Pain in General Practice: A Prospective Study
British Medical Journal 1998 (May 2);   316 (7141):   1356–1359 ~ FULL TEXT

This FULL TEXT article investigated the generally accepted statistic that 90% of low back pain (LBP) goes away by itself. The discrepancy lies in the method of the data collection. Croft et al point out that the original study to publish the "90% recovery" results was based on patient consultation records, not follow up interviews. By comparison, this study takes into account consultation rates as well as follow-up interviews. In fact, Croft's consultation rates show a 90% drop-out rate after 3 months, not resolution of the complaint! The follow-up interviews, however, showed that most patients simply stopped consulting their doctors about low back pain, even though they still suffered pain and disability 12 months later! Clearly, the number of visits to general practitioners cannot be used as a measure of how quickly the pain and disability goes away.

MDs Employ Spinal Manipulation After a Short Training Course:
Limited Benefit for Patients

The Back Letter 1998;   13 (11):   123 ~ FULL TEXT

Results: Overall, the results do not support training primary care physicians in manipulative techniques. "The incremental effect of adding manual therapy to an approach involving enthusiastic physicians, special evaluation and patient educational skills, standard medication therapies, and exercise prescription appears to be minimal," said Carey. More intense manual therapy might hold promise, but for now the evidence for training physicians in manual therapy remains to be established, said Carey.

Randomised Comparison of Chiropractic and Hospital
Outpatient Management for Low Back Pain: Results
from Extended Follow up

British Medical Journal 1995 (Aug 5);   311 (7001):   349–351 ~ FULL TEXT

At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.

Manipulative Therapy Versus Education Programs
in Chronic Low Back Pain

Spine (Phila Pa 1976). 1995 (Apr 15);   20 (8):   948–955

Triano and colleagues studied treatment effects for patients with low back pain persisting longer than seven weeks. Subjects were randomly assigned to a back education program, high-velocity low-amplitude (HVLA) manipulation and sham/mimic treatment procedure groups for a series of 10 treatment sessions. Sessions were scripted to balance for physical contact, attention, and intervention frequency and duration. Sessions involved a consistent time commitment and direct one-on-one attention from the physician, either in the form of teaching about spine anatomy and function, or in assessment and delivery of the sham/HVLA procedures. Although all treatment groups showed improvement over time, the patients receiving thrusting procedures demonstrated significantly greater and more rapid rates of improvement from their symptoms and in their ability to function.

Effective Management of Low Back Pain:
It’s Time to Accept the Evidence

J Can Chiropr Assoc. 1993 (Dec);   37 (4):   221–229 ~ FULL TEXT

Low back pain is a ubiquitous and economically costly problem. Unfortunately, the clinical management of low back pain is not yet well understood. Chiropractic management of back pain, long the black sheep of back care, has undergone a transition and is now a more respected and understood alternative to conservative medical care, itself under increased scrutiny due to unsatisfactory outcomes and unacceptable iatrogenic side effects. The substantial amount of clinical and related research on the effectiveness of manipulation for low back pain is summarized here from a larger study, divided into randomized control trials, case-control trials, meta-analyses and descriptive studies. The chiropractic management of low back pain is found to be a more effective way of dealing with this medical, social and economic problem. It is suggested that greater utilization of chiropractors be encouraged such that the “right people are doing the right things at the right time”.

Chiropractic Care for Common Industrial Low Back Conditions
Chiropractic Technique 1993 (Aug);   5 (3):   119–125 ~ FULL TEXT

This is the first guideline I have seen which actually states the number of visits which may be appropriate for a variety of common low back conditions.   I have used these "care plans" for years, presenting them to third party's as a "working diagnosis" care plan, which need ongoing "fine tuning" during patient care. Check out this Chiropractic Technique article, and the attached care plans, which have been released exclusively to Chiro.Org by the National College of Chiropractic. Thanks, Dana! You will find other information like this in the GUIDELINES Section.
Download the “Care Plans” –   in Word 97 Format   or

in Adobe Acrobat Format

They are formatted, so you can add your own letterhead and mail them out to claim adjusters tomorrow! Just use "save-as" and they are all yours!      Download The Adobe Acrobat Reader for Free
Low Back Pain of Mechanical Origin: Randomised Comparison
of Chiropractic and Hospital Outpatient Treatment

British Medical Journal 1990 (Jun 2);   300 (6737):   1431–1437

For patients with low back pain in whom manipulation is not contraindicated chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain.   Introducing chiropractic into NHS practice should be considered.

Patient Evaluations of Low Back Pain Care From
Family Physicians and Chiropractors

West J Med 1989 (Mar);   150 (3):   351–355 ~ FULL TEXT

Patients of chiropractors were three times as likely as patients of family physicians to report that they were very satisfied with the care they received for low back pain (66% versus 22%, respectively). Compared with patients of family physicians, patients of chiropractors were three times more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem.

A New Clinical Model For The Treatment Of Low-back Pain
Winner of the 1987 Volvo Award In Clinical Sciences

Spine (Phila Pa 1976) 1987 (Sep);   12 (7):   632–644

Because there is increasing concern about low–back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low–back pain should be a benign, self–limiting condition, that low back–disability as opposed to pain is a relatively recent Western epidemic, and that the role of medicine in that epidemic must be critically examined. The traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low–back disorders.

Spinal Manipulation in the Treatment of Low–back Pain
Canadian Family Physician 1985 (Mar);   31:   535–540 ~ FULL TEXT

he truly spectacular results from chiropractic treatment (approximately 80 percent of patients 'totally disabled' for an average of 7 years back on the job and doing well after 3 weeks of daily adjustments) reflect, in my view, not only the positive value of low back adjustments but also the exceptional skill of the particular chiropractor.

How to Shift LBP Paradigms: The "Hinges" of Practice
Specialists in the management of spinal disorders have seen tremendous changes in the last decade. While the low back pain (LBP) problem has been acknowledged as an epidemic, a consensus has gradually emerged as to why this has happened and what can be done about it . An overemphasis on the simplistic biomedical approach of identifying and treating the structural cause of pain has led to excesses in diagnostic testing, bed rest, narcotic analgesics, and surgery (Waddell). Meanwhile, an underemphasis on illness behavior has led to an under–utilization of functional (re–activation advice, manipulation and exercise) and cognitive–behavorial approaches (Feuerstein).

Vladimir Janda Citation Collection
Shortcuts are provided to the PubMed abstracts of all the articles which are available online.

What is the Natural History for Lower Back Pain?
We have all heard the statistics that say 83% of patients are better in 6 weeks. Is this universally advertised short term outcome true? What do we mean by better? If our goal is to improve the quality of care for back pain patients then we first need to establish benchmark outcomes of recovery. If improvement is the goal then 90% of patients are improving after only 3 weeks. But, if asymptomatic is the goal then only 46% reached this goal after 7 weeks. If not having any activity limitations due to pain is the goal, as AHCPR suggests, then only 38% have achieved this goal by 7 weeks.


The Trajectories of Low Back Pain

Leg Pain Location and Neurological Signs Relate to Outcomes in
Primary Care Patients with Low Back Pain

BMC Musculoskelet Disord. 2017 (Mar 31);   18 (1):   133 ~ FULL TEXT

The Quebec Task Force categories (QTFC) identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals' outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

What Have We Learned From Ten Years of Trajectory Research
in Low Back Pain?

BMC Musculoskelet Disord. 2016 (May 21);   17 (1):   220 ~ FULL TEXT

Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals' course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management.

Trajectories of Acute Low Back Pain:
A Latent Class Growth Analysis

Pain. 2016 (Jan);   157 (1):   225–234 ~ FULL TEXT

Characterising the clinical course of back pain by mean pain scores over time may not adequately reflect the complexity of the clinical course of acute low back pain. We analysed pain scores over 12 weeks for 1585 patients with acute low back pain presenting to primary care to identify distinct pain trajectory groups and baseline patient characteristics associated with membership of each cluster. This was a secondary analysis of the PACE trial that evaluated paracetamol for acute low back pain. Latent class growth analysis determined a 5 cluster model, which comprised:

567 (35.8%) patients who recovered by week 2 (cluster 1, rapid pain recovery)
543 (34.3%) patients who recovered by week 12 (cluster 2, pain recovery by week 12)
222 (14.0%) patients whose pain reduced but did not recover (cluster 3, incomplete pain recovery)
167 (10.5%) patients whose pain initially decreased but then increased by week 12
       (cluster 4, fluctuating pain); and
86   (5.4%) patients who experienced high-level pain for the whole 12 weeks (cluster 5, persistent high pain).

Exploring the Definition of Acute Low Back Pain: A Prospective Observational
Cohort Study Comparing Outcomes of Chiropractic Patients With
0–2, 2–4, and 4–12 Weeks of Symptoms and Multiple Comorbidities

J Manipulative Physiol Ther. 2016 (Mar);   39 (3):   141–149 ~ FULL TEXT

Patients with 0–2 weeks of symptoms were significantly more likely to "improve" at 1 week, 1 month, and 6 months compared with those with 2–4 weeks of symptoms (P < .015). Patients with 0–2 weeks of symptoms reported significantly higher NRS and Oswestry change scores at all data collection time points. Outcomes for patients with 2–4 weeks of symptoms were similar to patients having 4–12 weeks of symptoms.   The time period 0–4 weeks as the definition of "acute" should be challenged. Patients with 2–4 weeks of symptoms had outcomes similar to patients with subacute (4–12 weeks) symptoms and not with patients reporting 0–2 weeks of symptoms.

Patients With Low Back Pain Had Distinct Clinical Course Patterns
That Were Typically Neither Complete Recovery Nor Constant Pain.
A Latent Class Analysis of Longitudinal Data

Spine J. 2015 (May 1);   15 (5): 885–894 ~ FULL TEXT

The clinical course of LBP is complex. Most primary care patients do not become pain-free within a year, but only a small proportion reports constant severe pain. Some distinct patterns exist which were identified independently of the way the outcome was modeled. These patterns would not be revealed by using the simple summary measures traditionally applied in LBP research or when describing a patient's pain history only in terms of duration. The appropriate number of subgroups will depend on the intended purpose of subgrouping.

Is Puberty a Risk Factor For Back Pain in the Young?
A Systematic Critical Literature Review

Chiropractic & Manual Therapies 2014 (Oct 15);   22 (1):   27 ~ FULL TEXT

It has previously been established that back pain starts during childhood. [1–4] According to two recent systematic literature reviews [1, 2], the lifetime prevalence increases between the ages of 7 and 12 (on average from 1% to 17%) to reach the adult level around the age of 20. [5] In relation to low back pain, it appears that puberty is the time for a rapid increase. Girls start puberty earlier than boys, which may explain why they report back pain earlier than boys. [5]

Long-term Trajectories of Back Pain:
Cohort Study With 7-year Follow-up

BMJ Open. 2013 (Dec 11);   3 (12):   e003838 ~ FULL TEXT

Four clusters with different back pain trajectories at follow-up were identified: (1)   no or occasional pain
(2)   persistent mild pain
(3)   fluctuating pain and
(4)   persistent severe pain.
Trajectory clusters differed significantly from each other in terms of disability, psychological status and other symptoms. Most participants remained in a similar trajectory as 7 years previously (weighted κ 0.54; 95% CI 0.42 to 0.65).

Trajectories of Low Back Pain
Best Pract Res Clin Rheumatol. 2013 (Oct);   27 (5):   601–612 ~ FULL TEXT

Low back pain is not a self-limiting problem, but rather a recurrent and sometimes persistent disorder. To understand the course over time, detailed investigation, preferably using repeated measurements over extended periods of time, is needed. New knowledge concerning short-term trajectories indicates that the low back pain 'episode' is short lived, at least in the primary care setting, with most patients improving. Nevertheless, in the long term, low back pain often runs a persistent course with around two-thirds of patients estimated to be in pain after 12 months. Some individuals never have low back pain, but most have it on and off or persistently. Thus, the low back pain 'condition' is usually a lifelong experience. However, subgroups of patients with different back pain trajectories have been identified and linked to clinical parameters. Further investigation is warranted to understand causality, treatment effect and prognostic factors and to study the possible association of trajectories with pathologies.

Trajectories of Pain in Adolescents: A Prospective Cohort Study
Pain. 2011 (Jan);   152 (1):   66–73 ~ FULL TEXT

Identification of different patterns of change in pain over time - trajectories - has the potential to provide new information on the course of pain. Describing trajectories among adolescents would improve understanding of how pain conditions can develop. This prospective cohort study identified distinct trajectories of pain among adolescents (11-14 years) in the general population (n=1,336). Latent class growth analysis was carried out on the self-reported frequency of back pain, headache, stomach pain and facial pain, which was collected every 3 months for 3 years. Forty four percent of adolescents had a 'painful' trajectory for at least one pain site, and 12% reported persistent pain at one or more pain site. Headache was the most common; 25% of subjects were in a 'painful' trajectory and 5% reported persistent pain. Back pain and stomach pain were also common, with 22% and 21% of subjects in painful trajectories, respectively. Facial pain was the least common, with only 10% in a painful trajectory, and 1% reporting persistent pain. Trajectory characteristics were similar at baseline across pain sites, with the more painful trajectories having significantly higher levels of depression and somatization, lower life satisfaction and more females.

Identifying Episodes of Back Pain Using Medical Expenditures
Panel Survey Data: Patient Experience,
Use of Services, and Chronicity

J Manipulative Physiol Ther. 2010 (Oct);   33 (8):   562–575 ~ FULL TEXT

These findings suggest that other longitudinal studies based only on data that reflect service use, for example, claims data, may incorrectly infer the nature of back pain and back pain episodes. Many individuals report ongoing back pain that continues beyond their Episodes-of-Care, and many individuals with persistent back pain may use prescription drugs, medical services, and other health services only intermittently.

Characterizing the Course of Low Back Pain:   A Latent Class Analysis
American Journal of Epidemiology 2006 (Apr 15);   163 (8):   754–761 ~ FULL TEXT

Understanding the course of low back pain is important for clinicians and researchers because it provides information on the need for, and potential benefits of, treatment. [1, 2] It also helps patients learn what to expect in terms of symptoms, the impact of the problem on their life, and the interventions they may receive. Information on symptom course may enable patients with nonspecific low back pain to be classified into clinically meaningful subgroups. There are currently no accepted methods for classifying these patients, who constitute 85–95 percent of those seeking care for low back pain. [3] Thus, it is difficult to select clearly defined subgroups of patients for clinical trials, and the potential effectiveness of treatments may be masked by the heterogeneity of the patients studied.

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