Article

Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With Acute Low Back Pain

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Abstract

Study design: Randomized controlled trial. Objective: To assess changes in pain levels and physical functioning in response to standard medical care (SMC) versus SMC plus chiropractic manipulative therapy (CMT) for the treatment of low back pain (LBP) among 18 to 35-year-old active-duty military personnel. Summary of background data: LBP is common, costly, and a significant cause of long-term sick leave and work loss. Many different interventions are available, but there exists no consensus on the best approach. One intervention often used is manipulative therapy. Current evidence from randomized controlled trials demonstrates that manipulative therapy may be as effective as other conservative treatments of LBP, but its appropriate role in the healthcare delivery system has not been established. Methods: Prospective, 2-arm randomized controlled trial pilot study comparing SMC plus CMT with only SMC. The primary outcome measures were changes in back-related pain on the numerical rating scale and physical functioning at 4 weeks on the Roland-Morris Disability Questionnaire and back pain functional scale (BPFS). Results: Mean Roland-Morris Disability Questionnaire scores decreased in both groups during the course of the study, but adjusted mean scores were significantly better in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Mean numerical rating scale pain scores were also significantly better in the group that received CMT. Adjusted mean back pain functional scale scores were significantly higher (improved) in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Conclusion: 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.

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... Among three studies from the Cochrane review [286] and two subsequent RCTs [287,288], only one RCT reported by Goertz et al. [287] showed effectiveness of manipulation on pain improvement. Regarding physical function, manipulation was shown to be useful in two RCTs [288,289]. ...
... Among three studies from the Cochrane review [286] and two subsequent RCTs [287,288], only one RCT reported by Goertz et al. [287] showed effectiveness of manipulation on pain improvement. Regarding physical function, manipulation was shown to be useful in two RCTs [288,289]. ...
... Regarding physical function, manipulation was shown to be useful in two RCTs [288,289]. Patient satisfaction was investigated in one RCT [287], which showed high satisfaction when manipulation was added to standard medical care. However, because selection of controls for manipulation studies is inconsistent, differences in treatment outcomes are heterogeneous, and it is unclear whether they have clinical significance. ...
Article
Background The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine. Methods The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, “body of evidence” and “benefit and harm balance” were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members. Results Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature. Conclusions The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.
... Independent of duration, LBP is one of the most common complaints for patients presenting to primary care (77,78). Hence, the effectiveness of SMT is frequently evaluated by comparing its application to standard medical care or physical therapy (79)(80)(81)(82)(83)(84)(85)(86)(87). Standard medical care based on medication is more frequently used during the early stages of LBP (79,83,85), while interventions based on exercise therapy are commonly prescribed for chronic primary LBP (81,82,86,87). ...
... Hence, the effectiveness of SMT is frequently evaluated by comparing its application to standard medical care or physical therapy (79)(80)(81)(82)(83)(84)(85)(86)(87). Standard medical care based on medication is more frequently used during the early stages of LBP (79,83,85), while interventions based on exercise therapy are commonly prescribed for chronic primary LBP (81,82,86,87). Fewer studies have examined the differences with sham/placebo interventions (88)(89)(90)(91)(92)(93), and a handful have contrasted SMT to mobilization techniques for LBP (94)(95)(96). ...
... Most clinical trials have examined the effectiveness of SMT for LBP by comparing SMT to another intervention recommended for its treatment (60). Standard medical treatment offered in primary care for LBP of recent onset has been used as an active comparator against SMT alone or as an addition to medical care (79,83,85). Standard medical care consisted of anti-inflammatory and analgesic medication, plus advice to maintain normal daily activity levels. ...
Article
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Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.
... However, neither author responded; these two articles were excluded. Twenty articles were included in this review [12,16,[28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45]. ...
... The studies were most commonly conducted in the United States (n = 17) [16, 28-32, 34-43, 45], with one conducted in Australia (n = 1) [33], and two in Canada (n = 2) [12,44]. Most studies were cross-sectional (n = 9) [12,28,[31][32][33][34][35][36][37], six were case reports [38][39][40][41][42][43], three were randomized controlled trials [29,30,45], and two were qualitative designs [16,44]. ...
... Six case reports [38][39][40][41][42][43], three randomized controlled trials [29,30,45], and one cross-sectional study [12] described chiropractic services provided to active duty military personnel worldwide. In North America, chiropractic services were reported as initiated through referral from a primary care provider (gatekeeper) following initial assessment, except in the randomized controlled studies where access was predetermined by study design [29,30,45]. ...
Article
Full-text available
Background: Musculoskeletal injuries are one of the most prevalent battle and non-battle related injuries in the active duty military. In some countries, chiropractic services are accessed to manage such injuries within and outside military healthcare systems; however, there is no recent description of such access nor outcomes. This scoping review aimed to synthesize published literature exploring the nature, models, and outcomes of chiropractic services provided to active duty military globally. Method: We employed scoping review methodology. Systematic searches of relevant databases, including military collections and hand searches were conducted from inception to October 22, 2018. We included peer-reviewed English literature with qualitative and quantitative designs, describing chiropractic practice and services delivered to active duty military worldwide. Paired reviewers independently reviewed all citations and articles using a two-phase screening process. Data from relevant articles were extracted into evidence tables and sorted by study type. Results were descriptively analyzed. Results: We screened 497 articles and 20 met inclusion criteria. Chiropractic services were commonly provided on-base only in the US. Services were accessed by physician referral and commonly after initiation or non-response to other care. Use of scope of practice was determined by the system/facility, varying from intervention specific to comprehensive services. Back pain with and without radiculopathy accounted for most complaints. Treatment outcomes were reported primarily by case reports. However, two recent randomized trials reported improved pain, disability, and satisfaction when adding chiropractic care to usual medical care compared to usual medical care alone in management of low back pain. Specific reaction time measures in special operation forces military did not improve after chiropractic care compared to wait-list control. Conclusions: Our scoping review found the majority of published articles described chiropractic services in the active duty military in the US setting. Recent RCTs suggest a benefit of including chiropractic care to usual medical care in managing back pain in active duty military. Yet despite reported benefits in Australia, Canada, and the US, there is a need for further qualitative, descriptive, and clinical trial data worldwide to inform the role of chiropractic services in active duty military.
... Fifty-seven studies underwent phase II full-text screening. Sixteen relevant studies [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] were identified (eight observational studies including case reports and series, cross-sectional and non-experimental studies, and cohorts; four mixed methods studies; three pilot studies; one qualitative study). Fourteen studies were conducted in the US, and one study each was conducted in Canada and Sweden. ...
... The studies lacked explicit descriptions of the process of implementation of interventions for musculoskeletal care. Nonetheless, we used the information available to classify the interventions according to EPOC [21] as delivery arrangements [29][30][31][34][35][36][37][38][39][40][41][42][43][44] and implementation strategies [32,33,36,38,40,43,44] (Table 1). ...
... The service outcomes reported included timely access to care [30,37,38], efficiency with respect to patient encounters and specialist referrals [30,32,33,[37][38][39]42], and effectiveness of care (e.g., duty status, and discharge from care) [30,31,36,39,40]. With respect to patient outcomes, investigators reported improved symptomatology such as pain and perceived general health [31,[33][34][35][36]40], function including disability and physical fitness [31,[33][34][35][36]38], and patient and provider satisfaction [29,33,34,37,41]. ...
Article
Full-text available
Background: Musculoskeletal disorders are common in the active military and are associated with significant lost duty days and disability. Implementing programs of care to manage musculoskeletal disorders can be challenging in complex healthcare systems such as in the military. Understanding how programs of care for musculoskeletal disorders have been implemented in the military and how they impact outcomes may help to inform future implementation interventions in this population. Methods: We conducted a scoping review using the modified Arksey and O'Malley framework to identify literature on (1) implementation interventions of musculoskeletal programs of care in the active military, (2) barriers and facilitators of implementation, and (3) implementation outcomes. We identified studies published in English by searching MEDLINE, CINAHL, Embase, and CENTRAL (Cochrane) from inception to 1 June 2018 and hand searched reference lists of relevant studies. We included empirical studies. We synthesized study results according to three taxonomies: the Effective Practice and Organization of Care (EPOC) taxonomy to classify the implementation interventions; the capability, opportunity, motivation-behavior (COM-B) system to classify barriers and facilitators of implementation; and Proctor et al.'s taxonomy (Adm Policy Ment Health 38:65-76, 2011) to classify outcomes in implementation research. Results: We identified 1785 studies and 16 were relevant. All but two of the relevant studies were conducted in the USA. Implementation interventions were primarily associated with delivery arrangements (e.g., multidisciplinary care). Most barriers or facilitators of implementation were environmental (physical or social). Service and client outcomes indicated improved efficiency of clinical care and improved function and symptomology. Studies reporting implementation outcomes indicated the programs were acceptable, appropriate, feasible, or sustainable. Conclusion: Identification of evidence-based approaches for the management of musculoskeletal disorders is a priority for active-duty military. Our findings can be used by military health services to inform implementation strategies for musculoskeletal programs of care. Further research is needed to better understand (1) the components of implementation interventions, (2) how to overcome barriers to implementation, and (3) how to measure implementation outcomes to improve quality of care and recovery from musculoskeletal disorders.
... The locations of where the studies were completed was world-wide. Seven studies were completed in the United States [10][11][12][13][14][15][16], two studies were completed in South Korea [17,18], one study was completed in China [19], two studies were completed in Pakistan [20,21], one study was completed in Canada, [22], one study was completed in Brazil [23], four studies were completed in India [24][25][26][27], one study was completed in France [28], and one study was completed in Germany [29]. The three most common practitioners that performed treatment in the studies included medical doctors, physical therapists, and chiropractors. ...
... The three most common practitioners that performed treatment in the studies included medical doctors, physical therapists, and chiropractors. Four studies had medical doctors performing the treatments [11,12,17,29], ten studies had physical therapists performing the treatments [13,15,18,20,21,[24][25][26][27][28], five studies had chiropractors performing the treatments [10,14,19,22,23], and one study used both chiropractors and physical therapists [16]. The study characteristics can be found in Table 2. ...
... Five studies used 'standard care' as the overarching theme for the title of the comparison groups [10-12, 17, 19]. Of these five studies, 'standard medical care' was the name used in two studies [10,11], 'usual care' was used in two studies [12,17], and 'conventional care' was used in one study [19]. In the five studies that used 'standard care', the main intervention given to patients was verbal education on staying physically active. ...
Article
Background: Comparison interventions for low back pain are described in the literature utilizing different treatment interventions with various terminology. The effectiveness of these comparison groups is not well defined. Objectives: The objective of this systematic review is to assess the fidelity of comparison interventions within randomized controlled trials assessing the effect of manual therapy on low back pain. Methods: This systematic review utilized PubMed, CINAHL, Scopus, Cochrane, and Pedro databases. Articles were screened by two authors for eligibility criteria and then extracted, reviewed, and cross-checked for data that included sample size, patient demographics, manual therapy intervention, the control group protocol, and outcomes. The Cochrane Risk of Bias tool was used to determine disagreement among authors. A qualitative synthesis of the evidence was completed. Results: A total of 20 articles were included in this systematic review. The comparison interventions were categorized into themes based on the terminology used by the various studies. The themes consisted of “standard care”, “sham treatment”, “control groups”, and unnamed comparison interventions. These themes were then compared to the CPG based on the interventions utilized in each study. Conclusions: There appears to be significant variability in comparison interventions within randomized controlled trials assessing manual therapy effects on patients with low back pain. This variability may lead to inconsistent published effect sizes. It is imperative to correctly follow evidence-based practice from resources, such as the CPG, to determine the effectiveness of treatment interventions.
... There were 15 studies of SM for either acute, subacute, or a mixture of types of LBP (total participants, 2621). 33,34,38,39,[41][42][43][47][48][49][51][52][53][54][55] Six of these studies were of modest to moderate size (ie, >100 participants) and utilized 6 or more sessions of SM. 38,42,49,51,53,54 The results of these studies were mixed, with some reporting modest significant benefit of SM compared with active intervention (physical therapy, education ["back school"], medication, usual care) at about 4 weeks for pain intensity and/ or function, 42,49,54 but others reporting no significant between-group differences. 38,51,53 One RCT examined pregnant women with LBP 42 and found that adding SM and exercise to usual obstetric care provided modest improvement in pain and function/disability. ...
... Of these 8 later RCTs, 2 were negative trials 27,32 and 6 were positive trials. 36,[41][42][43]46,54 Inclusion of these trials into the meta-analysis might have lead Rubinstein et al 133 to draw a different conclusion. ...
Article
Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches—acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga—as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.
... 8 Two studies suggest significant improvements in pain, function, global improvement and satisfaction with care in samples of active duty military personnel receiving chiropractic care and standard medical care as compared to those receiving standard medical care alone. 11,12 Currently, the Canadian Forces Health Services (CFHS) provides a spectrum of health care services, including care provided in civilian facilities when services are not provided on-base. 6 Chiropractic care is an eligible CAF health practitioner benefit when prescribed by a physician, and is accessed off-base, outside the military health system. ...
... For example, a recent U.S. study reported significant improvements in pain, function, and satisfaction with care in the group of active duty military receiving chiropractic care and standard medical care compared to standard medical care alone. 11,12 Evidence-based Approach: "Very important" ...
Article
Introduction: Musculoskeletal (MSK) conditions have a significant impact on the health and operational readiness of military members. The Canadian Forces Health Services (CFHS) provides a spectrum of health services in managing Canadian Armed Forces (CAF) personnel health care needs with on-base and off-base services provided by civilian and uniformed health care professionals, including chiropractors. Although chiropractic services are available in US DoD and VA systems, little is known about the facilitators and barriers to integrating on-base chiropractic services within the CFHS. This study explored key informants' perceptions of facilitators and barriers to the integration of on-base chiropractic services within the CFHS. Methods: We conducted a qualitative study to describe and understand how an integrated chiropractic service could be designed, implemented, and evaluated within the current interdisciplinary CFHS. Telephone interviews were conducted, using a semi-structured interview guide, to explore key informants' perceptions and experiences of chiropractic care within the CFHS. In total, we invited 27 individuals across Canada to participate; 15 were identified through purposeful sampling, 12 through a snowball sampling technique, and 2 declined. The 25 participants included military personnel (52%), public servants and contractors employed by the Department of Defense (24%), as well as civilian health care providers (24%). All participants were health care providers [physicians (MD) (7), physiotherapists (PT) (13), chiropractors (DC) (5)]. Interviews were audio-recorded and transcribed verbatim. Transcripts were prepared and analyzed using an interpretivist approach that explored key informants' perceptions and experiences. Results: Qualitative analysis revealed numerous facilitators and barriers to chiropractic services in the CFHS. These were categorized under three broad themes: base-to-base variations, variable gatekeeper roles, and referral processes. Barriers to integrating chiropractic services included: lack of clarity about a chiropractor's clinical knowledge and skills; CFHS team members' negative prior experiences with chiropractors (e.g., inappropriate patient-focused communication, clinical management that was not evidence-based, ignorance of military culture); suboptimal bi-directional communication between CAF personnel and DCs across bases; and wide-ranging perspectives pertaining to duplication of services offered by PTs and DCs in managing MSK conditions. Facilitators associated with the integration of chiropractic services within a collaborative and interdisciplinary CAF environment included: patient benefits associated with multiple approaches utilized by different providers; adoption of up-to-date, high-quality evidence and guidelines to standardize care and curtail "dependency" between patient and providers; and co-location of providers to strengthen existing interprofessional communication and relationships. Key informants called for patient care that is collaborative, integrated and patient-centered, rather than "patient-driven" care; civilian providers understanding and respecting military culture rather than assuming transferability of patient management processes from the public civilian sector; standardization of communication protocols and measures to evaluate outcomes of care; and the need to move slowly and respectfully within the current CAF health care system if planning the on-base implementation of chiropractic services. Conclusion: This study illuminated many opportunities and barriers, in complex and diverse domains, related to introducing collaborative chiropractic services in the CFHS. The findings are relevant to increasing understanding and strengthening interprofessional collaborative care within the unique CAF health care delivery system.
... 19,20 Current guidelines recommend the use of spinal manipulative therapy and/or chiropractic care for LBP. 21,22 Although a previous pilot study of chiropractic care for active-duty US military patients with acute LBP showed promise, 23 and chiropractic care is available at 66 military health treatment facilities worldwide, 24 significant gaps in knowledge remain in military populations. ...
... The changes in patient-reported pain intensity and disability as well as satisfaction with care and low risk of harms favoring UMC with chiropractic care found in this pragmatic clinical trial are consistent with the existing literature on spinal manipulative therapy in both military 23 and civilian 20,[36][37][38] populations. The magnitude of mean between-group differences for both pain (NRS) and disability (RMDQ) are consistent with a moderate magnitude of effect as classified by the American College of Physicians and American Pain Society guidelines. ...
Article
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Importance It is critically important to evaluate the effect of nonpharmacological treatments on low back pain and associated disability. Objective To determine whether the addition of chiropractic care to usual medical care results in better pain relief and pain-related function when compared with usual medical care alone. Design, Setting, and Participants A 3-site pragmatic comparative effectiveness clinical trial using adaptive allocation was conducted from September 28, 2012, to February 13, 2016, at 2 large military medical centers in major metropolitan areas and 1 smaller hospital at a military training site. Eligible participants were active-duty US service members aged 18 to 50 years with low back pain from a musculoskeletal source. Interventions The intervention period was 6 weeks. Usual medical care included self-care, medications, physical therapy, and pain clinic referral. Chiropractic care included spinal manipulative therapy in the low back and adjacent regions and additional therapeutic procedures such as rehabilitative exercise, cryotherapy, superficial heat, and other manual therapies. Main Outcomes and Measures Coprimary outcomes were low back pain intensity (Numerical Rating Scale; scores ranging from 0 [no low back pain] to 10 [worst possible low back pain]) and disability (Roland Morris Disability Questionnaire; scores ranging from 0-24, with higher scores indicating greater disability) at 6 weeks. Secondary outcomes included perceived improvement, satisfaction (Numerical Rating Scale; scores ranging from 0 [not at all satisfied] to 10 [extremely satisfied]), and medication use. The coprimary outcomes were modeled with linear mixed-effects regression over baseline and weeks 2, 4, 6, and 12. Results Of the 806 screened patients who were recruited through either clinician referrals or self-referrals, 750 were enrolled (250 at each site). The mean (SD) participant age was 30.9 (8.7) years, 175 participants (23.3%) were female, and 243 participants (32.4%) were nonwhite. Statistically significant site × time × group interactions were found in all models. Adjusted mean differences in scores at week 6 were statistically significant in favor of usual medical care plus chiropractic care compared with usual medical care alone overall for low back pain intensity (mean difference, −1.1; 95% CI, −1.4 to −0.7), disability (mean difference, −2.2; 95% CI, −3.1 to −1.2), and satisfaction (mean difference, 2.5; 95% CI, 2.1 to 2.8) as well as at each site. Adjusted odd ratios at week 6 were also statistically significant in favor of usual medical care plus chiropractic care overall for perceived improvement (odds ratio = 0.18; 95% CI, 0.13-0.25) and self-reported pain medication use (odds ratio = 0.73; 95% CI, 0.54-0.97). No serious related adverse events were reported. Conclusions and Relevance Chiropractic care, when added to usual medical care, resulted in moderate short-term improvements in low back pain intensity and disability in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines. However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses to chiropractic care. Trial Registration ClinicalTrials.gov Identifier: NCT01692275
... Comparably, Carey et al. (1995) found that the patients who saw chiropractors were more satisfied than those who saw orthopedic surgeons [8]. Goertz et al. (2013) also found a statistically and clinically significant benefit to those receiving chiropractic manipulative therapy in addition to standard medical care compared with only standard medical care [14]. Nevertheless, chiropractic therapy and physical therapy are both shown to have a better effect compared with other nonpharmacologic interventions [7,15]. ...
... Comparably, Carey et al. (1995) found that the patients who saw chiropractors were more satisfied than those who saw orthopedic surgeons [8]. Goertz et al. (2013) also found a statistically and clinically significant benefit to those receiving chiropractic manipulative therapy in addition to standard medical care compared with only standard medical care [14]. Nevertheless, chiropractic therapy and physical therapy are both shown to have a better effect compared with other nonpharmacologic interventions [7,15]. ...
Preprint
Low back pain (LBP) is a pandemic and costly musculoskeletal condition in the United States. Patients with LBP may endure surgery, injections, and expensive visits to emergency departments. Some suggest that using physical therapy or chiropractic in the earlier stage of LBP reduces the utilization of expensive health services and lowers the treatment costs. Nevertheless, there is no consistent evidence to declare which one of these methods is a cost-effective treatment within a short (less than a year) period of time. The purpose of this study was to investigate the cost-effectiveness of chiropractic versus physical therapy in the United States. A decision tree analytic model was used for estimating the economic outcomes. The findings showed that in the chiropractic group, the total average cost was $48.56 lower than the physical therapy group, and daily adjusted life years (DALY) was 0.0043 higher than the physical therapy group. Chiropractic care was shown to be a cost-effective alternative compared with physical therapy for adults with at least three weeks of low back pain over six months.
... Nevertheless, chiropractic has shown to have similar benefits to PT. Carey et al. (1995) found that those patients who are treated by chiropractors are more satisfied than those who are treated by orthopedic surgeons [8]. Goertz et al. (2013) also found statistically and clinically significant benefits to those who receive additional chiropractic manipulative therapy compared with those who only receive standard medical care [18]. Hurwitz et al. (2002) showed that the effectiveness of chiropractic care is similar to medical care for LBP after 6 months of follow-up. ...
... Nevertheless, chiropractic has shown to have similar benefits to PT. Carey et al. (1995) found that those patients who are treated by chiropractors are more satisfied than those who are treated by orthopedic surgeons [8]. Goertz et al. (2013) also found statistically and clinically significant benefits to those who receive additional chiropractic manipulative therapy compared with those who only receive standard medical care [18]. Hurwitz et al. (2002) showed that the effectiveness of chiropractic care is similar to medical care for LBP after 6 months of follow-up. ...
Article
Full-text available
Low back pain (LBP) is a pandemic and costly musculoskeletal condition in the United States (U.S.). Patients with LBP may endure surgery, injections, and expensive visits to emergency departments. Some suggest that using physical therapy (PT) or chiropractic in the earlier stage of LBP reduces the utilization of expensive health services and lowers the treatment costs. Given that there are costs and benefits with each of these treatments, the remaining question is in a short period of time which of these treatments is optimal. The purpose of this study was to investigate the cost‐effectiveness of chiropractic versus PT in the U.S. A decision tree analytic model was used for estimating the economic outcomes. The findings showed that the total average cost in the chiropractic group was $48.56 lower than the PT group. The findings also showed that the daily adjusted life years (DALY) in the chiropractic group was 0.0043 higher than the PT group. Chiropractic care was shown to be a cost‐effective alternative compared with PT for adults with at least three weeks of LBP over six months
... Standard medical care included any or all of the following: a focused history and physical examination, diagnostic imaging as indicated, education about selfmanagement including maintaining activity levels as tolerated, pharmacological management with the use of analgesics and anti-inflammatory agents, and physical therapy and modalities such as heat/ice and referral to a pain clinic. 90 Spinal manipulation therapy plus standard medical care was more effective than standard medical care alone for reducing pain (NRS) at 2 weeks (MD = 2.2, 95% CI 1.2-3.1) and 1 month (MD = 1.2, 95% CI 0.2-2.3) ...
Article
Full-text available
Objective: The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments. Methods: The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee. Results: For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises). Conclusions: A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.
... It is a lipolysis enzyme produced from papaya, produced in Georgia by the Institute of Biochemistry and we have a long experience of its effective use. Other methods-manual therapy with soft techniques, independently or in combination with other methods, is used in the treatment of spinal disease based on the modern surveys [5,[16][17][18][19][20][21][22][23][24][25][26]. In some cases, manual therapy is associated with significant clinical improvement of chronic lumbar pain and can be used before invasive and expensive treatment [22]. ...
... Such concurrent use of chiropractic care and conventional medications and health provision is in line with previous studies. [28][29][30] Furthermore, previous randomized controlled trials have suggested the comanagement of chiropractic and medical care is likely to show more improvement in pain relief than medical care alone. [31][32][33] Our study found that a recommendation for an adult to consult a chiropractor is rarely initiated by a conventional health care provider, and many respondents reported that their conventional health care provider failed to enquire about their possible chiropractic use. ...
Article
Study design: Secondary analysis of a national survey. Objective: To investigate the prevalence, patterns, and predictors of chiropractic utilization in the US general population. Summary of background data: Chiropractic is one of the largest manual therapy professions in the US and internationally. Very few details have been reported about the use of chiropractic care in the US in recent years. Methods: Cross-sectional data from the 2012 National Health Interview Survey (n = 34,525) were analyzed to examine the lifetime and 12-month prevalence and utilization patterns of chiropractic use, profile of chiropractic users and health-related predictors of chiropractic consultations. Results: Lifetime and 12-month prevalence of chiropractic use were 24.0% and 8.4%, respectively. There is a growing trend of chiropractic use amongst US adults from 2002 to 2012. Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being. A substantial number of chiropractic users had received prescription (23.0%) and/or over-the-counter medications (35.0%) for the same health problem for which chiropractic was sought and 63.8% reported chiropractic care combined with medical treatment as helpful. Both adults older than 30 years (compared to younger adults), and those diagnosed with spinal pain (compared to those without spinal pain) were more likely to have consulted a chiropractor in the past 12 months. Conclusions: A substantial proportion of US adults utilized chiropractic services over the past 12 months and reported associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common. Studies on the current patient integration of chiropractic and conventional health services are warranted. Level of evidence: 3.
... There are studies which have questioned its efficacy to treat ailments -including lower back pain, the ailment for which it is most popular (Crothers, French, Hebert, & Walker, 2016;Dougherty, Karuza, Dunn, Savino, & Katz, 2014;Rubinstein, Terwee, Assendelft, de Boer, & van Tulder, 2013;Wong, Parent, Dhillon, Prasad, & Kawchuk, 2015). Contrasting these studies are others demonstrating its efficacy (Goertz et al., 2013;Santilli, Beghi, & Finucci, 2006). Other studies have highlighted risks of the practice, demonstrating correlations between spinal manipulation and strokes (Cassidy et al., 2009;Reuter, Hämling, Kavuk, Einhäupl, & Schielke, 2006;Stevinson & Ernst, 2002). ...
Article
Full-text available
Numerous studies have examined health-related YouTube videos, but very few studies have also investigated the health-related discussions taking place in YouTube comment sections. Taking up the topic of chiropractic, a popular form of “alternative medicine”, this study first sought to determine if debates or controversies surrounding chiropractic were present in the comments on popular YouTube chiropractic videos. If debates were present, the goal was then to use iterative coding methods to map out how debates were unfolding by describing the general characteristics of the discussions as well as the arguments used by opposing groups. Lastly, the objective was to determine levels of hostility in the debates. Our results demonstrate that there are debates taking place over the efficacy and legitimacy of chiropractic. Furthermore, while our study maps out a wide variety of arguments and debate characteristics, key findings show that those arguing “for chiropractic” rely primarily on personal anecdotes...
... Randomised controlled trials have been conducted on low back pain sufferers who were exposed to chiropractic manipulative therapy in conjunction with standard therapy, consisting of medication and general home care advice. Researchers concluded that the addition of chiropractic manipulation improved physical functioning in the tested population and demonstrated a significant advantage in the reduction of back pain compared to those receiving the standard therapy alone (Goertz, Long et al. 2013). The effect of yoga practice is also studied in low back pain patients and is found to offer good short-term effectiveness and moderate long-term effectiveness in controlled trials (Cramer, Lauche et al. 2013). ...
Article
Full-text available
The use of complementary and alternative medicine (CAM) has attracted much attention in recent years and has become a significant topic of debate within the healthcare sector. Many patients suffering from serious conditions such as cancer, Alzheimer’s disease, diabetes and lower back pain seek alternative therapies including CAM biological products. Clinicians and healthcare practitioners need to be aware of the available clinical evidence relating to CAM-based therapies when advising patients and recommending options. This review presents the recent clinical data investigating the efficacy of CAM therapies for disease management among these groups of patients. A number of cancer drugs are listed which have been developed from natural sources and which have recently gained approval from the EMA and FDA based on clinical trials. Reasons for using CAM and the most frequently used CAM therapies are mentioned as well as the degree of improvement of quality of life based on patients’ experiences.
... 44 Although there is evidence for elements of this approach 38 in people with acute LBP, from our searches it seems that the overall strategy relative to usual care has not been tested. Trials of stepped care with LBP have either tested a specific therapy for acute LBP against usual care 20,40 or dealt with chronic LBP patients. 4,40,44 Interestingly, some of the early advocates of stepped care apparently allowed for exceptions to the stepped care principle if this seemed warranted at initial assessment, but although sensible, this would seem to undermine the principles of stepped care and it raises the question of how these cases might be identified. ...
... Those seeking alternative care for sprains and muscle strains tend to seek chiropractic care, and there is growing evidence that chiropractic care is an effective treatment for back pain. [10][11][12][13][14][15] A large-scale study of 1.7 million people demonstrated that access to insurance coverage for chiropractic care was associated with reduced total health care expenditures, reduced low back surgery, and reduced health care costs for back pain episodes. 16 However, less is known about the impact of chiropractic care for athletes. ...
Article
Full-text available
Objective: The purpose of this study was to describe chiropractic care use at the World Games 2013. Methods: In this retrospective study, we reviewed treatment charts of athletes and non-athletes who sought chiropractic care at The World Games in Cali, Colombia, from July 25 to August 4, 2013. Doctors of chiropractic of the International Federation of Sports Chiropractic provided care. Chart notes included body region treated, treatment modality, and pretreatment and posttreatment pain ratings. Results: Of the participants, 537 of 2964 accredited athletes and 403 of 4131 accredited non-athletes sought chiropractic treatment; these represent utilization rates of 18.1% for athletes and 9.8% for non-athletes. A total of 1463 treatments were recorded for athletes (n = 897) and non-athletes (n = 566). The athletes who were treated represented 28 of 33 sports and 68 of 93 countries that were present at the games. Among athletes, the thoracic spine was the most frequent area of treatment (57.2%), followed by the lumbar spine (48.7%) and the cervical spine (38.9%). Myotherapy was the most frequently used treatment method (80.9%), followed by chiropractic manipulation (78.5%), taping (38.0%), and mobilization (24.6%). Reports of acute injury were higher among athletes (45.4%) compared with non-athletes (23.8%). Reported pain was reduced after treatment (P < .001), and 86.9% patients reported immediate improvement after receiving chiropractic treatment. Conclusions: The majority of people seeking chiropractic care at an international sporting competition were athletes. For those seeking care, the injury rate was higher among athletes than among non-athletes. The majority of patients receiving chiropractic care reported improvement after receiving care.
... Many CAM professions, such as chiropractic, are forming new partnerships with biomedicine, particularly in the U.S. Military Health System, 4,5 where CAM professions are now integrated with biomedicine and nursing in hospital settings. 6,7 Although hospital-based IM is now widespread in the United States, the Services have developed unique models of IM with different guiding principles and strategies for integration. ...
Article
Objectives: Biomedicine and complementary and alternative medicine are forming new relationships, under the rubric of integrative medicine. Recently, the military has adopted integrative medicine as the model for pain management. An evaluation was conducted on an integrative model for pain management at a major Army medical center to determine the distinct challenges that were encountered during the early stages of this integrative program. Methods: The design is a case study evaluation. Qualitative data were analyzed to determine whether the outcomes in terms of processes were in harmony with the program's mission. Study participants were patients (34), referring providers (25), program staff (20), administrators (18), and related medical center leadership (6). Results: The study uncovered the following challenges: misaligned culture and mission, resources, the valuing of services (relative value units), systemic transition, patient throughput, and stigma associated with the focus and location of the program in a psychology department. Conclusions: These challenges prevented the program from fully achieving its mission and potential. Although integrative medicine might be the appropriate model for pain management in the military, the structural and process elements to bring it about are not yet in place or fully understood.
... [10][11][12] Previous work has demonstrated positive patient and provider perceptions, beneficial outcomes, and expanded use of services in these systems. [13][14][15][16][17] Chiropractic services are also included in U.S. private medical settings ranging from large healthcare systems to smaller care delivery sites. [18][19][20] However, there is no central coordination or assessment of these programs. ...
Article
Full-text available
Objectives: Chiropractic care may have value in improving patient outcomes and decreasing opioid use, but little is known about the impetus for or process of incorporating these services into conventional medical settings. The purpose of this qualitative study was to describe organizational structures, care processes, and perceived value of chiropractic integration within U.S. private sector medical facilities. Design: Multisite, comparative organizational case study. Settings: Nine U.S. private sector medical facilities with on-site chiropractic care, including five hospitals and four clinics. Participants: One hundred and thirty-five key facility stakeholders including doctors of chiropractic (DCs), non-DC clinicians, support staff, administrators, and patients. Methods: Researchers conducted 2-day site visits to all settings. Qualitative data were collected from audio-recorded, semi-structured, role-specified, individual interviews; standardized organizational data tables; and archival document review. A three-member, interdisciplinary team conducted thematic content analysis of verbatim transcripts using an existing conceptual framework and emergent codes. Results: These nine medical facilities had unique organizational structures and reasons for initiating chiropractic care in their settings. Across sites, DCs were sought to take an evidence-based approach to patient care, work collaboratively within a multidisciplinary team, engage in interprofessional case management, and adopt organizational mission and values. Chiropractic clinics were implemented within existing human resources, physical plant, information technology, and administrative support systems, and often expanded over time to address patient demand. DCs usually were co-located with medical providers and integrated into the collaborative management of patients with musculoskeletal and co-morbid conditions. Delivery of chiropractic services was perceived to have high value among patients, medical providers, and administration. Patient clinical outcomes, patient satisfaction, provider productivity, and cost offset were identified as markers of clinic success. Conclusion: A diverse group of U.S. private sector medical facilities have implemented chiropractic clinics, and a wide variety of facility stakeholders report high satisfaction with the care provided.
... The use of a defined standardized MT that predominantly features mobilization techniques may be incompatible with current clinical beliefs that MT should be individualized according to the patient's overall presentation [29,30]. Moreover, manipulation is perceived by some as more effective than mobilization techniques [31]. ...
Article
Full-text available
Background Nonspecific acute low back pain (LBP) is a common reason for accessing primary care. German guidelines recommend non-steroidal anti-inflammatory drugs and physical activity as evidence-based treatments. Manual Therapy (MT) remains controversial. To increase evidence-based treatment options for general practitioners (GPs), a Pilot-Study was set up to gather information about the required conditions and setting for an RCT. Methods The open pilot-study assesses recruitment methods for GPs and patients, timelines, data collection and outcomes of treatment immediately (T0) and 1, 6 and 12 weeks after consultation (T1, T2, T3). Inclusion criteria for GPs were: no experience of MT; for patients: adults between 18 and 50 suffering from LBP for less than 14 days. Study process: Patients’ control-group (CG) was consecutively recruited first and received standard care. After GPs received a single training session in MT lasting two and a half hours, they consecutively recruited patients with LBP to the intervention group (IG). These patients received add-on MT. Primary outcomes: (A): timelines and recruitment success, (B): assessment tools and sample size evaluation, (C) clinical findings: pain intensity change from baseline to day 3 and time till (a) analgesic use stopped and (b) 2-point pain reduction on an 11-point scale occurred. Secondary outcomes: functional capacity, referral rate, use of other therapies, sick leave, patient satisfaction. Results 14 GPs participated, recruiting 42 patients for the CG and 45 for the IG; 49% (56%) of patients were women. Average baseline pain was 5.98 points, SD: ±2.3 (5.98, SD ±1.8). For an RCT an extended timeline and enhanced recruitment procedures are required. The assessment tools seem appropriate and provided relevant findings: additional MT led to faster pain reduction. IG showed reduced analgesic use and reduced pain at T1 and improved functional capacity by T2. Conclusions Before verifying the encouraging findings that additional MT may lead to faster pain reduction and reduced analgesic use via an RCT, the setting, patients’ structure, and inclusion criteria should be considered more closely. Trial registration Number: DRKS00003240 Registry: German Clinical Trials Registry (DRKS) URL: https://www.drks.de/drks_web/. Registration date: 14.11.2011. First patient: March 2012. Funding: the Rut and Klaus Bahlsen Stiftung, Hannover.
... Mutidisciplinary and interdisciplinary rehabilitation, as well as educational treatment methods for acute and chronic LBP were reviewed [3][4][5][6]20,59,62,[74][75][76][77][78][79][80][81][82][83][84][85][86][87][88][89][90]. For acute LBP, an insufficient number of trials for the eight treatment methods were noted; however, two clinical guidelines were included [4,6] ( If there was a strategic method (action, sequence, use of tools, etc.) for a goal through exercise, the method is 'specific' exercise. ...
Article
We aimed to determine the recommendation level for the treatment of acute and chronic low back pain (LBP). A systematic review (SR) of the literature was performed and all English-language articles that discuss acute and chronic LBP, including MEDLINE and the Cochrane Database of Systematic Reviews, were searched. Of the 873 searched literature reports, 259 articles, including 131 clinical trials, 115 SRs, nine meta-analyses, and four clinical guidelines were analyzed. In these articles, high-quality randomized controlled trials, SRs, and used well-written clinical guidelines were reviewed. The results indicated multiple acute and chronic LBP treatment methods in the literature, and these reports when reviewed included general behavior, pharmacological therapy, psychological therapy, specific exercise, active rehabilitation and educational interventions, manual therapy, physical modalities, and invasive procedures. The Trial conclusions and SRs were classified into four categories of A, B, C, and D. If there were not enough high-quality articles, it was designated as "I" (insufficient). This review and summary of guidelines may be beneficial for physicians to better understand and make recommendations in primary care.
... dolore anteriore di ginocchio, sindrome femororotulea ecc.) o altri segmenti del rachide lontani dal tratto lombare, in relazione al fenomeno dell'Interdipendenza regionale (2,(123)(124)(125)(126)(127). Sebbene l'utilizzo e lo studio delle manipolazioni spinali per il rachide lombare siano in aumento, non si sono registrati aumenti degli eventi avversi gravi (106,118,122,128,129). Infatti, in una recente revisione sistematica (106) nessun pratica clinica, comprendendo il grado di suscettibilità del paziente al trattamento ed escludendo le comorbidità non di competenza fisioterapica, si può affermare che dal punto di vista clinico i benefici della manipolazione siano superiori ai suoi rischi potenziali (133,144). ...
... [1][2][3] Moreover, clinical trials have shown greater efficacy when chiropractic treatment is added to usual medical care in managing patients with these conditions. 4,5 Chiropractic care also has the potential to be cost-effective, as chiropractors typically use a conservative (i.e. non-pharmacological, non-surgical) approach. ...
Article
Objective: To evaluate costs and consequences of a new back pain service provided by chiropractors integrated into a Community Health Centre in Cambridge, Ontario. The study sample included 95 consecutive patients presenting between January 2014 to January 2016 with a mixture of sub-acute and chronic back pain. Methods: A secondary cost-utility analysis was performed and conducted from the perspective of the healthcare institution. Cost-utility was calculated as cost per quality-adjusted life year (QALY) gained over a time horizon of 90 days. Results: According to the EuroQol 5 Domain questionnaire, nearly 70% of patients improved. The mean number of treatment sessions was 8.4, and an average of 0.21 QALYs were gained at an average cost per QALY of $1,042. Seventy-seven percent of patients did not visit their primary care provider over the 90-day period, representing potential cost savings to the institution of between $2,022.23 and $6,135.82. Conclusion: Adding chiropractic care to usual medical care was associated with improved outcomes at a reasonable cost in a sample of complex patients with sub-acute and chronic back pain. Future comparative cost-effectiveness studies are needed.
... An a priori power analysis was conducted using G * Power for between-within interactions in ANOVA (Faul et al., 2007). The parameters for this analysis were an alpha of 0.05, a power of 0.95, a conservative estimate of the correlation amongst repeated measures of r = 0, for three groups, two measurements and an effect size of f = 0.268, based on pain intensity data reported in a pragmatic trial of chiropractic spinal manipulation for low back pain (Goertz et al., 2013). The analysis yielded a required sample of at least 111 participants, 37 participants in each group to reach statistical significance. ...
Article
Full-text available
Background: In March 2020, the COVID-19 pandemic forced the Spanish government to declare a state of emergency. A stringent lockdown was enforced, restricting access to healthcare services, including chiropractic. Reduced access to care provision, in combination with psychological stress, social isolation and physical inactivity during lockdown, were shown to negatively influence pain conditions. However, data on strategies to mitigate the impact of the pandemic on these conditions is lacking. Methods: Upon easing of restrictions in May 2020, fifty-one chiropractic clinics throughout Spain pseudo-randomly invited patients, recruiting a total of 385 participants. During a 14-day period, participants were exposed to in-person chiropractic care in either one (n=177) or multiple encounters (n=109), or to no care (n=99). The effects of access to chiropractic care on patients' pain-related and psychological outcomes were assessed online through validated self-reported questionnaires before and after the period of care. Coprimary outcomes included pain intensity, pain interference and pain cognitions. Results: When comparing to participants without access to care, pain intensity and interference were significantly decreased at follow-up, irrespective of the number of encounters. Kinesiophobia was also significantly reduced at follow-up, though only after multiple encounters. The relationship between fear of movement, changes in pain intensity and interference was mediated by catastrophizing. Conclusion: Access to in-person chiropractic care may provide pain relief, associated with reductions in interference and pain cognitions. Prioritizing in-person care for patients with maladaptive pain cognitions may help dampen the detrimental consequences of the pandemic on physical and psychological well-being.
... Over the short term, there was an average improvement of 30% at 4 weeks (1 month), 40% at discharge or end of care (variable time), and 42% at 12 months. The improvements in pain intensity from the chiropractic studies (NRS range: 20-52%) are within the range of improvements of chiropractic treatment reported from RCTs, with 25% improvement in spinal pain after 2 weeks [63] and 24% improvement in low back pain after 4 weeks [64]. Acupuncture studies reported a range of improvements in NRS pain intensity, from 18% to 46% after 4 weeks [39,42], and the percent improvement after acupuncture for cancer-related pain (ESAS) was 36-38% at end of treatment or discharge [38,55], which is higher than improvements reported from RCTs, with 20% at 5 days after initial treatment [65]. ...
Article
Objective The goal of this systematic review was to evaluate practice-based, real-world research of individualized complementary and integrative health (CIH) therapies for pain as provided in CIH outpatient clinics. Methods A systematic review was conducted using PubMed, Ovid, Cochrane, Web of Science, Scopus and Embase through Dec 2020. The study was listed in the PROSPERO database (CRD42020159193). Major categories of variables extracted included study details and demographics; interventions; and outcomes. Results The literature search yielded 3,316 records with 264 assessed for full text review. Of those, 23 studies (including ∼8,464 patients) were specific to pain conditions as a main outcome. Studies included chiropractic, acupuncture, multimodal individualized intervention/programs, physiotherapy, and anthroposophic medicine therapy. Retention rates ranged from 53% to 91%, with studies offering monetary incentives showing the highest retention. The 0–10 numerical rating scale was the most common pain questionnaire (n = 10, 43% of studies), with an average percent improvement across all studies and timepoints of 32% (range 18–60%). Conclusions Findings from this systematic review of practice-based, real-word research indicate that CIH therapies exert positive effects on various pain outcomes. Although all studies reported beneficial impacts on one or more pain outcomes, the heterogeneous nature of studies limits our overall understanding of CIH as provided in clinical settings. Accordingly, we present numerous recommendations to improve publication reporting and guide future research. Our call to action is future, practice-based CIH research is needed, but should be more expansive and in association with a CIH scientific society with academic and healthcare members.
... 9 Manipulative therapy (MT) is defined as joint manipulation and/or mobilisation with the aim to restore compromised function of joints. 10 This type of therapy is increasingly being used in children [11][12][13] because it is generally recommended as a treatment option for adults with spinal pain, [14][15][16][17][18] and is delivered by various health professions, both on its own and in combination with other types of therapy, such as advice, exercises and softtissue treatment. 18 One study recently demonstrated a small but statistically significant effect of adding MT to exercise therapy 19 in adolescents with low back pain. ...
Article
Full-text available
Background A substantial number of children experience spinal pain, that is, back and/or neck pain. Today, no ‘gold-standard’ treatment for spinal pain in children exists, but manipulative therapy is increasingly being used in spite of a lack of evidence of its effectiveness. This study investigates the effectiveness of adding manipulative therapy to other conservative care for spinal pain in a school-based cohort of Danish children aged 9–15 years. Methods and findings The design was a two-arm pragmatic randomised controlled trial, nested in a longitudinal open cohort study in Danish public schools. 238 children from 13 public schools were randomised individually from February 2012 to April 2014. A text message system and clinical examinations were used for data collection. Interventions included either (1) advice, exercises and soft-tissue treatment or (2) advice, exercises and soft-tissue treatment plus manipulative therapy. The primary outcome was number of recurrences of spinal pain. Secondary outcomes were duration of spinal pain, change in pain intensity and Global Perceived Effect. We found no significant difference between groups in the primary outcome (control group median 1 (IQR 1–3) and intervention group 2 (IQR 0–4), p=0.07). Children in the group receiving manipulative therapy reported a higher Global Perceived Effect: OR 2.22, (95% CI 1.19 to 4.15). No adverse events were reported. Main limitations are the potential discrepancy between parental and child reporting and that the study population may not be comparable to a normal care-seeking population. Conclusions Adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment—if any—for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population. Trial registration number NCT01504698; Results.
Chapter
Manual medicine is aimed at orthopedic surgeons, general practitioners, rheumatologists, internists and traumatologists, as well as physiotherapists in clinics and practices.
Article
Objective The purpose of this report is to record noteworthy events that occurred during the early years of chiropractic in the United States Military Health System (MHS). Methods We used mixed methods to create this historical account, including documents, artifacts, research papers, and reports from personal experiences. Results Chiropractic care was first included in the MHS in 1995, after years of legislative activity. The initial program was a 3-year study of the feasibility and advisability of integrating chiropractic in the MHS. This period was called the Chiropractic Health Care Demonstration Project; 20 pioneering chiropractors began their MHS journeys at 10 military bases in fiscal year 1995. The Demonstration Project was extended for 2 more years to gather research data, and 3 additional military facilities were added during those years to accomplish that purpose. The Demonstration Project concluded in 1999. In 2000, Congress approved the development of permanent chiropractic services and benefits for members of the uniformed services. These new clinics opened in 2002. Conclusion This is the first article to chronicle the history of chiropractic in the MHS, and highlights some of the important events in the early years of chiropractors working within the MHS. Because of the efforts of the early MHS chiropractors to pave the way for a permanent chiropractic benefit for the deserving members of the United States uniformed services, chiropractic care is now offered at more than 60 United States military facilities.
Chapter
The results of the study clearly showed majority improvements through chiropractic treatments. Combination therapies such as chiropractic in combination with massages and chiropractic and physiotherapy as well as all other applications of physiotherapy also delivered very good results. Finally, out of 35 of the evaluated results, 19 showed best results in therapy comparison and endpoint improvement through chiropractic treatments.
Article
Full-text available
Background: Spinal manipulation therapy (SMT) is a popular though controversial practice. The debates surrounding efficacy and risk of SMT are only partially evident in popular discourse. Objective: This study aims to investigate the presence of critiques and debates surrounding efficacy and risk of SMT on the social media platform Twitter. The study examines whether there is presence of debate and whether critical information is being widely disseminated. Methods: An initial corpus of 31,339 tweets was compiled through Twitter's Search Application Programming Interface using the query terms "chiropractic," "chiropractor," and "spinal manipulation therapy." Tweets were collected for the month of December 2015. Post removal of tweets made by bots and spam, the corpus totaled 20,695 tweets, of which a sample (n=1267) was analyzed for skeptical or critical tweets. Additional criteria were also assessed. Results: There were 34 tweets explicitly containing skepticism or critique of SMT, representing 2.68% of the sample (n=1267). As such, there is a presence of 2.68% of tweets in the total corpus, 95% CI 0-6.58% displaying explicitly skeptical or critical perspectives of SMT. In addition, there are numerous tweets highlighting the health benefits of SMT for health issues such as attention deficit hyperactivity disorder (ADHD), immune system, and blood pressure that receive scant critical attention. The presence of tweets in the corpus highlighting the risks of "stroke" and "vertebral artery dissection" is also minute (0.1%). Conclusions: In the abundance of tweets substantiating and promoting chiropractic and SMT as sound health practices and valuable business endeavors, the debates surrounding the efficacy and risks of SMT on Twitter are almost completely absent. Although there are some critical voices of SMT proving to be influential, issues persist regarding how widely this information is being disseminated.
Article
Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most frequently prescribed drugs for the treatment of sciatica. A previous Cochrane review on the efficacy of NSAIDs summarised findings for acute and chronic low back pain (LBP) and sciatica. This is an update of the original review (2008) focusing on people suffering from sciatica. Objectives: To determine the efficacy of NSAIDs in pain reduction, overall improvement, and reported side effects in people with sciatica. Search methods: We performed electronic searches up to 24 June 2015 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed, and two trials registers. We searched reference lists of included studies and relevant reviews on the topics for additional trials. Selection criteria: We included randomised controlled trials (double-blind, single-blind, and open-label) that assessed the efficacy of NSAIDs in sciatica. We included all trials that compared NSAIDs to placebo, to other NSAIDs, or to other medication. Additional interventions were allowed if there was a clear contrast for the treatment with NSAIDs in the trial. Data collection and analysis: Three review authors independently assessed the risk of bias and extracted the data. Where feasible we calculated pooled results using Review Manager 5.3. We reported pain relief outcomes using mean difference (MD) with 95% confidence intervals (95% CI). We used risk ratios (RR) with 95% CI to report global improvement of treatment, adverse effects, and additional medication. We performed a meta-analysis if possible. We assessed level of evidence using the GRADE approach. We used standard methodological procedures recommended by The Cochrane Collaboration. Main results: We included 10 trials reported in 9 publications (N = 1651). Only one trial out of 10 was assessed at low risk of bias. Five trials used the currently recommended daily dose for the drug, and two trials used lower daily doses available over the counter. Three trials investigated NSAIDs no longer approved for human use. The follow-up duration was short in all studies but one.Three trials (n = 918) compared the effects of NSAIDs to those of placebo on pain reduction. The pooled mean difference showed comparable pain reduction (visual analogue scale, 0 to 100) in the NSAIDs and placebo groups (MD -4.56, 95% CI -11.11 to 1.99). Heterogeneity was high (I2 = 82%), and the quality of the evidence was very low. When we excluded one trial with a short follow-up of eight hours, the mean difference further decreased (MD -0.09, 95% CI -9.89 to 9.71). Three trials (n = 753) compared NSAIDs to placebo regarding global improvement. We found low-quality evidence that NSAIDs are more effective than placebo with a risk ratio of 1.14 (95% CI 1.03 to 1.27). One trial (n = 214) studied the effect of NSAIDs on disability, finding very low-quality evidence that NSAIDs are no more effective than placebo on disability. Four trials (n = 967) comparing NSAIDs to placebo reported adverse effects, with low-quality evidence that the risk for adverse effects is higher in the NSAID group than in the placebo group (RR 1.40, 95% CI 1.02 to 1.93). The adverse effects reported in this review are consistent with those previously reported in the literature. Authors' conclusions: This updated systematic review including 10 trials evaluating the efficacy of NSAIDs versus placebo or other drugs in people with sciatica reports low- to very low-level evidence using the GRADE criteria. The efficacy of NSAIDs for pain reduction was not significant. NSAIDs showed a better global improvement compared to placebo. These findings must be interpreted with caution, as the level of evidence according to the GRADE classification was very low for the outcome pain reduction and low for global improvement due to small study samples, inconsistent results, imprecision, and a high risk of bias in the included trials. While the trials included in the analysis were not powered to detect potential rare side effects, we found an increased risk for side effects in the short-term NSAIDs use. As NSAIDs are frequently prescribed, the risk-benefit ratio of prescribing the drug needs to be considered.
Article
Objective: The purpose of this review was to determine the most commonly reported and utilized low back pain (LBP) Patient Reported Outcome Measures (PROMs) within the chiropractic literature and to investigate their temporal and methodological publication characteristics. Methods: A systematic search of English-language publications in 5 electronic databases (PubMed, Cochrane [CENTRAL], CINAHL/EBSCO, PsycINFO, and Index to Chiropractic Literature) was conducted for articles published from the inception of each database through June 2016. Results: One hundred forty-four articles were retrieved that utilized 75 different LBP PROMs. The 4 most commonly used LBP PROMs in the chiropractic literature were the Oswestry Disability Index, Numeric Rating Scale, Visual Analogue Scale, and Roland Morris Questionnaire. Conclusions: This research has created a unique list of the most commonly used LBP PROMs within the chiropractic literature.
Article
Background Lower back pain is one of the most common public health problems worldwide, with far-reaching social, psychological, and financial consequences for those affected. It can result in impairment of quality of life and lasting damage. This article deals with the following question: Is chiropractic treatment of lower back pain a clinically relevant, effective treatment method compared to other therapies, and does it therefore represent a standard treatment?Methods The literature research was conducted in the PubMed database. The evidence level of the individual studies was determined based on the PEDro scale. After determining the evidence levels of the individual studies, the studies rated level I were evaluated using tables according to the PICO model in comparison to other treatment methods. Investigated endpoints were back pain and the resulting restriction of movement.ResultsOf 1046 researched articles, there were 169 on the topic, including 54 systematic reviews and 115 randomized clinical trials (RCTs); 13 RCTs were suitable for a direct treatment comparison for the review. In the direct comparison with McKenzie therapy, better results were achieved for McKenzie. Otherwise, there were slightly better results for the intervention groups.Conclusion Just like McKenzie therapy, the chiropractic treatments achieved best results in improvement of lower back pain and the resulting movement restrictions. The differences in results between the intervention and control groups were small. The studies investigated exhibited methodological weaknesses. The results show that chiropractic treatment of low back pain is not a clinically relevant, effective treatment and is therefore not a standard therapy based on the studies evaluated.
Article
Background Lower back pain is one of the most common public health problems worldwide, with far-reaching social, psychological, and financial consequences for those affected. It can result in impairment of quality of life and lasting damage. This article deals with the following question: Is chiropractic treatment of lower back pain a clinically relevant, effective treatment method compared to other therapies, and does it therefore represent a standard treatment?Methods The literature research was conducted in the PubMed database. The evidence level of the individual studies was determined based on the PEDro scale. After determining the evidence levels of the individual studies, the studies rated level I were evaluated using tables according to the PICO model in comparison to other treatment methods. Investigated endpoints were back pain and the resulting restriction of movement.ResultsOf 1046 researched articles, there were 169 on the topic, including 54 systematic reviews and 115 randomized clinical trials (RCTs); 13 RCTs were suitable for a direct treatment comparison for the review. In the direct comparison with McKenzie therapy, better results were achieved for McKenzie. Otherwise, there were slightly better results for the intervention groups.Conclusion Just like McKenzie therapy, the chiropractic treatments achieved best results in improvement of lower back pain and the resulting movement restrictions. The differences in results between the intervention and control groups were small. The studies investigated exhibited methodological weaknesses. The results show that chiropractic treatment of low back pain is not a clinically relevant, effective treatment and is therefore not a standard therapy based on the studies evaluated.
Article
Background: A 2007 American College of Physicians guideline addressed nonpharmacologic treatment options for low back pain. New evidence is now available. Purpose: To systematically review the current evidence on nonpharmacologic therapies for acute or chronic nonradicular or radicular low back pain. Data sources: Ovid MEDLINE (January 2008 through February 2016), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists. Study selection: Randomized trials of 9 nonpharmacologic options versus sham treatment, wait list, or usual care, or of 1 nonpharmacologic option versus another. Data extraction: One investigator abstracted data, and a second checked abstractions for accuracy; 2 investigators independently assessed study quality. Data synthesis: The number of trials evaluating nonpharmacologic therapies ranged from 2 (tai chi) to 121 (exercise). New evidence indicates that tai chi (strength of evidence [SOE], low) and mindfulness-based stress reduction (SOE, moderate) are effective for chronic low back pain and strengthens previous findings regarding the effectiveness of yoga (SOE, moderate). Evidence continues to support the effectiveness of exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture for chronic low back pain (SOE, low to moderate). Limited evidence shows that acupuncture is modestly effective for acute low back pain (SOE, low). The magnitude of pain benefits was small to moderate and generally short term; effects on function generally were smaller than effects on pain. Limitation: Qualitatively synthesized new trials with prior meta-analyses, restricted to English-language studies; heterogeneity in treatment techniques; and inability to exclude placebo effects. Conclusion: Several nonpharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain; findings include new evidence on mind-body interventions. Primary funding source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42014014735).
Article
Importance Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT. Objective To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain. Data Sources Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms. Data Extraction and Synthesis Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Main Outcomes and Measures Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks. Findings Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, −9.95 [95% CI, −15.6 to −4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, −0.39 [95% CI, −0.71 to −0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT. Conclusions and Relevance Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.
Article
While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they: possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included: larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.
Book
Rainer Thiele deals with chiropractic and examines two questions: Is chiropractic treatment of lower back pain a successful therapeutic approach? Is chiropractic treatment a standard treatment for headaches? On the topic of chiropractic in lower back pain, a congress abstract was published by the author using the latest randomized clinical studies and discussed as a poster contribution to the 16th Congress for Health Services Research in Berlin. A systematic review answers the question about chiropractic treatment of headaches. Contents • Chiropractic Treatment for Headache • Chiropractic Treatment for Lower Back Pain Target Groups • Researchers, lecturers and students of chiropractic, osteopathy and orthopedics • Chiropractors, osteopaths, orthopedists, pain medics About the Author Dr. scient. med. Rainer Thiele wrote this work as part of his doctoral studies in medical science at the UFL (Private University of Liechtenstein) as a cumulative dissertation. He is managing director of the specialist practice for Chiropractic / Osteopathy and Sports Medicine in Munich.
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Chronic pain management is a major challenge for both patients and providers seeking effective and less costly management options. Opioid medication use for chronic pain is highly prevalent, resulting in significant unwanted side-effects for many patients. Additional costs related to chronic pain management include those associated with more than 70 million annual office visits for evaluation and treatment, work absenteeism, disability, and psychological complications. Many patients with chronic pain suffer from spinal disorders and other conditions of the neuro-musculoskeletal system. The chiropractic profession consists of highly trained, licensed, portal-of-entry access practitioners, specifically trained to assess, triage, and conservatively manage neuro-musculoskeletal conditions, especially those of the spine. Including chiropractic practitioners capable of collaborating within rehabilitation care teams may reduce the need for secondary procedures like injections or surgery. The purpose of this chapter is to provide an overview of the chiropractic profession including common clinical evaluation and management principles and procedures, especially as they apply to patients suffering from conditions causing chronic pain.
Article
Objective The purpose of this study was to describe the prevalence of chiropractic utilization and examine sociodemographic characteristics associated with utilization in a representative sample of US children and adolescents aged 4 to 17 years. Methods Data are from 9734 respondents to the 2012 National Health Interview Survey. Age, sex, race/ethnicity, geography, family income, parental educational attainment, and other health care providers served as exposure variables. Chiropractic utilization in the past 12 months (yes/no) was the targeted outcome. Weighted crude and adjusted logistic regression models, controlling for relevant covariates, were performed. Results The 12-month prevalence of chiropractic utilization in US children was 3.0% (95% confidence interval: 2.6%-3.6%). The adjusted odds (95% confidence interval) of chiropractic utilization were higher among 11- to 17-year-olds (2.02 [1.41-2.90]) (vs 4- to10-year-olds), Midwest residents (2.45 [1.36-4.44]) (vs Northeast), families with incomes ≥$100000 (3.25 [1.87-5.66]) (vs <$35000), and those that visited other Complementary and Integrative Health (also known as Complementary and Alternative Medicine) practitioners (11.26 [7.19-17.64]). Blacks and Asians had lower adjusted odds of chiropractic utilization compared with whites (0.17 [0.06-0.47] and 0.17 [0.07-0.43], respectively). Sex, parental education, and having an orthodox medical personal physician were not associated with utilization. Conclusion Although overall prevalence was low, sociodemographic characteristics of child and adolescent users of chiropractic care were identified. Age, race/ethnicity, region of residence, family income, and utilization of other Complementary and Integrative Health services were associated with chiropractic utilization, after adjusting for sociodemographic covariates.
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Background: Little is known about the preferred treatment strategies of chiropractors in managing low back pain patients with prior lumbar fusions. There are several case reports which describe chiropractic care following surgical intervention, but there are no cohort or experimental studies published. Therefore, we sought to examine self-reported management approaches and practice patterns related to the management of patients with prior surgical lumbar fusion, among United States Veterans Affairs (VA) chiropractors. Methods: An electronic survey was administered nationwide to all chiropractors providing clinical care within VA. Questions were informed by a prior survey and piloted on a sample of chiropractors external to VA. Statistical analysis included respondent background information, and quantitative analysis of chiropractic referral patterns and practices. This survey collect information on 1) provider demographics, 2) VA referral patterns, and 3) attitudes, beliefs, practices and interventions utilized by VA chiropractors to manage patients with a history of surgical lumbar fusion. Results: The survey response rate was 46.3% (62/134). The respondents were broadly representative of VA chiropractic providers in age, gender, and years in practice. The majority of respondents (90.3%) reported seeing at least 1 post-fusion patient in the past month. The most common therapeutic approaches utilized by VA chiropractors were healthy lifestyle advice (94.9%), pain education (89.8%), exercise prescription (88.1%), stretching (66.1%) and soft tissue manual therapies (62.7%). A relatively smaller proportion described always or frequently incorporating lumbar (16.9%), thoracic (57.6%) or pelvic (39.0%) spinal manipulation. Conclusion: This survey provides preliminary data on VA chiropractic services in the management of patients with prior lumbar fusion. These patients are often seen by VA chiropractors, and our findings support the need for further study to advance understanding of interventions utilized by chiropractors in this patient population.
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Manuelle Medizin richtet sich an Orthopäden/Unfallchirurgen, Allgemeinmediziner, Rheumatologen, Internisten und Traumatologen, sowie an Krankengymnasten und Physiotherapeuten in Klinik und Praxis.
Book
Rainer Thiele beschäftigt sich in diesem Buch mit der Chiropraktik und untersucht dabei zwei Fragestellungen: Ist chiropraktische Behandlung bei unteren Rückenschmerzen ein erfolgreicher Therapieansatz? Ist chiropraktische Behandlung bei Kopfschmerzen eine Standardtherapie? Zur Thematik Chiropraktik bei unteren Rückenschmerzen wurde mittels neuester randomisierten klinischen Studien ein Kongress-Abstract veröffentlicht, welches als Posterbeitrag zum 16. Kongress für Versorgungsforschung in Berlin diskutiert wurde. Eine systematische Übersichtsarbeit beantwortet die Frage zum Thema chiropraktische Behandlung bei Kopfschmerzen. Der Inhalt • Chiropraktische Behandlung bei Kopfschmerzen • Chiropraktische Behandlung bei unteren Rückenschmerzen Die Zielgruppen • Forschende, Dozierende und Studierende der Fachbereiche Chiropraktik, Osteopathie und Orthopädie • Chiropraktiker, Osteopathen, Orthopäden, Schmerzmediziner Der Autor Rainer Thiele verfasste diese Arbeit im Rahmen seines Doktorratsstudiums im Fach Medizinwissenschaften an der UFL (Private Universität Liechtenstein) als kumulative Dissertation. Er ist Geschäftsführer der Gemeinschaftspraxis für amerik. Chiropraktik/Osteopathie und Sportheilkunde in München.
Article
Objective The purpose of this article is to provide an essential overview of chiropractic services in United States military and veterans’ health care systems. Methods We reviewed literature, legislation, and policies from 1936 through September 2021 pertaining to chiropractic services in the United States military and veterans’ health systems. Using these sources and our combined experience in these systems, we identified fundamental themes in the delivery of chiropractic care in the health care systems of the Department of Defense (providing health care for active duty service members) and the Department of Veterans Affairs (providing health care for veterans) in main topic areas. Results We identified 7 main topic areas relevant to the 2 systems: populations served by chiropractors; health care systems; integration; utilization and supply of chiropractic care; vetting of chiropractors; roles and evaluation of chiropractors; and oversight and leadership. Key information about chiropractic care in these systems was synthesized into the main topic areas. Benefits of high-quality within-system chiropractic care to active-duty service members and veterans are presented. The assets that within-system chiropractors bring to the Department of Defense and Department of Veterans Affairs health care systems are discussed for each main topic area. Conclusion This article contains an essential overview of chiropractic services in the Department of Defense and the Department of Veterans Affairs. It offers clarity regarding the integration of chiropractic services into these health care systems and includes a 1-page brief of talking points that may help better inform ongoing discussions of chiropractic services in these 2 different but intertwined environments.
Article
Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.
Article
Objective: The purpose of this case report was to describe the chiropractic management of thoracolumbar syndrome using multimodal therapies. Clinical features: A 33-year-old woman with 3 weeks of back pain presented to a chiropractic clinic. Nerve tension tests and local tenderness were present in a pattern described by Maigne, and she was diagnosed with thoracolumbar syndrome (Maigne syndrome) at her initial visit. Intervention and outcomes: The Oswestry Disability Index for low back pain (62%), STarT low back screen tool for clinical outcomes (6 points total, with a 2-point subscale), numeric pain rating scale (6/10 constant, 10/10 with provocation), and test-retest exercise audits were outcome measures. She received 3 treatment sessions, each with progressive exercise audits, and discharged with advice. At discharge, the patient scores substantially improved (Oswestry Disability Index: 8%, STarT: 1 point total, numeric pain rating scale: 1/10, 10% of the time), and she exhibited greater confidence in home care. Endurance tests were performed to establish baselines for future care, which included static back endurance test (timed 52 seconds) and side bridge endurance test (timed 43 seconds). Conclusion: The patient responded positively to chiropractic care. After a short course of care, the patient reported reduced pain, alleviated symptoms, and improved physical function.
Article
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Low back pain (LBP) is a well-recognized public health problem with no clear gold standard medical approach to treatment. Thus, those with LBP frequently turn to treatments such as spinal manipulation (SM). Many clinical trials have been conducted to evaluate the efficacy or effectiveness of SM for LBP. The primary objective of this paper was to describe the current literature on patient-centered outcomes following a specific type of commonly used SM, high-velocity low-amplitude (HVLA), in patients with LBP. A systematic search strategy was used to capture all LBP clinical trials of HVLA using our predefined patient-centered outcomes: visual analogue scale, numerical pain rating scale, Roland-Morris Disability Questionnaire, and the Oswestry Low Back Pain Disability Index. Of the 1294 articles identified by our search, 38 met our eligibility criteria. Like previous SM for LBP systematic reviews, this review shows a small but consistent treatment effect at least as large as that seen in other conservative methods of care. The heterogeneity and inconsistency in reporting within the studies reviewed makes it difficult to draw definitive conclusions. Future SM studies for LBP would benefit if some of these issues were addressed by the scientific community before further research in this area is conducted.
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The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.
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The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions. The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs. By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments. 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.
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This report presents selected estimates of complementary and alternative medicine (CAM) use among U.S. adults and children, using data from the 2007 National Health Interview Survey (NHIS), conducted by the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS). Trends in adult use were assessed by comparing data from the 2007 and 2002 NHIS. Estimates were derived from the Complementary and Alternative Medicine supplements and Core components of the 2007 and 2002 NHIS. Estimates were generated and comparisons conducted using the SUDAAN statistical package to account for the complex sample design. In 2007, almost 4 out of 10 adults had used CAM therapy in the past 12 months, with the most commonly used therapies being nonvitamin, nonmineral, natural products (17.7%) and deep breathing exercises (12.7%). American Indian or Alaska Native adults (50.3%) and white adults (43.1%) were more likely to use CAM than Asian adults (39.9%) or black adults (25.5%). Results from the 2007 NHIS found that approximately one in nine children (11.8%) used CAM therapy in the past 12 months, with the most commonly used therapies being nonvitamin, nonmineral, natural products (3.9%) and chiropractic or osteopathic manipulation (2.8%). Children whose parent used CAM were almost five times as likely (23.9%) to use CAM as children whose parent did not use CAM (5.1%). For both adults and children in 2007, when worry about cost delayed receipt of conventional care, individuals were more likely to use CAM than when the cost of conventional care was not a worry. Between 2002 and 2007 increased use was seen among adults for acupuncture, deep breathing exercises, massage therapy, meditation, naturopathy, and yoga. CAM use for head or chest colds showed a marked decrease from 2002 to 2007 (9.5% to 2.0%).
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To determine whether treatment with spinal manipulative therapy (SMT) administered in addition to standard care is associated with clinically relevant early reductions in pain and analgesic consumption. 104 patients with acute low back pain were randomly assigned to SMT in addition to standard care (n = 52) or standard care alone (n = 52). Standard care consisted of general advice and paracetamol, diclofenac or dihydrocodeine as required. Other analgesic drugs or non-pharmacological treatments were not allowed. Primary outcomes were pain intensity assessed on the 11-point box scale (BS-11) and analgesic use based on diclofenac equivalence doses during days 1-14. An extended follow-up was performed at 6 months. Pain reductions were similar in experimental and control groups, with the lower limit of the 95% CI excluding a relevant benefit of SMT (difference 0.5 on the BS-11, 95% CI -0.2 to 1.2, p = 0.13). Analgesic consumptions were also similar (difference -18 mg diclofenac equivalents, 95% CI -43 mg to 7 mg, p = 0.17), with small initial differences diminishing over time. There were no differences between groups in any of the secondary outcomes and stratified analyses provided no evidence for potential benefits of SMT in specific patient groups. The extended follow-up showed similar patterns. SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain.
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This paper reports the results of a 'cost-of-illness' study of the socio-economic costs of back pain in the UK. It estimates the direct health care cost of back pain in 1998 to be pound1632 million. Approximately 35% of this cost relates to services provided in the private sector and thus is most likely paid for directly by patients and their families. With respect to the distribution of cost across different providers, 37% relates to care provided by physiotherapists and allied specialists, 31% is incurred in the hospital sector, 14% relates to primary care, 7% to medication, 6% to community care and 5% to radiology and imaging used for investigation purposes. However, the direct cost of back pain is insignificant compared to the cost of informal care and the production losses related to it, which total pound10668 million. Overall, back pain is one of the most costly conditions for which an economic analysis has been carried out in the UK and this is in line with findings in other countries. Further research is needed to establish the cost-effectiveness of alternative back pain treatments, so as to minimise cost and maximise the health benefit from the resources used in this area.
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Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews. Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure. Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.
Article
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This report presents selected estimates of complementary and alternative medicine (CAM) use among U.S. adults, using data from the 2002 National Health Interview Survey (NHIS), conducted by the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS). Data for the U.S. civilian noninstitutionalized population were collected using computer-assisted personal interviews (CAPI). This report is based on 31,044 interviews of adults age 18 years and over. Statistics shown in this report were age adjusted to the year 2000 U.S. standard population. Sixty-two percent of adults used some form of CAM therapy during the past 12 months when the definition of CAM therapy included prayer specifically for health reasons. When prayer specifically for health reasons was excluded from the definition, 36% of adults used some form of CAM therapy during the past 12 months. The 10 most commonly used CAM therapies during the past 12 months were use of prayer specifically for one's own health (43.0%), prayer by others for one's own health (24.4%), natural products (18.9%), deep breathing exercises (11.6%), participation in prayer group for one's own health (9.6%), meditation (7.6%), chiropractic care (7.5%), yoga (5.1%), massage (5.0%), and diet-based therapies (3.5%). Use of CAM varies by sex, race, geographic region, health insurance status, use of cigarettes or alcohol, and hospitalization. CAM was most often used to treat back pain or back problems, head or chest colds, neck pain or neck problems, joint pain or stiffness, and anxiety or depression. Adults age 18 years or over who used CAM were more likely to do so because they believed that CAM combined with conventional medical treatments would help (54.9%) and/or they thought it would be interesting to try (50.1%). Most adults who have ever used CAM have used it within the past 12 months, although there is variation by CAM therapy.
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Four important domains directly related to low back pain are: pain intensity, low-back-pain-specific disability, patient satisfaction with treatment outcome, and work disability. Within each of the domains, different questionnaires have been proposed. This chapter focuses on validated and widely used questionnaires. Details of the background and the measurement properties, and of the minimally clinically important change (MCIC) using these questionnaires, are described. The MCIC can be estimated using various methods and there is no consensus in the literature on what the most appropriate technique is. This chapter focuses primarily on two adequate and frequently used methods for estimating the MCIC. We argue that the MCIC should not be considered as a fixed value and that the MCIC values presented in this chapter are used as indications. For patients with subacute or chronic low back pain, the MCIC for pain on a visual analogue scale (VAS) should at least be 20mm and for acute low back pain it seems reasonable to suggest that the MCIC should at least be at the level of approximately 35mm. If a numerical rating scale (NRS) is used it seems reasonable to suggest that the MCIC should at least be 3.5 and 2.5 for patients with acute and chronic low back pain, respectively. For functional disability as measured with the Roland Disability Questionnaire it seems reasonable that the MCIC should at least be 3.5 points, whereas an MCIC of at least 10 points when the Oswestry Disability Index is used. For global perceived effect, we argue that the MCIC is most appropriately defined in terms of at least 'much improved' or 'very satisfied', instead of including 'slightly improved'. Finally, we argue that, from the point of view of cost effectiveness, every day of earlier return to work is important. The exact value for the MCIC can be determined, taking into account the aim of the measurement, the initial scores, the target population and the method used to assess MCIC.
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Cohort study. To estimate the Minimal Clinically Important Change (MCIC) of the pain intensity numerical rating scale (PI-NRS), the Quebec Back Pain Disability Scale (QBPDS), and the Euroqol (EQ) in patients with low back pain. MCIC can provide valuable information for researchers, healthcare providers, and policymakers. Data from a randomized controlled trial with 442 patients with low back pain were used. The MCIC was estimated over a 12-week period, and three different methods were used: 1) mean change scores, 2) minimal detectable change, and 3) optimal cutoff point in receiver operant curves. The global perceived effect scale (GPE) was used as an external criterion. The effect of initial scores on the MCIC was also assessed. The MCIC of the PI-NRS ranged from 3.5 to 4.7 points in (sub)acute patients and 2.5 to 4.5 points in chronic patients with low back pain. The MCIC of the QBPDS was estimated between 17.5 to 32.9 points and 8.5 to 24.6 points for (sub)acute and chronic patients with low back pain. The MCIC for the EQ ranged from 0.07 to 0.58 in (sub)acute patients and 0.09 to 0.28 in patients with chronic low back pain. Reporting the percentage of patients who have made a MCIC adds to the interpretability of study results. We present a range of MCIC values and advocate the choice of a single MCIC value according to the specific context.
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The economic burden of low back pain (LBP) is very large and appears to be growing. It is not possible to impact this burden without understanding the strengths and weaknesses of the research on which these costs are calculated. To conduct a systematic review of LBP cost of illness studies in the United States and internationally. Systematic review of the literature. Medline was searched to uncover studies about the direct or indirect costs of LBP published in English from 1997 to 2007. Data extracted for each eligible study included study design, population, definition of LBP, methods of estimating costs, year of data, and estimates of direct, indirect, or total costs. Results were synthesized descriptively. The search yielded 147 studies, of which 21 were deemed relevant; 4 other studies and 2 additional abstracts were found by searching reference lists, bringing the total to 27 relevant studies. The studies reported on data from Australia, Belgium, Japan, Korea, the Netherlands, Sweden, the UK, and the United States. Nine studies estimated direct costs only, nine indirect costs only, and nine both direct and indirect costs, from a societal (n=18) or private insurer (n=9) perspective. Methodology used to derive both direct and indirect cost estimates differed markedly among the studies. Among studies providing a breakdown on direct costs, the largest proportion of direct medical costs for LBP was spent on physical therapy (17%) and inpatient services (17%), followed by pharmacy (13%) and primary care (13%). Among studies providing estimates of total costs, indirect costs resulting from lost work productivity represented a majority of overall costs associated with LBP. Three studies reported that estimates with the friction period approach were 56% lower than with the human capital approach. Several studies have attempted to estimate the direct, indirect, or total costs associated with LBP in various countries using heterogeneous methodology. Estimates of the economic costs in different countries vary greatly depending on study methodology but by any standards must be considered a substantial burden on society. This review did not identify any studies estimating the total costs of LBP in the United States from a societal perspective. Such studies may be helpful in determining appropriate allocation of health-care resources devoted to this condition.
Article
Background: Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. Purpose: To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. Data Sources: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews. Study Selection: Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure. Data Extraction: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). Data Synthesis: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. Conclusions: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.
Article
Study Design. This study is an analysis of national survey data from 5 sample years. Objectives. The authors characterized the frequency of office visits for low back pain, the content of ambulatory care, and how these vary by physician specialty. Summary of Background Data. Few recent data are available regarding ambulatory care for low back pain or how case mix and patient management vary by physician specialty. Methods. Data from the National Ambulatory Medical Care Survey were grouped into three time periods (1980-81, 1985, 1989-90). Frequency of visits for low back pain, referral status, tests, and treatments were tabulated by physician speciatly. Results. There were almost 15 million office visity for "mechanical" low back pain in 1990, ranking this problem fifth as a reason for all physician visits. Low back pain accounted for 2.8 percent of office visity in all three time periods. Nonspecific diagnostic lables were most common, and 56 percent of visits were to primary care physicians. Specialty variations were observed in caseload, diagnostic mix, and management. Conclusion. Back pain remains a major reason for all physician office visity. This study describes visit, referral, and management patterns among specialties providing the most care.
Article
The aim of the current study was to determine: the prevalence of low back pain (LBP) and associated disability; the frequency of consultation to general practice; whether there were differences in management by age. We conducted a cross-sectional population study in Aberdeen city and Cheshire County, UK. Participants were 15,272 persons aged 25 years and older. The 1-month period prevalence of LBP was 28.5%. It peaked at age 41-50 years, but at ages over 80 years was reported by 1 in 4 persons. Older persons were more likely to consult, and the prevalence of severe LBP continued to increase with age. Management by general practitioners differed by age of the patient. Older persons (> 70 vs ≤ 40 years) were more likely to only have been prescribed painkillers (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.28-2.35) or only pain killers with other medications (OR 1.45, 95% CI 1.07-1.98). They were less likely to be prescribed physiotherapy or exercise (OR 0.63, 95% CI 0.46-0.85) or to be referred to a specialist (OR 0.77, 95% CI 0.57-1.04). Older persons were more likely to have previously received exercise therapy for pain, were less likely to be enthusiastic about receiving it now (P<0.0001), and were less likely to think it would result in improved symptoms (P<0.0001). It is important that older persons, who have the highest prevalence of LBP with disability and are most likely to consult, are receiving optimal pharmacological and nonpharmacological management.
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Systematic review of interventions. To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain. SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention. Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. The primary outcomes were pain, functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence. We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief (mean difference -4.16, 95% confidence interval -6.97 to -1.36) and functional status (standardized mean difference -0.22, 95% confidence interval -0.36 to -0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT. High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.
Article
Chiropractors commonly use a combination of interventions to treat people with low-back pain (LBP). To determine the effects of combined chiropractic interventions (that is, a combination of therapies, other than spinal manipulation alone) on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with LBP, aged 18 and older. We searched: The Cochrane Back Review Group Trials Register (May 2009), CENTRAL (The Cochrane Library 2009, Issue 2), and MEDLINE (from January 1966), EMBASE (from January 1980), CINAHL (from January 1982), MANTIS (from Inception) and the Index to Chiropractic Literature (from Inception) to May 2009. We also screened references of identified articles and contacted chiropractic researchers. All randomised trials comparing the use of combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies. At least two review authors selected studies, assessed the risk of bias, and extracted the data using standardised forms. Both descriptive synthesis and meta-analyses were performed. We included 12 studies involving 2887 participants with LBP. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of sub-populations of people with LBP.No trials were located of combined chiropractic interventions compared to no treatment. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (SMD -0.25 (95% CI -0.46 to -0.04) and MD -0.89 (95%CI -1.60 to -0.18)) compared to other treatments, but there was no significant difference in long-term pain (MD -0.46 (95% CI -1.18 to 0.26)). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 (95% CI -0.70 to -0.02)). However, the effect was small and all studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and for studies that had a mixed population of LBP. Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.
Article
The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP). A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies. 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.
Article
This study is an analysis of national survey data from 5 sample years. The authors characterized the frequency of office visits for low back pain, the content of ambulatory care, and how these vary by physician specialty. Few recent data are available regarding ambulatory care for low back pain or how case mix and patient management vary by physician specialty. Data from the National Ambulatory Medical Care Survey were grouped into three time periods (1980-81, 1985, 1989-90). Frequency of visits for low back pain, referral status, tests, and treatments were tabulated by physician specialty. There were almost 15 million office visits for "mechanical" low back pain in 1990, ranking this problem fifth as a reason for all physician visits. Low back pain accounted for 2.8 percent of office visits in all three time periods. Nonspecific diagnostic labels were most common, and 56 percent of visits were to primary care physicians. Specialty variations were observed in caseload, diagnostic mix, and management. Back pain remains a major reason for all physician office visits. This study describes visit, referral, and management patterns among specialties providing the most care.
Article
A systematic literature review of population prevalence studies of low back pain between 1966 and 1998 was conducted to investigate data homogeneity and appropriateness for pooling. Fifty-six studies were analyzed using methodologic criteria that examined sample representativeness, data quality, and pain definition. Acceptable studies were assessed for homogeneity and appropriateness for pooling. Thirty were methodologically acceptable. Of these there were significant differences in study design, patient age, mode of data collection, potential temporal effects, and prevalence results. Point prevalence ranged from 12% to 33%, 1-year prevalence ranged from 22% to 65%, and lifetime prevalence ranged from 11% to 84%. A limited number of studies were left for analysis, making the pooling of data difficult. A model using uniform best-practice methods is proposed.
Article
A prospective repeated-measures design was applied. To examine the measurement properties of the Back Pain Functional Scale (BPFS) and the Roland-Morris Questionnaire (RMQ) and to formulate hypotheses and sample size estimates for a subsequent comparison study. Although there are numerous functional status measures for patients with low back pain, most have been conceived of and validated with a group rather than an individual patient as the unit of interest. Also, little has been done to formally compare-this includes the generation of a priori hypotheses, followed by statistical hypotheses testing-the many competing measures. Subjects were 77 patients with low back pain who were referred by physicians to 10 outpatient physical therapy clinics located in Canada and the United States. The questionnaires were administered at patients' initial visits, within 48 hours of the initial visit, and at 1-, 2-, and 3-week follow-up visits. Reliability, cross-sectional validity, and longitudinal validity (sensitivity to change) coefficients were calculated. Test-retest reliability estimates of 0.81 and 0. 88 were obtained for the RMQ and BPFS, respectively. The measures demonstrated similar levels of cross-sectional validity. Correlations of 0.56 and 0.65 were noted between a prognostic rating of change and the RMQ and BPFS, respectively. The RMQ demonstrated a ceiling effect. Approximately 180 patients are needed for a subsequent head-to-head comparison study of the measures. The BPFS appears to have sound measurement properties, and a formal head-to-head comparison study with the RMQ is warranted.
Article
A proposed standard "core set" of outcome measures for low back pain includes 5 domains: back-specific function, generic health status, pain, work disability, and patient satisfaction. This paper focuses on the 2 recommended back-specific measures of function: the Roland-Morris Disability Questionnaire (RDQ) and the Oswestry Disability Index (ODI). We specifically address their ability to measure change. A systematic review of the literature identified a total of 78 and 71 (RDQ and ODI, respectively) articles as potentially relevant. Detailed tables are provided for each citation, with the type of back pain population studied, the type of change measured, the estimate of change, and the interval over which the change was studied. These tables should be used as a reference for sample size calculation. The responsiveness of the RDQ found in the literature ranges from 2 to 8 points on its 0 to 24 scale depending on what change is being measured. As a rough guide, Roland recommends that a change in 2-3 points on the RDQ should be considered the minimum clinically important change. Choosing any value larger than 5 in designing a clinical trial would risk underpowering the trial, since fewer patients are needed if a trial is designed on the basis of a large change score.
Article
The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.
Available at http://quickfacts.census.gov/ qfd/states
US Census Bureau 2010. Available at http://quickfacts.census.gov/ qfd/states/48/4826664.html. Accessed January 24, 2012.
User's Manual for the SF-12v2™ Health Survey (with a Supplement Documenting SF-12® Health Survey) QualityMetric Incorporated
  • Je Ware
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Ware JE, Kosinski M, Turner-Bowker DM, et al. User's Manual for the SF-12v2™ Health Survey (with a Supplement Documenting SF-12® Health Survey). Lincoln, RI : QualityMetric Incorporated ; 2002.
Complementary and Alternative Therapies for Back Pain II Evidence Report/Technology Assessment No. 194 (Prepared by the University of Ottawa Evidence-based Practice Center under Contract No. 290-2007- 10059-I (EPCIII) Agency for Healthcare Research and Quality
  • A Furlan
  • F Yazdi
  • A Tsertsvadze
Furlan A, Yazdi F, Tsertsvadze A, et al. Complementary and Alternative Therapies for Back Pain II. Evidence Report/Technology Assessment No. 194 (Prepared by the University of Ottawa Evidence-based Practice Center under Contract No. 290-2007- 10059-I (EPCIII). Rockville, MD : Agency for Healthcare Research and Quality ; 2010. AHRQ Publication No.10(11)E007 [October 2010].
An updated overview of clinical guidelines for the management of non-specifi c low back pain in primary care
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Koes BW, van TM, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specifi c low back pain in primary care. Eur Spine J 2010 ; 19 : 2075 – 2094.
Prepared by the University of Ottawa Evidence-based Practice Center under Contract No. 290-2007-10059-I (EPCIII)
  • A Furlan
  • F Yazdi
  • A Tsertsvadze
Furlan A, Yazdi F, Tsertsvadze A, et al. Complementary and Alternative Therapies for Back Pain II. Evidence Report/Technology Assessment No. 194 (Prepared by the University of Ottawa Evidence-based Practice Center under Contract No. 290-2007-10059-I (EPCIII). Rockville, MD : Agency for Healthcare Research and Quality ; 2010. AHRQ Publication No.10(11)E007 [October 2010].
Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review
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Rubinstein SM, van MM, Assendelft WJ, et al. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine (Phila Pa 1976) 2011 ; 36 : E825 -46.
User's Manual for the SF-12v2™ Health Survey (with a Supplement Documenting SF-12® Health Survey)
  • J E Ware
  • M Kosinski
  • D M Turner-Bowker
Ware JE, Kosinski M, Turner-Bowker DM, et al. User's Manual for the SF-12v2™ Health Survey (with a Supplement Documenting SF-12® Health Survey). Lincoln, RI : QualityMetric Incorporated ; 2002.