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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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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:

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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…)

Perspectives of Older Adults on Co-management of Low Back Pain by Doctors of Chiropractic and Family Medicine Physicians

By |January 26, 2018|Integrative Care|

Perspectives of Older Adults on Co-management of Low Back Pain by Doctors of Chiropractic and Family Medicine Physicians: A Focus Group Study

The Chiro.Org Blog

SOURCE:   BMC Complement Altern Med. 2013 (Sep 16); 13: 225

Kevin J Lyons, Stacie A Salsbury, Maria A Hondras, Mark E Jones, Andrew A Andresen and Christine M Goertz

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

BACKGROUND:   While older adults may seek care for low back pain (LBP) from both medical doctors (MDs) and doctors of chiropractic (DCs), co-management between these providers is uncommon. The purposes of this study were to describe the preferences of older adults for LBP co-management by MDs and DCs and to identify their concerns for receiving care under such a treatment model.

METHODS:   We conducted 10 focus groups with 48 older adults who received LBP care in the past year. Interviews explored participants’ care seeking experiences, co-management preferences, and perceived challenges to successful implementation of a MD–DC co-management model. We analyzed the qualitative data using thematic content analysis.

RESULTS:   Older adults considered LBP co-management by MDs and DCs a positive approach as the professions have complementary strengths. Participants wanted providers who worked in a co-management model to talk openly and honestly about LBP, offer clear and consistent recommendations about treatment, and provide individualized care. Facilitators of MD–DC co-management included collegial relationships between providers, arrangements between doctors to support interdisciplinary referral, computer systems that allowed exchange of health information between clinics, and practice settings where providers worked in one location. Perceived barriers to the co-management of LBP included the financial costs associated with receiving care from multiple providers concurrently, duplication of tests or imaging, scheduling and transportation problems, and potential side effects of medication and chiropractic care. A few participants expressed concern that some providers would not support a patient-preferred co-managed care model.

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Integrated Health Care Page


The Quality of Life of Children Under Chiropractic Care Using PROMIS-25

By |January 2, 2018|Pediatrics|

The Quality of Life of Children Under Chiropractic Care Using PROMIS-25: Results from a Practice-Based Research Network

The Chiro.Org Blog

SOURCE:   J Altern Complement Med. 2017 (Dec 20) [Epub]

Joel Alcantara, DC, Andrea E. Lamont, PhD,
Jeanne Ohm, DC, and Junjoe Alcantara, DC

The International Chiropractic Pediatric Association,
327N Middletown Road
Media, PA 610-565-2360

OBJECTIVES:   To characterize pediatric chiropractic and assess pediatric quality of life (QoL).

DESIGN:   A prospective cohort. Setting/Locations: Individual offices within a practice-based research network located throughout the United States.

SUBJECTS:   A convenience sample of children (8-17 years) under chiropractic care and their parents.

EXPOSURE:   Chiropractic spinal adjustments and adjunctive therapies.

OUTCOME MEASURES:   Survey instrument measuring sociodemographic information and correlates from the clinical encounter along with the Patient Reported Outcomes Measurement Information System (PROMIS)-25 to measure QoL (i.e., depression, anxiety, and pain interference). Sociodemographic and clinical correlates were analyzed using descriptive statistics (i.e., frequencies/percentages, means, and standard deviations). The PROMIS-25 data were analyzed using scoring manuals, converting raw scores to T score metric (mean = 50; SD = 10). A generalized linear mixed model was utilized to examine covariates (i.e., sex, number of visits, and motivation for care) that may have played an important role on the PROMIS outcome.

RESULTS:   The original data set consisted of 915 parent-child dyads. After data cleaning, a total of 881 parents (747 females, 134 males; mean age = 42.03 years) and 881 children (467 females and 414 males; mean age = 12.49 years) comprised this study population. The parents were highly educated and presented their child for mainly wellness care. The mean number of days and patient visits from baseline to comparative QoL measures was 38.12 days and 2.74 (SD = 2.61), respectively. After controlling for the effects of motivation for care, patient visits, duration of complaint, sex, and pain rating, significant differences were observed in the probability of experiencing problems (vs. no reported problems) across all QoL domains (Wald = 82.897, df = 4, p < 0.05). Post hoc comparisons demonstrated the children were less likely to report any symptoms of depression (Wald = 6.1474, df = 1, p < 0.05), anxiety (Wald = 20.603, df = 1, p < 0.05), fatigue (Wald = 22.191, df = 1, p < 0.05), and pain interference (Wald = 47.422, df = 1, p < 0.05) after a trial of chiropractic care.

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Chiropractic Pediatrics Section and the:

Outcome Assessment Page


The Use of the RAND VSQ9 to Measure the Quality of Life and Visit-Specific Satisfaction of Pregnant Patients

By |December 25, 2017|Pediatrics|

The Use of the Patient Reported Outcomes Measurement Information System and the RAND VSQ9 to Measure the Quality of Life and Visit-Specific Satisfaction of Pregnant Patients Under Chiropractic Care Utilizing the Webster Technique

The Chiro.Org Blog

SOURCE:   J Altern Complement Med. 2017 (Dec 20) [Epub]

Joel Alcantara, Andrea Lamont Nazarenko,
Jeanne Ohm, and Junjoe Alcantara

The International Chiropractic Pediatric Association,
Media, PA.

OBJECTIVE:   To quantify the quality of life (QoL) and visit-specific satisfaction of pregnant women.

DESIGN:   A prospective cohort within a practice-based research network (PBRN). Setting/locations: Individual chiropractic offices.

SUBJECTS:   Pregnant women (age ≥18 years) attending chiropractic care.

INTERVENTION(S):   Chiropractic care (i.e., The Webster Technique, spinal adjustments, and adjunctive therapies).

MAIN OUTCOME MEASURES:   The RAND VSQ9 to measure visit-specific satisfaction and the Patient Reported Outcomes Measurement Information System (PROMIS®)-29 to measure QoL.

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Chiropractic Pediatrics Section and the:

Outcome Assessment Page


Patient Expectations of Benefit from Common Interventions for Low Back Pain and Effects on Outcome

By |October 12, 2017|Patient Expectations, Spinal Pain|

Patient Expectations of Benefit from Common Interventions for Low Back Pain and Effects on Outcome: Secondary Analysis of a Clinical Trial of Manual Therapy Interventions

The Chiro.Org Blog

SOURCE:   J Man Manip Ther. 2011 (Feb);   19 (1):   20–25

Mark D Bishop, Joel E Bialosky & Josh A Cleland

Department of Physical Therapy,
University of Florida, USA.

OBJECTIVES:   The purpose of this secondary analysis was 1) to examine patient expectations related to a variety of common interventions for low back pain (LBP) and 2) to determine the influence that specific expectations about spinal manipulation might have had on self-report of disability.

METHODS:   We collected patients’ expectations about the benefit of specific interventions for low back pain. We also collected patients’ general expectations about treatment and tested the relationships among the expectation of benefit from an intervention, receiving that intervention and disability-related outcomes.

RESULTS:   Patients expected exercise and manual therapy interventions to provide more benefit than surgery and medication. There was a statistical association between expecting relief from thrust techniques and receiving thrust techniques, related to meeting the general expectation for treatment (chi-square: 15.5, P = 0.008). This was not the case for patients who expected relief from thrust techniques but did not receive it (chi-square: 6.9, P = 0.4). Logistic regression modeling was used to predict change in disability at treatment visit 5. When controlling for whether the general expectations for treatment were met, intervention assignment and the interaction between intervention assignment and expectations regarding thrust techniques, the parsimonious model only included intervention as the significant contributor to the model (P < 0.001). The adjusted odds ratio of success comparing thrust techniques to non-thrust in this study was 41.2 (11.0, 201.7).

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Patient Expectations of Relief

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Chiropractic and Spinal Pain Page


What Techniques Might Be Used to Harness Placebo Effects in Non-malignant pain?

By |September 30, 2017|Placebo|

What Techniques Might Be Used to Harness Placebo Effects in Non-malignant pain? A Literature Review and Survey to Develop a Taxonomy

The Chiro.Org Blog


Felicity L Bishop, Beverly Coghlan, Adam WA Geraghty,
Hazel Everitt, Paul Little, Michelle M Holmes,
Dionysis Seretis, George Lewith

Department of Psychology,
Faculty of Social Human and Mathematical Sciences,
University of Southampton,
Southampton, UK.

OBJECTIVES:   Placebo effects can be clinically meaningful but are seldom fully exploited in clinical practice. This review aimed to facilitate translational research by producing a taxonomy of techniques that could augment placebo analgesia in clinical practice.

DESIGN:   Literature review and survey.

METHODS:   We systematically analysed methods which could plausibly be used to elicit placebo effects in 169 clinical and laboratory-based studies involving non-malignant pain, drawn from seven systematic reviews. In a validation exercise, we surveyed 33 leading placebo researchers (mean 12 years’ research experience, SD 9.8), who were asked to comment on and add to the draft taxonomy derived from the literature.

RESULTS:   The final taxonomy defines 30 procedures that may contribute to placebo effects in clinical and experimental research, proposes 60 possible clinical applications and classifies procedures into five domains: the patient’s characteristics and belief (5 procedures and 11 clinical applications), the practitioner’s characteristics and beliefs (2 procedures and 4 clinical applications), the healthcare setting (8 procedures and 13 clinical applications), treatment characteristics (8 procedures and 14 clinical applications) and the patient—practitioner interaction (7 procedures and 18 clinical applications).

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Looking Ahead: Chronic Spinal Pain Management

By |September 13, 2017|Low Back Pain|

Looking Ahead: Chronic Spinal Pain Management

The Chiro.Org Blog

SOURCE:   Journal of Pain Research 2017 (Aug 30); 10: 2089–2095

Gregory F Parkin-Smith, Stephanie J Davies,
Lyndon G Amorin-Woods

School of Health Professions,
Murdoch University,
Perth, WA, Australia

The other day, we oversaw a seminar on pain management for a local consumer pain group, where all consumers (patients) in attendance were experiencing chronic, persistent spinal pain. Each person had a unique story, and their experience and perceived cause of their pain differed. The quality of life in all these consumers was markedly reduced, which was the only clear similarity, confirming that there may be some similarities in the pain experience, but the pain experience was more often unique and individual. These consumers’ criticisms of care services were consistent, however, with dissatisfaction with their access to care and overall management of their pain. They described variable and often difficult access, limited continuity of care, they were often not taken seriously by health care providers, they received scant information about chronic pain and its prognosis and there were often noteworthy variations in the treatment they received. We agree that these criticisms are commonplace and a frequent gripe directed at health care practitioners about the “system.” [1] Moreover, the problems associated with care delivery are confounded by a number of patient/consumer factors, such as lifestyle habits, nutrition, body weight, depression, health literacy, geographical isolation and poor socioeconomic conditions, making the management of persistent pain even more complicated. [2] There is no doubt that, in the future, matching the care service and treatment with the individual patient will become an essential component of care services, as has been implied in published research. [3-6]

Health care practitioners involved in the triage and management of patients with persistent spinal pain will need to become more vigilant about individualizing and coordinating care for each patient, to achieve the best possible outcomes. For example, Cecchi et al concluded that patients with chronic (persistent) lower baseline pain (LBP)-related disability predicted “nonresponse” to standard physiotherapy, but not to spinal manipulation (an intervention commonly employed by chiropractors [7-9]), implying that spinal manipulation should be considered as a first-line conservative treatment. [9] We note that spinal manipulation is now suggested as the first-line intervention by Deyo, [10] since not a single study examined in a recent systematic review found that spinal manipulation was less effective than conventional care. [11]

Garcia et al, [12] conversely, showed that high pain intensity may be an important treatment effect modifier for patients with chronic low back pain receiving Mckenzie therapy (a treatment frequently used by physiotherapists). These examples demonstrate the importance of matching treatments with the characteristics of the patient.

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Chiropractic and Spinal Pain Management