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”.
The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: A Randomized Controlled Trial on the Effectiveness of Clinical Practice Guidelines in the Medical and Chiropractic Management of Patients with Acute Mechanical Low Back Pain
This is the first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP. Compared to family physician-directed UC, full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.
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).
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.
A New Clinical Model For The Treatment Of Low-back Pain Winner of the 1987 Volvo Award In Clinical Sciences
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.
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.
Low Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment
For patients with low back pain in whom manipulation is not contraindicated chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain. Introducing chiropractic into NHS practice should be considered.
Time is a strong ally of the low back pain patient. In human terms, however, there appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks’ duration.
Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow up
At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.
The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.
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.
Congruence Between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America
The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.
A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain
For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.
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.
Clinical Guidelines for the Management of Low Back Pain in Primary Care: An International Comparison
The comparison of clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations were generally similar. Updates of the guidelines are planned in most countries, although so far produced only in the United Kingdom. However, new evidence may lead to stronger conclusions and enable future guidelines to become even more concordant.
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. Just because it “walks and talks” like a herniated disc doesn’t mean it is a herniated disc. Additionally, a patient presenting with pain, numbness and tingling in the thumb, index and middle finger doesn’t automatically mean it’s carpal tunnel syndrome. If a herniated dis or carpal tunnel syndrome is reported without confirmation and consequently doesn’t exist, it could hurt the patient’s ability to get health insurance or employment in the future.
Additional accuracy is needed when utilizing certain rehabilitation procedures. For example, if you plan on utilizing myofascial release (97140) on the shoulder, a soft tissue diagnosis such as 719.51 (shoulder stiffness) makes sense.
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 in future adults.
Evaluation of Chiropractic Management of Pediatric Patients with Low Back Pain: A Prospective Cohort Study
Patients responded favorably to chiropractic management, and there were no reported complications. Future investigations should establish the natural history and compare chiropractic management with other forms of treatment to gain knowledge about the effectiveness of chiropractic in managing pediatric LBP.
Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up
Improvements were found in both intervention groups, but manual therapy showed significantly greater improvement than exercise therapy in patients with chronic low back pain. The effects were reflected on all outcome measures, both on short and long-term follow-up.
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.
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.
Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment
The apparent safety of spinal manipulation, especially when compared with other “medically accepted” treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.
A Practice-Based Study of Patients With Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-Week to 48-Month Follow-up
Study findings were consistent with systematic reviews of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP. Patient choice and interdisciplinary referral should be prime considerations by physicians, policymakers, and third-party payers in identifying health services for patients with LBP.
Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain: A Systematic Review and Best Evidence Synthesis
Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and neck pain. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.
A Randomized Clinical Trial Comparing Chiropractic Adjustments to Muscle Relaxants for Subacute Low Back Pain
Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing Global Impression of Severity Scale (GIS).
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 Preventive Spinal Manipulation for Chronic Low-Back Pain and Related Disabilities: A Preliminary Study
Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.
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.
Effects of a Managed Chiropractic Benefit on the Use of Specific Diagnostic and Therapeutic Procedures in the Treatment of Low Back and Neck Pain
Among employer groups with chiropractic coverage compared with those without such coverage, there is a significant reduction in the use of high-cost and invasive procedures for the treatment of low back pain and neck pain. The presumed mechanism of this effect is the substitution of chiropractic care for medical care for the treatment of back and neck pain. The resultant chiropractic care is far less likely to lead to the use of these invasive procedures. This reduction is more pronounced when measured on a per-episode basis than on a per-patient basis.
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.
Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.
A Clinical Prediction Rule To Identify Patients With Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study
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).
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.
Our study clearly demonstrates correlations between low back pain in childhood/adolescence and low back pain in adulthood. This should lead to a change in focus from the adult to the young population in relation to research, prevention, and treatment.
Hormonal and Reproductive Factors Are Associated with Chronic Low Back Pain and Chronic Upper Extremity Pain in Women — The MORGEN Study
In adult women, hormonal and reproductive factors are associated with chronic musculoskeletal pain in general. Factors related to increased estrogen levels may specifically increase the risk of chronic LBP.
Is Comorbidity in Adolescence a Predictor for Adult Low Back Pain? A Prospective Study of a Young Population
Young people from 12 to 22 years of age with persistent LBP during the previous year have an odds ratio of 3.5 persistent LBP eight years later. Both headache and asthma are also positively associated with future LBP and there is a large clustering of LBP, headache and asthma in adolescence.
A Theoretical Model For The Development Of A Diagnosis-based Clinical Decision Rule For The Management Of Patients With Spinal Pain
In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.
Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline
Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
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).
Menstrual pain associated with primary dysmenorrhea may be alleviated with treatment of motion segment restrictions of the lumbosacral spine with drop table technique.
A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-back Pain in a National Health Service Outpatient Clinic
This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.
Prognosis in Patients with Recent Onset Low Back Pain in Australian Primary Care: Inception Cohort Study
In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.
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.
Chiropractic Management of Low Back Pain and Low Back-Related Leg Complaints: A Literature Synthesis
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.
Regarding some aspects of the DBCDR, there are a number of studies that allow the clinician to have a reasonable degree of confidence in his or her findings. This is particularly true for centralization signs, neurodynamic signs and psychological perpetuating factors. There are other aspects of the DBCDR in which a lesser degree of confidence is warranted, and in which further research is needed.
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.
Doctors Likely to Encounter Children With Musculoskeletal Complaints Have Low Confidence in Their Clinical Skills
Self-rated confidence in pediatric musculoskeletal clinical assessment was lowest, compared with other bodily systems, within doctors to whom children with MSK problems are likely to present. Core clinical skills are learnt at undergraduate level, and this study reflects poor levels of pMSK training which needs to be addressed.
Many of those who tried spinal injections found them to be very helpful, although the techniques their doctors used varied. Most respondents had used some type of medication. Forty-five percent of those who took prescription drugs said they helped a lot, double the percentage of those who said they were helped by over-the-counter medications.
Outcome of Pregnancy-Related Lumbopelvic Pain Treated According to a Diagnosis-Based Decision Rule: A Prospective Observational Cohort Study
The management strategy used in this study appeared to yield favorable outcomes in this patient population and appears to be a safe option for patients with PRLP, although because of this study’s sample size, rare complications are not likely to be detected. In addition, the absence of randomization and a control group limits interpretation with regard to clinical effectiveness. Randomized, controlled trials are necessary to distinguish treatment effects from the natural history of PRLP.
A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up
Our findings suggest that patients with LRSHD who are treated according to a strict DBCDR tend to have favorable outcome to treatment. This favorable outcome appears to be maintained over the long term. Fear beliefs also appear to improve with the approach, and a significant relationship between improvement in disability and improvement in fear beliefs was found. The absence of a control group does not allow firm conclusions to be drawn, but further research in the form of large cohort studies and randomized, controlled trials would be beneficial in determining the efficacy of this treatment approach in patients with LRSHD. The treatments used in the study appear to be safe in this patient population.
Spinal Manipulation Compared with Back School and with Individually Delivered Physiotherapy for the Treatment of Chronic Low Back Pain: A Randomized Trial with One-year Follow-up
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.
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.
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.
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.
Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.
This new reports on interviews with 31,044 individuals who used CAM for low back pain.
The results are quite fascinating:
- The top 6 CAM therapies for LBP, from the most-used are chiropractic, massage, herbal therapy, acupuncture, yoga/tai chi/qi gong, and relaxation techniques.
- Chiropractic use (76% of respondents) was greater than all the other 5 therapies combined
An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care
This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain.
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.
Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer
Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.
Facet arthropathy is a commonly accepted causative or contributing agent to low back pain syndromes. The ability of integrated SPECT/CT to precisely localise metabolically active facet joints may provide direction of treatment to manual therapies focused on improving spinal function. It is postulated here that improvements in biomechanical function, accompanied by patient subjective improvement, may demonstrate improvement or resolution of SPECT/CT findings of facet arthropathy. Research would have to be carefully designed to test this hypothesis.
Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: An Historical Cohort Study
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.
A Hospital-Based Standardized Spine Care Pathway: Report of a Multidisciplinary, Evidence-Based Process
By adopting the NCQA BPRP as an SCP, training physicians in this SCP, and using a back pain classification, Jordan Hospital Spine Care demonstrated the quality and value of care rendered to a population of patients. This was accomplished with a relatively low cost and with high patient satisfaction.
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.
Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence
In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.
It was confirmed that BP starts early in life, but the patterns of onset and development over time vary for different parts of the spine and between genders. Because of these differences, it is recommended to report on BP in youngsters separately for the three spinal regions, and to differentiate in the analyses between the genders and age groups. Although only a small minority reported BP at two or all three surveys, tracking of BP (particularly NP) and care seeking was noted from one survey to the other. On the positive side, individuals without BP at a previous survey were likely to remain pain free at the subsequent survey.
Supervised Exercise, Spinal Manipulation, and Home Exercise for Chronic Low Back Pain: A Randomized Clinical Trial
For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favored the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.
The results of this study showed improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care.
In summary, this study examined the effects of spinal manipulation on the motor evoked potential and short-latency stretch reflex amplitudes of the erector spinae muscles in patients with chronic low back pain and asymptomatic controls. We did not observe changes in these outcomes in either group when assessed ~ 10-minutes following a single spinal manipulative thrust. Interestingly, when data were analyzed according to whether spinal manipulation caused an audible joint sound, regardless of patient group, we observed that study participants exhibiting an audible response exhibited a significant reduction in the short-latency stretch reflex. These findings suggest that a single SM treatment does not systematically alter corticospinal or stretch reflex excitability of the erector spinae muscles; however, they do indicate that the stretch reflex is attenuated when spinal manipulation causes an audible joint sound. This finding provides insight into the mechanism(s) of action of spinal manipulation, and suggests that spinal manipulation may mechanistically act by down regulating the gain of the muscle spindles and/or the various segmental sites of the Ia reflex pathway. Developing a better understanding of the physiologic effects of various manual therapies to treat low back pain will in the long-term assist in optimizing and developing strategic treatment strategies for specific patient populations with LBP.
Does Maintained Spinal Manipulation Therapy for Chronic Non-specific Low Back Pain Result in Better Long Term Outcome?
SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.
The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability and efficacy of treatment based on the DBCDG.
The Relationships Between Measures of Stature Recovery, Muscle Activity and Psychological Factors in Patients with Chronic Low Back Pain
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.
Manual Therapy Followed by Specific Active Exercises Versus a Placebo Followed by Specific Active Exercises on the Improvement of Functional Disability in Patients with Chronic Non Specific Low Back Pain: A Randomized Controlled Trial
This study confirmed the immediate analgesic effect of manual therapy (MT) over sham therapy (ST). Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic mechanisms at cortical level should be investigated more thoroughly.
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.
Predictors of Improvement in Patients With Acute and Chronic Low Back Pain Undergoing Chiropractic Treatment
Patients with chronic and acute pain reporting that they were “much better” or “better” on the Patient Global Impression of Change scale at 1 week after the first chiropractic visit were 4 to 5 times more likely to be improved at both 1 and 3 months compared with patients who were not improved at 1 week. Patients with acute pain reported more severe pain and disability initially but recovered faster. Patients with chronic and acute back pain both reported good outcomes, and most patients with radiculopathy also improved.
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.
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.
Spinal High-velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain: A Double-blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo
A total of 101 patients with acute LBP (for <48 hr) were recruited from 5 outpatient practices, exclusion criteria were numerous and strict. Outcomes registered by a second and blinded investigator included self-rated physical disability, function (SF-12), off-work time, and rescue medication between baseline and 12 weeks after randomization. In a subgroup of patients with acute nonspecific LBP, spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo.
Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients with Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study
The results of this trial suggest that CMT in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP.
Evidence-based Classification Of Low Back Pain In The General Population: One-year Data Collected With SMS Track
It is now possible and indeed necessary to follow the 45 year old advice by LM Rowe to study LBP as a continuum . In our study, frequent data collection over one year made it possible to identify three substantial subgroups in the general population; those without LBP, those with episodic LBP, and those with persistent LBP. Further subsets were identified.
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.
Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity
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.
A Comparison of Chiropractic Manipulation Methods and Usual Medical Care for Low Back Pain: A Randomized Controlled Clinical Trial
Manual manipulation provided significantly greater short-term reduction in self-reported disability and pain compared to Activator and usual medical care.
Tracking Low Back Problems in a Major Self-Insured Workforce: Toward Improvement in the Patient’s Journey
Approaches marked by higher resource utilization and lower guideline congruence are linked to greater low back pain total costs. Total cost is a needed input for guideline development.
Dose-response and Efficacy of Spinal Manipulation for Care of Chronic Low Back Pain: A Randomized Controlled Trial
The number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.