This section was compiled by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org
If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary. If you want information about a specific disease, you can access the Merck Manual. You can also search Pub Med for more abstracts on this, or any other health topic.
Low Back Pain Guidelines from Around the World
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
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.
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.
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.
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 . Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health  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 .
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.
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
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.
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
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.
New Study Reveals That Back Surgery Fails 74% of the Time
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.
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.
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  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 . There has been a recent movement toward comparative effectiveness research , 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 .
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. ), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society ) or interdisciplinary (the European Back Pain Guidelines ).
Neurophysiologic Effects of Spinal Manipulation in Patients
With Chronic Low Back Pain
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 .
Chiropractic Management of Postsurgical Lumbar Spine Pain:
A Retrospective Study of 32 Cases
J Manipulative Physiol Ther 2011 (Jul); 34 (6): 408–412
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.
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.
Cost-effectiveness of Guideline-endorsed Treatments for Low Back Pain: A Systematic Review
Eur Spine J. 2011 (Jan 13) [Epub ahead of print]
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.
A Hospital-Based Standardized Spine Care Pathway: Report of a Multidisciplinary, Evidence-Based Process
J Manipulative Physiol Ther 2011 (Feb); 34 (2): 98–106
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 ~ FULL TEXT
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.
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.
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.
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: 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.
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  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
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
Clin Rehabil 2010 (Jan); 24 (1): 26–36
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
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
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.
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.”
Chiropractic Management of Low Back Disorders: Report From a Consensus Process
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651–658
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 . We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain . 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
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).
Prospective Case Series on the Effects of Lumbosacral Manipulation
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 , and 7.6% reported at least 1 episode of severe acute low back pain (see Glossary) within a 1-year period . 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 . 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 . You will enjoy these recommendations because their ONLY recommendation for active treatment of acute low back pain is spinal adjusting (manipulation).
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.
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!
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.
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.
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).
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.
• 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.  Read both British Medical Journal articles about the UK BEAM Trial now.
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!
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. 
Furthermore, musculoskeletal conditions are the most common cause of long-term pain and physical disability. ” 
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.
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)
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.
Cost-effectiveness of Medical and Chiropractic Care for Acute
and Chronic Low Back Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 555–563
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.
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.
Dose-response for Chiropractic Care of Chronic Low Back Pain
Spine J 2004 (Sep); 4 (5): 574–583
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.
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.
Biomechanical and Neurophysiological Responses to Spinal Manipulation
in Patients With Lumbar Radiculopathy
J Manipulative Physiol Ther. 2004 (Jan); 27 (1): 1–15
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.
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.
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.
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.
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 atFlashCode.
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.
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.
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 . 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 . 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.
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.
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).
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.