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Integrative Acupuncture and Spinal Manipulative Therapy Versus Either Alone for Low Back Pain: A Randomized Controlled Trial Feasibility Study
Abstract
Objectives:
The objective of this study was to assess the feasibility of conducting a large-scale randomized controlled trial (RCT) examining whether an integrative care model combining spinal manipulative therapy (SMT) and acupuncture can lead to better outcomes for low back pain (LBP) than either therapy alone.
Methods:
This study was conducted at a complementary and alternative medicine university health center. Participants with acute or chronic LBP were randomized to (1) acupuncture, (2) SMT, or (3) integrative acupuncture and SMT groups. Treatments were provided over 60 days by licensed doctors of chiropractic and acupuncturists. Acupuncture treatments consisted of needling of acupoints combined with electrotherapy, moxibustion, cupping, and Tui Na. SMT used specific contact points on vertebral processes, along with soft tissue therapy and physiotherapy. Primary outcome measures were the Roland-Morris LBP Disability Questionnaire and 0 to 10 Numeric Rating Scale for LBP.
Results:
Participants in all 3 groups experienced clinically meaningful improvements in the primary outcome measures; however, no between-group differences in outcomes were apparent.
Conclusions:
This study indicated that it is feasible to conduct an RCT to compare the effectiveness of integrative acupuncture and SMT for LBP to either therapy alone. Future studies should include a larger sample to increase the power for detecting clinically meaningful differences between groups.
... Kizhakkeveettil et al.'s [23] randomized controlled trial involved 101 individuals having chronic back pain in California, USA. The study evaluated the impacts of acupuncture over a period of 120 days. ...
... PRISMA flow diagram Fig. 2. Risk of bias graph of included studies[19][20][21][22][23][24][25][26][27][28][29] ...
... Characteristics of Included Studies[21][22][23][24][25][26][27][28][29][30][31] ...
Millions of people suffer from lower back pain, which has social, economic, and health consequences. One of the most difficult areas to effectively manage is Chronic Low Back Pain. This systematic review and meta-analysis examine the effectiveness exclusive of surgery, including acupuncture, physiotherapy or medication (NSAIDs), chiropractic procedure, or mental therapy as advised by WHO guidelines. Thirteen studies were reviewed investigating the effect of these treatments on pain relief, functional improvement, and patient satisfaction. Pain scores, functional improvements, and patient satisfaction in the acupuncture group were superior to placebo. Adherence to physiotherapy and patient satisfaction was also good. Substantially less differential added benefits emerged from complementary intervention acupuncture (encircled in red), resulting in moderate to low satisfaction levels compared to medication, especially physiotherapy. Chiropractic effectively decreased LBP and improved function, and participants were generally very satisfied. Mental therapy provided psychological support that alleviated pain intensity and promoted improved physical function, significantly increasing the satisfaction level in these patients as part of their overall pain relief. Nonsurgical treatments, such as acupuncture (Acumoxa), physiotherapy medication, and chiropractic mental therapy, are result-oriented in relieving symptoms of CLBP. Patient satisfaction was highest for acupuncture and medication. Nonetheless, differences in research methodology and population characteristics are likely to make generalizations of what we can learn from the results a more challenging task. Future studies should improve on these limitations and the long-term safety/efficacy of these treatments. Only if alternative treatments like chiropractic and mental therapy, as suggested by WHO, are integrated in management, a line of approach for CLBP will be completed.
... In some countries, SMT and acupuncture are recommended in international clinical guidelines and as rst-line treatments [10,17]. Some studies comparing the effect of SMT and acupuncture on pain relief and functional improvement showed that SMT was more effective while others had opposite results [18][19][20]. As we know, choosing an effective and safe treatment could avoid wasting time and effort. ...
... In the remaining 238 records, 229 studies were excluded for the following reasons: animal researches, no data available, no back pain, no comparison, inappropriate comparison, reviews. As a result, a total of 9 RCTs were included with 714 patients in this meta-analysis [18][19][20][26][27][28][29][30][31]. The detailed process of studies identi cation and screening was provided in Fig. 1. ...
... More than half of the studies (55.6% (n=5/9)) used both a random sequence generation and an allocation concealment [20,[26][27][28]31]. None of the studies attempted to blind patients. ...
Background
Spinal manipulation therapy (SMT) and acupuncture are commonly used for low back pain (LBP) among complementary and alternative therapies. However, it remains unclear which of the two therapies is more effective for LBP. Therefore, the purpose of this meta-analysis was to evaluate the effectiveness of SMT and acupuncture on LBP.
Methods
Four electronic databases were searched for randomized controlled trials (all years until July 2021), including PubMed, Embase, Web of Science, and Cochrane Library. Two reviewers independently abstracted data, assessed risk of bias, and rated the quality of evidence. The primary outcome was pain; secondary outcomes included functional status and adverse events. Review Manager 5.3 software and Stata 12.0 were used for all statistical analyses.
Results
9 RCTs with a total of 714 participants were identified, who were on average middle aged (39-60 years) without signs of radiating pain. These trials included patients with mild to moderate pain. Overall, moderate quality of evidence suggested that SMT had better effects for pain relief (MD: 0.32, 95%CI: 0.09 to 0.55, I²=34%) and similar effects in function (MD: 0.24, 95%CI: -0.45 to 0.94, I²=21%) when compared to acupuncture. Moderate quality of evidence showed SMT reduced pain better than acupuncture at month 2 (MD: 0.61, 95%CI: 0.08 to 1.14, I²=0%) and at month 12 (MD: 1.02, 95%CI: 0.28 to 1.75, I²=42%). In addition, Low quality of evidence showed SMT may provide better improvement in pain at month 3 (MD: 0.74, 95%CI: 0.09 to 1.39, I²=42%) and in function at month 4 (MD: 3.50, 95%CI: 0.71 to 6.29). Adverse events associated with SMT and acupuncture were rare and mild.
Conclusions
SMT showed better effects than acupuncture for chronic low back pain, while SMT and acupuncture had similar effects in functional improvement. Although SMT and acupuncture were tolerable and safe, patients should be informed about the potential risks of adverse events before starting therapy.
... Acredita-se que o tempo de permanência das agulhas nas participantes desta pesquisa tenha sido suficiente para alcançar a redução da dor. Salienta-se resultados semelhantes em estudo realizado no sul da Califórnia, que também deixou as agulhas de acupuntura durante 30 minutos, evidenciando que, sozinha ou em combinação, a terapia foi eficaz no tratamento da lombalgia e, como consequência, a qualidade de vida dos participantes apresentou tendências gerais de melhoria (23) . ...
... Os achados deste estudo sugerem que a acupuntura pode ajudar a reduzir alguns dos efeitos prejudiciais que a DL tem na sociedade, como o uso de medicamentos e os custos indiretos, como o afastamento de alguma atividade ou função (23) . A acupuntura ofereceu significativos efeitos para redução ou alívio da dor nas gestantes, porém é importante que os profissionais da saúde as auxiliem a administrar suas emoções e estilo de vida, para que se possa atuar a favor de sua qualidade de vida. ...
Objective:
To evaluate the effects of acupuncture in the treatment of low back pain in pregnant women in the second and third trimesters of pregnancy.
Method:
A quasi-experimental pre-post design was applied to pregnant women at a gestational age between 14 and 37 weeks, who had complaints of low back pain. Acupuncture sessions were performed, working systemic and auricular points. The McGill questionnaire was used to assess pain, as well as the instrument for identifying the sociodemographic, clinical and obstetric profile.
Results:
The acupuncture technique performed in up to six sessions in 56 pregnant women with low back pain had positive effects on the participants' health. According to the pain assessment, there was a statistically significant reduction in the low back pain among the pregnant women as early as in the second session, with a gradual improvement with the advancement of the number of sessions. There were no serious adverse events related to acupuncture.
Conclusion:
Acupuncture offered significant effects for reducing or relieving pain in pregnant women. The participants expressed satisfaction and well-being as they left each session.
... Integrative treatment Improvement in pain and enhance quality of life [199,200] Spinal manipulative therapy Improvement in low back pain [201] Chiropractic and integrative care Pain reduction [202] Yoga Reducing long-term lower back pain [186,203,204] Cognitive behavioural therapy (CBT) and mindfulness Stress reduction can improve LBP [189] Alexander Technique Reduced the incidence of LBP [191,205] Massage Reduced pain [206] Dieting Weight loss can reduce Lower back pain [196] Spinal manipulation and transcutaneous electrical stimulation Reduced pain [207] Acupuncture Positive impact [206] Theramine (amino acid supplement) Positive impact [91] Preprints.org (www.preprints.org) ...
Many people in the USA have lost their lives or become addicted to opioids via prescription opioids given for chronic pain. The chronic pain epidemic has emerged due to a convergence of factors, including the medicalization of pain as well as injuries happening in the workplace, in the home, or during recreation. Opioid prescriptions rose precipitously from the late 1990’s through to approximately 2020, and despite public awareness, still are increasing. This review examines literature on integrative approaches to chronic pain as delineated by pain type. The review is organized by the most common causes of chronic pain, and randomized controlled trials, meta-analyses and systematic reviews are extracted for each cause of chronic pain. Several promising interventions may alleviate chronic pain of some causes, and some interventions may work across pain causes. Lowering inflammation through dietary or lifestyle regimens may be a general way of reducing pain. Pain can be alleviated through several adjunctive and integrative treatment approaches, which may serve to lower the need for opioid medication.
... Mainly based on the theory of meridians and collaterals in traditional Chinese medicine, this treatment effectively combines acupoint stimulation and physical therapy. By stimulating a distant acupoint along the meridian, it can transport the long-distance Qi and blood to the affected area for local circulation, increase the range of waist motion, and relieve pain [18]. ...
Aim:
This study is aimed at investigating the effect of acupuncture along meridians on pain degree and treatment of acute lumbar sprain.
Methods:
A total of 96 patients with acute lumbar sprain from May 2019 to March 2021 in our hospital were selected and divided into the study and control groups. The patients in the control group were administered conventional western medicine and massage therapy, while the study group underwent acupuncture along meridians based on the control group. The therapeutic effect, visual analogue scale (VAS), Roland-Morris Disability Questionnaire (RMDQ), and lumbar range of motion (ROM) scores, emG inversion times, emG amplitude of the sacrospinalis muscle, and the serum TNF-α and IL-6 levels were determined.
Results:
The total effective rate of the study group was significantly higher than that of the control group. After treatment, the VAS, RMDQ, and ROM scores of the study group were significantly lower than those of the control group. Before the intervention, the EMG inversion times and the EMG amplitude of the spinous process muscle in the study group were not significantly different from those in the control group. After the intervention, the number and amplitude of EMG reversal in the study group were significantly higher than those in the control group. After the intervention, the serum levels of TNF-α (pg/ml) and IL-6 (pg/ml) in the study group were significantly lower than those in the control group. Conclusion. Meridian acupuncture for acute lumbar sprain can effectively improve body function, relieve pain, regulate serum inflammatory factors, and improve the overall therapeutic effect.
... This should not be confounded with multimodal therapy approaches combining active and passive physical treatments with psychosocial and behavioral interventions for chronic LBP within a treatment concept (5). A recently published three-armed trial to evaluate the effectiveness of manipulative treatment and acupuncture combined or alone by Kizhakkeveettil et al. is highly welcome to improve guidance of clinicians which treatment options should be combined (6). To make a long story short, they did not observe any benefit from combining both treatment options compared to each alone. ...
Acupuncture has been used as a therapeutic intervention for the treatment of numerous diseases and symptoms for thousands of years, and low back pain has been studied and treated the most in acupuncture clinics. Traditional theory strongly suggests that the selection of acupoints will influence their clinical effects and combinations (e.g., the clinical effects of a particular acupoint or combination on reducing pain), but this idea was not considered in earlier systematic reviews and meta-analyses. We performed a systematic review, meta-analysis, and network analysis to evaluate the magnitude of the effects of acupoints used to treat low back pain in randomized controlled clinical trials. We found that acupuncture significantly reduced pain in patients with low back pain compared with the control group. The most frequently prescribed acupoints were BL23, GV3, BL20, BL40, and BL25, whereas the acupoints with the highest average effect size scores were BL20, GV3, GB30, GB34, and BL25. Further, the combinations of BL23-BL40, BL23-B25, and BL23-BL60 were the most frequently prescribed, while BL23-GV3, BL40-GV4, and BL23-BL25 showed the largest average effect size. By calculating clinical outcomes based on average effect sizes, we found that the most popular acupoints might not always be associated with the best results. Although a more thorough investigation is necessary to determine the clinical effects of each acupoint and combination on patients, we suggest that our approach may offer a fresh perspective that will be useful for future research.
Objective
The objective of this study was to compare patients’ perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment.
Methods
Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data: SMT, PDT, and 2 crossover cohorts (where participants experienced both types of treatments). A total of 195 Medicare beneficiaries responded to the survey. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short Form Health Survey to measure HRQoL.
Results
Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort's reported concern about PDT (P = .03).
Conclusion
Among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.
Objective
This study aims to improve the reporting quality of randomized controlled trials (RCTs) by evaluating RCTs of acupuncture for low back pain (LBP) based on the CONSORT and STRICTA statements.
Methods
Literature from the Cochrane Library, Medline, Embase, Ovid, China National Knowledge Infrastructure (CNKI), WanFang database, and Chongqing Weipu (VIP) was systematically searched from 2010 to 2020. The general characteristics and the overall quality score (OQS) of the literature were evaluated by two investigators. The agreement between investigators was calculated using Cohen’s kappa statistics.
Results
A total of 31 RCTs were extracted in the final analysis. Based on the CONSORT statement, the items “title and abstract”, “background and objectives”, “intervention”, “outcomes”, “statistical methods”, “baseline data”, “outcomes and estimation” and “interpretation” have a positive rate of greater than 80%. The items “implementation”, “generalizability” and “protocol” have a positive rate of less than 30%. Based on the STRICTA statement, the items “style of acupuncture”, “needle retention time”, “number of treatment sessions”, “frequency and duration of treatment” and “precise description of the control or comparator” have a positive rate of greater than 80%. The item “extent to which the treatment was varied” has a positive rate of less than 30%. The agreements among most items are determined to be moderate or good.
Conclusion
The reporting quality of RCTs of acupuncture for LBP is moderate. Researchers should rigidly follow the CONSORT and STRICTA statements to enhance the quality of their studies.
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.
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.
Background
Acupuncture is one of the most popular forms of complementary and alternative medicine, and its usage is linked to an improvement of physical and psychological symptoms. Main Objectives: Determine whether the use of acupuncture as an adjunct to physiotherapy treatment is more effective than physiotherapy alone or acupuncture alone in MSK conditions.
Methodology
A systematic review of the literature was conducted using three major databases, from March 2019 to May 2019, i.e., Cochrane Library, PubMed, and PEDro (Physiotherapy Evidence Database). The inclusion criteria were limited to randomized controlled trials (RCT) published in English, only studies published within the past decade, and investigating adult populations with MSK conditions.
Results
From the 227 titles and abstracts that were identified, 75 were duplicates, leaving us with 152 studies for the initial screening. Eight studies [13-20] were included in this review for a qualitative analysis. The studies that assessed pain did not found statistically significant results that support the combination of physiotherapy and acupuncture, the same results were also obtained for Range of motion in knee osteoarthritis. Muscular tension was found statistically significant within-group improvements for all parameters in comparison with the baseline. For Isometric Neck Muscle Strength (INMS), the studies reported significant improvements within the groups, with Physiotherapy combined with Acupuncture being more effective than Acupuncture or Physiotherapy alone. The Constant Shoulder Assessment (CSA), for shoulder function was significantly higher in the exercise plus acupuncture group compared with the exercise group.
Conclusion
As an integrative or complementary therapy for pain, acupuncture has been increasingly used. However, this review did not find significant evidence to support that the addition of acupuncture to physiotherapy treatment has an added benefit to pain relief. This review did, however, find benefits of adding acupuncture to treatment to reducing neck disability and improving muscular strength and shoulder function.
Resumen
El dolor lumbar corresponde a uno de los síntomas más prevalentes en la humanidad, siendo la segunda causa más frecuente de atención médica a nivel mundial. Existen diversos enfoques de diagnóstico y tratamiento para dolor lumbar, entre ellos la temporalidad del síntoma, el trabajo de diagnóstico sindromático, los síntomas de alarma, también llamados “banderas rojas”, que pueden hacer sospechar patologías de mayor gravedad o urgencia. El estudio etiológico puede ser necesario en casos agudos con estas banderas rojas y en casos crónicos. Este estudio se realiza principalmente con imágenes (radiografías, tomografía computada, resonancia magnética, SPECT/CT) y ocasionalmente con exámenes de laboratorio. La mayor parte de los tratamientos están enfocados en el manejo conservador, principalmente el ejercicio físico guiado y asociado a fármacos analgésicos. Existen terapias alternativas tales como la acupuntura, el tai-chi, entre otros, algunas de ellas han mostrado ser un buen complemento al manejo del dolor lumbar. El enfoque multidisciplinario es la tendencia más actual de manejo, esto incluye el trabajo e intervención de diversos profesionales abordando el problema de forma integral, incluyendo el manejo psicoterapéutico. Intervenciones como las infiltraciones de columna han demostrado reducir el dolor por tiempos cortos, siendo útiles como puente para realizar un tratamiento apropiado. La cirugía solo se reserva para casos refractarios, siendo controversiales los resultados existentes en la literatura.
Acupuncture is a practice based in Traditional Chinese Medicine, in which needles are used to restore the body's internal balance. Recently, there has been growing interest in the use of acupuncture for various pain conditions. Acupuncture's efficacy in five pain conditions—low back pain, migraines, fibromyalgia, neck pain, and abdominal pain—was evaluated in this evidence-based, comprehensive review. Based on the most recent evidence, migraine and fibromyalgia are two conditions with the most favorable outcomes after acupuncture. At the same time, abdominal pain has the least evidence for the use of acupuncture. Acupuncture is efficacious for reducing pain in patients with low back pain, and for short term pain relief for those with neck pain. Further research needs to be done to evaluate acupuncture's efficacy in these conditions, especially for abdominal pain, as many of the current studies have a risk of bias due to lack of blinding and small sample size.
Objective:
To assess the effectiveness of acupuncture for non-specific low back pain (NSLBP) through systematic review of published randomised controlled trials (RCTs).
Methods:
Studies were identified in electronic databases from their inception to February 2018, and were grouped according to the control interventions. The outcomes of interest were pain intensity and disability. Methodological quality was evaluated using the Cochrane risk-of-bias criteria and the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) checklist. The review was reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
Results:
25 trials (n=7587 participants) were identified and included in a meta-analysis. The results showed that acupuncture was more effective at inducing pain relief than: no treatment (standardised mean difference (SMD) -0.69, 95% CI -0.99 to -0.38); sham acupuncture in the immediate term (SMD -0.33, 95% CI -0.49 to -0.18), short term (SMD -0.47, 95% CI -0.77 to -0.17), and intermediate term (SMD -0.17, 95% CI -0.28 to -0.05); and usual care in the short term (SMD -1.07, 95% CI -1.81 to -0.33) and intermediate term (SMD -0.43, 95% CI -0.77 to -0.10). Also, adjunctive acupuncture with usual care was more effective than usual care alone at all time points studied. With regard to functional improvement, the analysis showed a significant difference between acupuncture and no treatment (SMD -0.94, 95% CI -1.57 to -0.30), whereas the other control therapies could not be assessed.
Conclusion:
We draw a cautious conclusion that acupuncture appears to be effective for NSLBP and that acupuncture may be an important supplement to usual care in the management of NSLBP.
Objective:
To identify the potential association of self-reported gender on pain and disability among patients in a randomized controlled trial of integrative acupuncture and spinal manipulation therapy (SMT) for low back pain (LBP).
Methods:
In the original study, 100 participants with LBP were randomized to receive acupuncture, SMT, or both combined. Eighty completed treatment and were followed for 60 days. Primary outcome measures were the Roland-Morris Disability Questionnaire and numeric pain scales. This study was a secondary analysis and used regression models to estimate and test for gender-specific differences in outcomes from baseline through end of treatment.
Results:
Women assigned to acupuncture averaged a 3.8-point reduction in highest LBP vs 2.0 points for SMT, whereas men assigned to SMT averaged a 3.5-point reduction vs 1.8 points for acupuncture (P for interaction = .04). There was a trend toward the same for disability (P for interaction = .12). For women, acupuncture alone led to better outcomes without SMT, and for men, SMT alone led to better outcomes without acupuncture. Women who received acupuncture were more likely to experience 50% or greater reductions in disability and pain, whereas men who received SMT were more likely to experience 50% or greater reductions in disability and pain.
Conclusion:
An association was found between self-reported gender and response to LBP treatment. Women demonstrated a greater reduction in pain and disability with acupuncture and men with SMT. Future clinical trials should consider sex as a potential determinant of treatment outcomes for LBP.
Pain is a complex feeling with emotional driving and vegetative nerve reactions, and is one of the most common symptoms in the clinic. Pain has dual meanings to the human body. On the one hand, pain serves as a warning sign of injury, disease, and abnormality. A person with a loss of congenital pain cannot quickly respond to internal and external insults that often cause trauma, scald, or other injury. Those that have no pain or are insensitive to pain cannot respond to visceral disorders in time, which delays or misleads the diagnosis and treatment. On the other hand, persistent or severe pain brings suffering to the patient, and needs to be treated. However, many issues remain unsolved in term of pain management, e.g., analgesics-induced drug addiction. An abundance of research has shown that acupuncture or electroacupuncture can induce a good analgesic effect with little side effects. This chapter will summarize clinical and laboratory research on this topic and update recent progress.
The form of the public health system in India is a three tiered pyramid-like structure consisting primary, secondary, and tertiary healthcare services. The content of India's health system is mono-cultural and based on western bio-medicine. Authors discuss need for health sector reforms in the wake of the fact that despite huge investment, the public health system is not delivering. Today, 70% of the population pays out of pocket for even primary healthcare. Innovation is the need of the hour. The Indian government has recognized eight systems of healthcare viz., Allopathy, Ayurveda, Siddha, Swa-rigpa, Unani, Naturopathy, Homeopathy, and Yoga. Allopathy receives 97% of the national health budget, and 3% is divided amongst the remaining seven systems. At present, skewed funding and poor integration denies the public of advantage of synergy and innovations arising out of the richness of India's Medical Heritage. Health seeking behavior studies reveal that 40-70% of the population exercise pluralistic choices and seek health services for different needs, from different systems. For emergency and surgery, Allopathy is the first choice but for chronic and common ailments and for prevention and wellness help from the other seven systems is sought. Integrative healthcare appears to be the future framework for healthcare in the 21(st) century. A long-term strategy involving radical changes in medical education, research, clinical practice, public health and the legal and regulatory framework is needed, to innovate India's public health system and make it both integrative and participatory. India can be a world leader in the new emerging field of "integrative healthcare" because we have over the last century or so assimilated and achieved a reasonable degree of competence in bio-medical and life sciences and we possess an incredibly rich and varied medical heritage of our own.
A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990.
To document trends in alternative medicine use in the United States between 1990 and 1997.
Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively.
A total of 1539 adults in 1991 and 2055 in 1997.
Prevalence, estimated costs, and disclosure of alternative therapies to physicians.
Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or = .001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P = .002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at 12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services.
Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
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.
While several recent large randomized trials found clinically relevant effects of acupuncture over no treatment or routine care, blinded trials comparing acupuncture to sham interventions often reported only minor or no differences. This raises the question whether (sham) acupuncture is associated with particularly potent nonspecific effects. We aimed to investigate the size of nonspecific effects associated with acupuncture interventions.
MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials and reference lists were searched up to April 2010 to identify randomized trials of acupuncture for any condition, including both sham and no acupuncture control groups. Data were extracted by one reviewer and verified by a second. Pooled standardized mean differences were calculated using a random effects model with the inverse variance method.
Thirty-seven trials with a total of 5754 patients met the inclusion criteria. The included studies varied strongly regarding patients, interventions, outcome measures, methodological quality and effect sizes reported. Among the 32 trials reporting a continuous outcome measure, the random effects standardized mean difference between sham acupuncture and no acupuncture groups was -0.45 (95% confidence interval, -0.57, -0.34; I2 = 54%; Egger's test for funnel plot asymmetry, P = 0.25). Trials with larger effects of sham over no acupuncture reported smaller effects of acupuncture over sham intervention than trials with smaller nonspecific effects (β = -0.39, P = 0.029).
Sham acupuncture interventions are often associated with moderately large nonspecific effects which could make it difficult to detect small additional specific effects. Compared to inert placebo interventions, effects associated with sham acupuncture might be larger, which would have considerable implications for the design and interpretation of clinical trials.
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.
Acupuncture has a beneficial effect when treating many diseases and painful conditions, and therefore is thought to be useful as a complementary therapy or to replace generally accepted pharmacological intervention. The attributive effect of acupuncture has been investigated in inflammatory diseases, including asthma, rhinitis, inflammatory bowel disease, rheumatoid arthritis, epicondylitis, complex regional pain syndrome type 1 and vasculitis. Large randomised trials demonstrating the immediate and sustained effect of acupuncture are missing. Mechanisms underlying the ascribed immunosuppressive actions of acupuncture are reviewed in this communication. The acupuncture-controlled release of neuropeptides from nerve endings and subsequent vasodilative and anti-inflammatory effects through calcitonine gene-related peptide is hypothesised. The complex interactions with substance P, the analgesic contribution of beta-endorphin and the balance between cell-specific pro-inflammatory and anti-inflammatory cytokines tumour necrosis factor-alpha and interleukin-10 are discussed.
Low back pain is a considerable health problem in all developed countries and is most commonly treated in primary healthcare settings. It is usually defined as pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). The most important symptoms of non-specific low back pain are pain and disability. The diagnostic and therapeutic management of patients with low back pain has long been characterised by considerable variation within and between countries among general practitioners, medical specialists, and other healthcare professionals.1 2 w1 Recently, a large number of randomised clinical trials have been done, systematic reviews have been written, and clinical guidelines have become available. The outlook for evidence based management of low back pain has greatly improved. This review presents the current state of science regarding the diagnosis and treatment of low back pain.
We used the Cochrane Library to identify relevant systematic reviews that evaluate the effectiveness of conservative, complementary, and surgical interventions. Medline searches were used to find other relevant systematic reviews on diagnosis and treatment of low back pain, with the keywords “low back pain”, “systematic review”, “meta-analysis”, “diagnosis”, and “treatment”. Our personal files were used for additional references. We also checked available clinical guidelines and used Clinical Evidence as source for clinically relevant information on benefits and harms of treatments.3 4
Most of us will experience at least one episode of low back pain during our life. Reported lifetime prevalence varies from 49% to 70% and point prevalences from 12% to 30% are reported in Western countries.w2 w3
The diagnostic process is mainly focused on the triage of patients with specific or non-specific low back pain. Specific low back pain is defined as symptoms caused by a specific pathophysiological mechanism, such …
Literature review, expert panel, and a workshop during the "VIII International Forum on Primary Care Research on Low Back Pain" (Amsterdam, June 2006).
To develop practical guidance regarding the minimal important change (MIC) on frequently used measures of pain and functional status for low back pain.
Empirical studies have tried to determine meaningful changes for back pain, using different methodologies. This has led to confusion about what change is clinically important for commonly used back pain outcome measures.
This study covered the Visual Analogue Scale (0-100) and the Numerical Rating Scale (0-10) for pain and for function, the Roland Disability Questionnaire (0-24), the Oswestry Disability Index (0-100), and the Quebec Back Pain Disability Questionnaire (0-100). The literature was reviewed for empirical evidence. Additionally, experts and participants of the VIII International Forum on Primary Care Research on Low Back Pain were consulted to develop international consensus on clinical interpretation.
There was wide variation in study design and the methods used to estimate MICs, and in values found for MIC, where MIC is the improvement in clinical status of an individual patient. However, after discussion among experts and workshop participants a reasonable consensus was achieved. Proposed MIC values are: 15 for the Visual Analogue Scale, 2 for the Numerical Rating Scale, 5 for the Roland Disability Questionnaire, 10 for the Oswestry Disability Index, and 20 for the QBDQ. When the baseline score is taken into account, a 30% improvement was considered a useful threshold for identifying clinically meaningful improvement on each of these measures.
For a range of commonly used back pain outcome measures, a 30% change from baseline may be considered clinically meaningful improvement when comparing before and after measures for individual patients. It is hoped that these proposals facilitate the use of these measures in clinical practice and the comparability of future studies. The proposed MIC values are not the final answer but offer a common starting point for future research.
Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Study Design: Systematic review of the literature.
Objective: To evaluate whether an integrated approach that includes different Complementary and Alternative Medicine (CAM) therapies combined or CAM therapies combined with conventional medical care is more effective for the management of low back pain (LBP) than single modalities alone.
Summary of Background Data: LBP is one of the leading causes of disability worldwide, yet its optimal management is still unresolved.
Methods: The PRISMA Statement guidelines were followed. The Cochrane Back Review Group scale was used to rate the quality of the studies found.
Results: Twenty-one studies were found that met the inclusion criteria. The CAM modalities used in the studies included spinal manipulative therapy, acupuncture, exercise therapy, physiotherapy, massage therapy, and a topical ointment. Twenty studies included acupuncture and/or spinal manipulative therapy. Nine high quality studies showed that integrative care was clinically effective for the management of LBP. Spinal manipulative therapy combined with exercise therapy and acupuncture combined with conventional medical care or with exercise therapy appears to be promising approaches to the management of chronic cases of LBP.
Conclusions: There is support in the literature for integrated CAM and conventional medical therapy for the management of chronic LBP. Further research into the integrated management of LBP is clearly needed to provide better guidance for patients and clinicians.
Study design:
Systematic review and meta-analysis.
Objective:
To assess the efficacy of opioids in adults with chronic low back pain (CLBP).
Summary of background data:
Opioids for CLBP has increased dramatically. However, the benefits and risks remain unclear.
Methods:
We updated a 2007 Cochrane Review through October 2012 of randomized controlled trials from multiple databases. Use of noninjectable opioids in CLBP for at least 4 weeks was compared with placebo or other treatments; comparisons with different opioids were excluded. Outcomes included pain and function using standardized mean difference (SMD) or risk ratios with 95% confidence intervals (CIs), and absolute risk difference with 95% CI for adverse effects. Study quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation criteria.
Results:
Fifteen trials (5540 participants), including twelve new, met the criteria. Tramadol was better than placebo for pain (SMD, -0.55; 95% CI, -0.66 to -0.44) and function (SMD, -0.18; 95% CI, -0.29 to -0.07). Compared with placebo, transdermal buprenorphine decreased pain (SMD, -2.47; 95% CI, -2.69 to -2.25), but not function (SMD, -0.14; 95% CI, -0.53 to 0.25). Strong opioids (morphine, hydromorphone, oxycodone, oxymorphone, and tapentadol), were better than placebo for pain (SMD, -0.43; 95% CI, -0.52 to -0.33) and function (SMD, -0.26; 95% CI, -0.37 to -0.15). One trial demonstrated little difference with tramadol compared with celecoxib for pain relief. Two trials (272 participants) found no difference between opioids and antidepressants for pain or function. Reviewed trials had low to moderate quality, high drop-out rates, short duration, and limited interpretability of functional improvement. No serious adverse effects, risks (addiction or overdose), or complications (sleep apnea, opioid-induced hyperalgesia, hypogonadism) were reported.
Conclusion:
There is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat CLBP compared with placebo. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven.
The latest Global Burden of Disease Study, published at the end of 2012, has highlighted the enormous global burden of low back pain. In contrast to the previous study, when it was ranked 105 out of 136 conditions, low back pain is now the leading cause of disability globally, ahead of 290 other conditions. It was estimated to be responsible for 58.2 million years lived with disability in 1990, increasing to 83 million in 2010. This chapter illustrates the ways that the Global Burden of Disease data can be displayed using the data visualisation tools specifically designed for this purpose. It also considers how best to increase the precision of future global burden of low back pain estimates by identifying limitations in the available data and priorities for further research. Finally, it discusses what should be done at a policy level to militate against the rising burden of this condition.
Chronic low back pain is one of the most common reasons that people seek medical treatment, and the consequent disability creates a great financial burden on individuals and society. The etiology of chronic low back pain is not clear, which means it is often refractory to treatment. Acupuncture has been reported to be effective in providing symptomatic relief of chronic low back pain. However, it is not known whether the effects of acupuncture are due to the needling itself or nonspecific effects arising from the manipulation. To determine the effectiveness of acupuncture therapy, a meta-analysis was performed to compare acupuncture with sham acupuncture and other treatments. Overall, 2678 patients were identified from thirteen randomized controlled trials. The meta-analysis was performed by a random model (Cohen's test), using the I-square test for heterogeneity and Begg's test to assess for publication bias. Clinical outcomes were evaluated by pain intensity, disability, spinal flexion, and quality of life. Compared with no treatment, acupuncture achieved better outcomes in terms of pain relief, disability recovery and better quality of life, but these effects were not observed when compared to sham acupuncture. Acupuncture achieved better outcomes when compared with other treatments. No publication bias was detected. Acupuncture is an effective treatment for chronic low back pain, but this effect is likely to be produced by the nonspecific effects of manipulation.
Retrospective analysis of an insurance claims database.
To examine the comorbidities, treatment patterns, health care resource utilization, and direct medical costs of patients with chronic low back pain (CLBP) in clinical practice.
Although the socioeconomic impact of CLBP is substantial, characterization of comorbidities, pain-related pharmacotherapy, and health care resource use/costs of patients with CLBP relative to non-CLBP controls have been infrequently documented.
Using the LifeLink Health Plan Claims Database (IMS Health Inc., Watertown, MA), patients with CLBP, defined using the International Classification of Diseases, Ninth Revision, Clinical Modification, were identified and matched (age, sex, and region) with non-CLBP individuals. Comorbidities, pain-related pharmacotherapy, and health care service use/costs (pharmacy, outpatient, inpatient, total) were compared for the 2 groups during 2008.
A total of 101,294 patients with CLBP and controls were identified (55% women; mean age was 47.2 ± 11.6 years). Relative to controls, patients with CLBP had a greater comorbidity burden including a significantly higher (P < 0.0001) frequency of musculoskeletal and neuropathic pain conditions and common sequelae of pain such as depression (13.0% vs. 6.1%), anxiety (8.0% vs. 3.4%), and sleep disorders (10.0% vs. 3.4%). Pain-related pharmacotherapy was significantly greater (P < 0.0001) among patients with CLBP including opioids (37.0% vs. 14.8%; P < 0.0001), nonsteroidal anti-inflammatory drugs (26.2% vs. 9.6%; P < 0.0001), and tramadol (8.2% vs. 1.2%; P < 0.0001). Prescribing of "adjunctive" medications for treating conditions associated with pain (i.e., depression, anxiety, and insomnia) was also significantly greater (P < 0.0001) among patients with CLBP; 36.3% of patients received combination therapy. Health care costs were significantly higher in the CLBP cohort (P < 0.0001), reflecting greater resource utilization. Total direct medical costs were estimated at 17,507 in the CLBP group and 10,845 in the control group; P < 0.0001).
Patients with CLBP are characterized by greater comorbidity and economic burdens compared with those without CLBP. This economic burden can be attributed to greater prescribing of pain-related medications and increased health resource utilization.
This systematic review was undertaken to evaluate which complementary and alternative medicine (CAM) therapies are being used for persons with back pain in the United States.
MEDLINE, CINHAHL, EMBASE, and Cochrane Central, and a variety of CAM specific databases were searched from 1990 to November 2007. A grey literature search was also undertaken, particularly for clinical practice guidelines (CPG) related to CAM.
Standard systematic review methodology was employed. Eligibility criteria included English studies of adults with back pain, and a predefined list of CAM therapies.
A total of 103 publications were evaluated; of these 29 did not present CAM therapy use stratified for back pain. There were a total of 65 utilization studies, 43 of which were American. Four publications evaluated the concurrent use of four or more CAM therapies and these suggest that chiropractic/manipulation is the most frequently used modality followed by massage and acupuncture. A limited number of publications evaluated utilization rates within multiple regions of the back and show that CAM was used least for treating the thoracic spine and most for the low back. However, rates of the use of massage were similar for neck and lower back regions. Concurrent use of different CAM or conventional therapies was not well reported. From 11 eligible CPG, only one (for electro-acupuncture) provided recommendations for frequency of use for low back pain of all acuity levels. Eighteen cost publications were reviewed and all but one publication (cost-effectiveness) were cost identification studies. There is limited information on the impact of insurance coverage on costs and utilization specific to back pain.
There are a few studies evaluating the relative utilization of various CAM therapies for back pain. For those studies evaluating utilization of individual CAM therapies, the specific characteristics of the therapy, the providers, and the clinical presentation of the back pain patients were not adequately detailed; nor was the overlap with other CAM or conventional treatments.
The revised Oswestry Low Back Pain Questionnaire (ROLBPQ) and Roland-Morris Activity Scale (RMAS) were compared in a randomized controlled trial of chiropractic manipulation, stroking massage, corset and transcutaneous muscular stimulation (TMS). This trial employed specific inclusion and exclusion criteria, including nonspecific low back pain for a duration of 3 wk to 6 months and ages between 18 and 55. We had the opportunity to ask 85 patients to answer the questionnaires. Sixty-three patients, who completed the initial and final evaluations, were used for data analysis. Both ROLBPQ and RMAS showed good internal consistency with alpha coefficients ranging from .77 to .93. Both instruments showed a significant difference between the chiropractic manipulation and massage groups (p less than .05). RMAS was able to further show significant differences between the chiropractic manipulation and TMS groups, and between the corset and massage groups, but the ROLBPQ failed to do so. RMAS also showed that chiropractic manipulation had a better but nonsignificant result than corset, possibly due to insufficient sample size and/or duration of treatment. We conclude that both instruments are reliable for measuring low back pain disability, and chiropractic manipulation has a superior short-term benefit when compared to stroking massage and TMS in subacute low back pain patients. In addition, it appears that RMAS is preferable in a clinical trial situation for subacute low back pain because it is more sensitive than ROLBPQ to detect changes.
Background context: Modern scientific investigations into spinal manipulative therapy (SMT) began in 1975. Conditions often treated include acute and chronic low back pain, radicular pain, neck pain, and some forms of headache. The field of spinal manipulation has often been treated by the literature, incorrectly, as being homogeneous. Much of the confusion regarding this form of treatment can be traced to the ambiguity surrounding the procedures themselves. This report summarizes the clinical biomechanics of SMT and evidence for its associated manipulable lesion is reviewed. Finally, a classification system based on biomechanics is proposed that may facilitate more detailed research in the future.
Randomized clinical trial.
To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care.
Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking.
A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms.
Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.
Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.
Many nonpharmacologic therapies are available for treatment of low back pain.
To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).
English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts.
Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.
We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.
We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland-Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica.
Our primary source of data was systematic reviews. We included non-English-language trials only if they were included in English-language systematic reviews.
Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.