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

By |January 31, 2016|Depression Screening, Low Back Pain|

Deconstructing Chronic Low Back Pain in the Older Adult – Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment.
Part IV: Depression

The Chiro.Org Blog

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

Joseph A. Carley, Jordan F. Karp, Angela Gentili,
Zachary A. Marcum, M. Carrington Reid, Eric Rodriguez,
Michelle I. Rossi, Joseph Shega, Stephen Thielke,
Debra K. Weiner

Departments of Psychiatry,
University of Pittsburgh,
Pittsburgh, PA, USA

OBJECTIVE:   To present the fourth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression.

METHODS:   The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a three-member content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor’s clinical practice.

RESULTS:   We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP.

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Low Back Pain and Chiropractic Page


Nutritional Factors Affecting Postpartum Depression

By |August 5, 2014|Nutrient Deficiency, Postpartum Depression, Supplementation|

Nutritional Factors Affecting Postpartum Depression

The Chiro.Org Blog

SOURCE:   J Clin Chiropractic Pediatrics 2011 (Jun);   12 (1):   849–860

Lia M. Nightingale, PhD

Assistant Professor, Division of Life Sciences,
Palmer College of Chiropractic,
1000 Brady Street, Davenport, IA 52803, USA.

Pregnancy and lactation represent a period of substantial physiological changes for the mother and increased nutritional requirements to meet these adjustments. A number of nutritional depletions occur during pregnancy. Serum concentrations of iron and folate take months before they normalize to pre-pregnancy levels. Additionally, many micronutrients required during pregnancy interfere with each other, making absorption difficult. Postpartum depression is the primary complication of childbirth, possibly caused by several nutritional and non-nutritional factors. The current review highlights the impact nutrition may have on the etiology of this debilitating disorder, most notably on prevention of inflammation and maintenance of a healthy central nervous system. The most notable nutritional deficiencies associated with postpartum depression include omega-3 fatty acids, folate, iron, and zinc; however, supplementation trials for prevention of postpartum depression are severely lacking. Practical recommendations are given to minimize micronutrient interference and reduce the risk of postpartum depression.

Key Words:   postpartum depression, nutrition, diet, folate, essential fatty acids, iron, zinc

From the Full-Text Article:


Depression is the second leading cause of disability for those of reproductive age. [1] Although all forms of depression are devastating, postpartum depression (PPD) has long-lasting consequences for all family members involved. Postpartum depression is the most common complication of childbirth, defined as having major or minor depressive episodes that occur within 12 months after delivery. [2, 3] Postpartum depression has been associated with impaired mother-child interactions, poorer child development, and more violent behavior in children with mothers displaying PPD. [4-6]

Pregnancy is a time of increased nutritional requirements to support fetal growth and development. There are several lines of thought concerning the cause of PPD, including the link between nutritional intake and risk of depression. Therefore, the goal of this review is to examine maternal depletion of nutrients, assess whether these nutritional factors may play a role in PPD, and summarize simple recommendations to implement in practice.


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Women’s Health Page and the:

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Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity

By |January 19, 2014|Depression Screening, Low Back Pain, Outcome Assessment|

Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity

The Chiro.Org Blog

Chiropractic & Manual Therapies 2014 (Jan 17); 22: 4

Alice Kongsted, Benedicte Aambakk, Sanne Bossen
and Lise Hestbaek

The Nordic Institute of Chiropractic and Clinical Biomechanics,
Campusvej 55,
5230 Odense, M, Denmark

Background   Depression is an important prognostic factor in low back pain (LBP) that appears to be infrequent in chiropractic populations. Identification of depression in few patients would consequently implicate screening of many. It is therefore desirable to have brief screening tools for depression. The objective of this study was to investigate if one or two items from the Major Depression Inventory (MDI) could be a reasonable substitute for the complete scale.

Methods   The MDI was completed by 925 patients consulting a chiropractor due to a new episode of LBP. Outcome measures were LBP intensity and activity limitation at 3-months and 12-months follow-up. Single items on the MDI that correlated strongest and explained most variance in the total score were tested for associations with outcome. Finally, the predictive capacity was compared between the total scale and the items that showed the strongest associations with outcome measures.

Results   In this cohort 9% had signs of depression. The total MDI was significantly associated with outcome but explained very little of the variance in outcome. Four single items performed comparable to the total scale as prognostic factors. Items 1 and 3 explained the most variance in all outcome measures, and their predictive accuracies in terms of area under the curve were at least as high as for the categorised complete scale.

Conclusions   Baseline depression measured by the MDI was associated with a worse outcome in chiropractic patients with LBP. A single item (no. 1 or 3) was a reasonable substitute for the entire scale when screening for depression as a prognostic factor.

From the FULL TEXT Article:


Pain and depression often co-exist [1-3] , and although the causal relation between the two is not clear, [4, 5] evidence suggests that pain negatively affects outcome in depression as well as vice versa [6].

Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health [7] for which the risk of a poor prognosis is increased in the presence of depression [8, 9] . It is a condition for which there is no generally effective treatment, but non-pharmacological treatment addressing psychological symptoms in addition to the physical symptoms has been demonstrated to improve outcome in LBP patients with high scores on psychological questions [10].

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Low Back Pain Page and the:

The Biopsychosocial Model Page and the:

The Outcome Assessment Questionnaires Page


Clinical Brief: Depression Screening and Treatment

By |September 6, 2011|Depression Screening|

Clinical Brief: Depression Screening and Treatment

The Chiro.Org Blog

SOURCE:   Topics in Integrative Health Care 2011 (June 30); 2 (2)

By Cheryl Hawk, DC, PhD, CHES

Depression is a condition seen frequently in primary care practice as well as by practitioners who treat patients with chronic pain. The U.S. Preventive Services Task Force recommends that all adults be screened for depression and those who screen positive for depression be appropriately referred for additional assessment and management. Cognitive behavioral therapy, pharmacotherapy, physical activity and mindful exercise are all accepted approaches to treatment of depression.

The FULL TEXT Article:


Depression, formally referred to as major depressive disorder (MDD), has a lifetime prevalence of 13%. When screened at a primary care visit, about 43% of patients who suffer from MDD report suicidal ideation within the past week. [1]

Depression is ranked 1st for causes of years of life lived with a disability (YLD) and 3rd for quality-adjusted life years (QALY) in older adults. [2] Depression may increase the risk of physical disability, coronary heart disease and diabetes mellitus and mortality. It is also a major risk factor for suicide. Depression has a significant economic burden; direct and indirect costs were estimated to be $83 billion in 2000. [2]

Assessment of Depression in Primary Care (more…)

A Scoping Review of Biopsychosocial Risk Factors and Co-morbidities for Common Spinal Disorders

By |June 8, 2018|Biopsychosocial Model|

A Scoping Review of Biopsychosocial Risk Factors and Co-morbidities for Common Spinal Disorders

The Chiro.Org Blog

SOURCE:   PLoS One. 2018 (Jun 1); 13 (6):e0197987

Bart N. Green, Claire D. Johnson, Scott Haldeman, Erin Griffith, Michael B. Clay, Edward J. Kane, Juan M. Castellote, Shanmuganathan Rajasekaran, Matthew Smuck, Eric L. Hurwitz, Kristi Randhawa, Hainan Yu, Margareta Nordin

Qualcomm Health Center,
Stanford Health Care,
San Diego, California

OBJECTIVE:   The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders.

METHODS:   A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities.

RESULTS:   Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers’ compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders.

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The Biopsychosocial Model Page


The Comparative Prognostic Value of Directional Preference and Centralization

By |May 30, 2018|Centralization, Directional Preference|

The Comparative Prognostic Value of Directional Preference and Centralization: A Useful Yool for Front-line Clinicians?

The Chiro.Org Blog

SOURCE:   J Man Manip Ther. 2008; 16 (4): 248–254

Audrey Long, BSc, PT, Stephen May, MSc, and Tak Fung, PhD

Senior Statistical Consultant,
University of Calgary,
Calgary AB, Canada.

A large number of prognostic factors have been associated with recovery from an episode of back pain, and much emphasis has been placed on psychosocial prognostic factors. The large number of prognostic factors and the lack of comparative analysis of different factors make use of these difficult in clinical practice. The aim of this study was to evaluate the comparative usefulness of a range of factors to predict outcome using data from a randomized controlled trial (RCT) in which 312 patients with sub-acute to chronic back pain received a mechanical evaluation and were sub-grouped based on the presence or absence of directional preference (DP). Patients were then randomized to treatment that was matched or unmatched to that DP.

Patients with a minimal reduction of 30% in Roland-Morris Disability Questionnaire (RMDQ) score were defined as the good outcome group. Seventeen baseline variables were entered into a step-wise logistic regression analysis for the ability to predict a good outcome. Of the patients, 84 met the good outcome criteria and had a mean RMDQ decrease of 58.2% (9.8 points) in 4 visits. Leg pain, work status, depression, pain location, chronicity, and treatment assignment were significant predictors of outcome in univariate analysis. Only leg bothersomeness rating and treatment assignment survived multivariate analysis. Subjects with DP/centralization who received matched treatment had a 7.8 times greater likelihood of a good outcome. Matching patients to their DP is a stronger predictor of outcome than a range of other biopsychosocial factors.

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Low Back Pain and Chiropractic Page


Patients Receiving Chiropractic Care in a Neurorehabilitation Hospital

By |May 18, 2018|Chiropractic Care|

Patients Receiving Chiropractic Care in a Neurorehabilitation Hospital: A Descriptive Study

The Chiro.Org Blog

SOURCE:   J Multidiscip Healthc. 2018 (May 3); 11: 223–231

Robert D Vining, Stacie A Salsbury, W Carl Cooley, Donna Gosselin, Lance Corber, and Christine M Goertz

Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
Davenport, IA, USA.

OBJECTIVES:   Individuals rehabilitating from complex neurological injury require a multidisciplinary approach, which typically does not include chiropractic care. This study describes inpatients receiving multidisciplinary rehabilitation including chiropractic care for brain injury, spinal cord injury (SCI), stroke, and other complex neurological conditions.

DESIGN:   Chiropractic services were integrated into Crotched Mountain Specialty Hospital (CMSH) through this project. Patient characteristics and chiropractic care data were collected to describe those receiving care and the interventions during the first 15 months when chiropractic services were available.

SETTING:   CMSH, a 62–bed subacute multidisciplinary rehabilitation, skilled nursing facility located in Greenfield, New Hampshire, USA.

RESULTS:   Patient mean (SD) age (n=27) was 42.8 (13) years, ranging from 20 to 64 years. Males (n=18, 67%) and those of white race/ethnicity (n=23, 85%) comprised the majority. Brain injury (n=20) was the most common admitting condition caused by trauma (n=9), hemorrhage (n=7), infarction (n=2), and general anoxia (n=2). Three patients were admitted for cervical SCI, 1 for ankylosing spondylitis, 1 for traumatic polyarthropathy, and 2 for respiratory failure with encephalopathy. Other common comorbid diagnoses potentially complicating the treatment and recovery process included myospasm (n=13), depression (n=11), anxiety (n=10), dysphagia (n=8), substance abuse (n=8), and candidiasis (n=7). Chiropractic procedures employed, by visit (n=641), included manual myofascial therapies (93%), mechanical percussion (83%), manual muscle stretching (75%), and thrust manipulation (65%) to address patients with spinal-related pain (n=15, 54%), joint or regional stiffness (n= 14, 50%), and extremity pain (n=13, 46%). Care often required adapting to participant limitations or conditions. Such adaptations not commonly encountered in outpatient settings where chiropractic care is usually delivered included the need for lift assistance, wheelchair dependence, contractures, impaired speech, quadriplegia/paraplegia, and the presence of feeding tubes and urinary catheters.


Prognostic Significance of Subgroup Classification for Infant Patients with Crying Disorders

By |April 26, 2018|Colic|

Prognostic Significance of Subgroup Classification for Infant Patients with Crying Disorders: A Prospective Cohort Study

The Chiro.Org Blog

SOURCE:   J Can Chiropr Assoc. 2012 (Mar); 56 (1): 40–48

Joyce Miller, BS, DC and Dave Newell, BS, MSc, PhD

Anglo-European College of Chiropractic
(Bournemouth University),
3-15 Parkwood Road,
Bournemouth, Dorset BH5 2DF, UK

INTRODUCTION:   Few convincing treatment options have been identified for the excessively crying infant. One explanation may be a lack of identification of patient subgroups. This study used a clinically plausible categorization protocol to subgroup infants and compared changes in symptoms between these subgroups during treatment.

METHODS:   An observational cohort design was employed. All infants presenting with excessive infant crying between July 2007 and March 2008 were categorized into three subgroups,

(A)   infant colic,

(B)   irritable infant syndrome of musculoskeletal origin (IISMO) and

(C)   inefficient feeding crying infants with disordered sleep (IFCIDS) based on history and physical findings.

Mothers completed questionnaires which rated their own and their child’s characteristics prior to and at the end, of a course of manual therapy. Independent associations between infant subgroups and changes in continuous outcomes (crying, stress, sleep, and consolability) were assessed. Multivariable analysis of covariance was used to identify and control for potential confounders.

RESULTS:   A total of 158 infants were enrolled. There was no significant difference in demographic profile between groups or any significant difference in infant crying or level of maternal stress at the start. Only the putative subgroups were significantly associated with differences in outcomes. In general, colic babies improved the most in consolability and crying.

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Infantile Colic and Chiropractic Page


Infant Demographic Profile and Parent Report of Treatment Outcomes at a Chiropractic Clinic in the UK

By |April 25, 2018|Pediatrics|

Infant Demographic Profile and Parent Report of Treatment Outcomes at a Chiropractic Clinic in the UK:
An Observational Study

The Chiro.Org Blog

SOURCE:   J Clinical Chiropractic Pediatrics 2017 (Jan); 17 (1): 1398–1404

Johanna M. Jaskulski, MChiro and Joyce E. Miller, BS, DC, PhD

Private practice.
ProChiro Baesweiler,
Nordrhein-Westfalen, Deutschland

Background:   Children, particularly infants, commonly present to chiropractors. Few studies have concentrated on the demographic profile of infants as well as clinical changes reported by parents of infants under chiropractic care.

Objectives:   To identify the demographic profile of infants presenting to a chiropractic clinic and to investigate any change of infant symptoms and maternal feelings following an episode of chiropractic care.

Setting:   This health care observation study was performed at a chiropractic teaching clinic on the south coast of England.

Subjects/Patients:   The study included all mother-infant dyads who presented to the clinic between August 2011 and June 2015 and could read and write English and who consented to complete the forms. Exclusion criteria were mothers of infants older than one year of age at presentation.

Methods:   All mothers were asked to complete two questionnaires at the initial visit and two follow-up questionnaires at discharge. Data collected were sociodemographic characteristics along with questions asking for graded responses regarding the daily amount of irritable behavior in their child, level of distress the mother feels with her child’s behavior, restfulness of infant sleep during the week and difficulty to console the child when crying as well as to the clinical experience provided. Additionally, the validated Edinburgh Postnatal Depression Scale (EPDS) was used as a report of the mother’s feelings.

Results:   413 mothers completed the intake questionnaires. 197 (48%) mothers completed the discharge questionnaires. At intake, 50.3% (n=182) of the patients were four weeks of age or younger. The presenting complaint appeared before the age of two weeks in 79.1% (n=161) of the cases. 30.2% (n=160) presented with colic/crying and 22.9% (n=121) with a feeding related complaint. The modal length of an episode of care was two weeks. Over the course of treatment, average maternal distress levels reduced by 48%. Mean amount of irritability reduced by 31%; mean restfulness of sleep improved by 27% and mean difficulty to console reduced by 38% in the infant. The median EPDS score dropped by 50% over the time of care. 96.3% of parents rated 8–10 satisfaction with care on a scale of 1–10.

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Chiropractic Pediatrics Section


Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain

By |April 12, 2018|Guidelines, Low Back Pain|

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain:

A Guideline From the Canadian Chiropractic Guideline Initiative

The Chiro.Org Blog

SOURCE:   J Manipulative Physiol Ther. 2018 (Mar 29) [Epub]

André E. Bussières, DC, FCCS(C), PhD, Gregory Stewart, DC, Fadi Al-Zoubi, PT, MSc, Philip Decina, DC, Martin Descarreaux, DC, PhD, Danielle Haskett, BSc, Cesar Hincapié, DC, PhD, Isabelle Pagé, DC, MSc, Steven Passmore, DC, PhD, John Srbely, DC, PhD, Maja Stupar, DC, PhD, Joel Weisberg, DC, Joseph Ornelas, DC, PhD

School of Physical and Occupational Therapy,
Faculty of Medicine, McGill University,
Montreal, Québec, Canada

OBJECTIVE: &nbsp The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

METHODS: &nbsp The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

RESULTS: &nbsp For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

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Low Back Pain Guidelines Page