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Self-management at the Core of Back Pain Care:
10 Key Points for Clinicians

By |December 13, 2021|Biopsychosocial Model, Exercise and Chiropractic, Low Back Pain|

Self-management at the Core of Back Pain Care:
10 Key Points for Clinicians

The Chiro.Org Blog


SOURCE:   Braz J Phys Ther 2021 (Jul); 25 (4): 396–406

Alice Kongsted, Inge Ris, Per Kjaer, Jan Hartvigsen

Department of Sports Science and Clinical Biomechanics,
University of Southern Denmarkm
Odense M, Denmark;

Chiropractic Knowledge Hub,
Odense M, Denmark.



Background:   A paradigm shift away from clinician-led management of people with chronic disorders to people playing a key role in their own care has been advocated. At the same time, good health is recognised as the ability to adapt to changing life circumstances and to self-manage. Under this paradigm, successful management of persistent back pain is not mainly about clinicians diagnosing and curing patients, but rather about a partnership where clinicians help individuals live good lives despite back pain.

Objective:   In this paper, we discuss why there is a need for clinicians to engage in supporting self-management for people with persistent back pain and which actions clinicians can take to integrate self-management support in their care for people with back pain.

Discussion:   People with low back pain (LBP) self-manage their pain most of the time. Therefore, clinicians and health systems should empower them to do it well and provide knowledge and skills to make good decisions related to LBP and general health. Self-management does not mean that people are alone and without health care, rather it empowers people to know when to consult for diagnostic assessment, symptom relief, or advice. A shift in health care paradigm and clinicians’ roles is not only challenging for individual clinicians, it requires organisational support in clinical settings and health systems. Currently, there is no clear evidence showing how exactly LBP self-management is most effectively supported in clinical practice, but core elements have been identified that involve working with cognitions related to pain, behaviour change, and patient autonomy.

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Spinal Manipulative Therapy and Exercise for Older Adults

By |May 17, 2019|Exercise and Chiropractic|

Spinal Manipulative Therapy and Exercise for Older Adults with Chronic Low Back Pain: A Randomized Clinical Trial

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SOURCE:   Chiropractic & Manual Therapies 2019 (May 15); 27: 21

Craig Schulz, Roni Evans, Michele Maiers, Karen Schulz, Brent Leininger and Gert Bronfort

University of Minnesota,
Mayo Building C504,
420 Delaware Street SE,
Minneapolis, MN 55455, USA


Background   Low back pain (LBP) is a common disabling condition in older adults which often limits physical function and diminishes quality of life. Two clinical trials in older adults have shown spinal manipulative therapy (SMT) results in similar or small improvements relative to medical care; however, the effectiveness of adding SMT or rehabilitative exercise to home exercise is unclear.

Methods   We conducted a randomized clinical trial assessing the comparative effectiveness of adding SMT or supervised rehabilitative exercise to home exercise in adults 65 or older with sub-acute or chronic LBP. Treatments were provided over 12–weeks and self-report outcomes were collected at 4, 12, 26, and 52 weeks. The primary outcome was pain severity. Secondary outcomes included back disability, health status, medication use, satisfaction with care, and global improvement. Linear mixed models were used to analyze outcomes. The primary analysis included longitudinal outcomes in the short (week 4–12) and long-term (week 4–52). An omnibus test assessing differences across all groups over the year was used to control for multiplicity. Secondary analyses included outcomes at each time point and responder analyses. This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration.

Results   241 participants were randomized and 230 (95%) provided complete primary outcome data. The primary analysis showed group differences in pain over the one-year were small and not statistically significant. Pain severity was reduced by 30 to 40% after treatment in all 3 groups with the largest difference (eight percentage points) favoring SMT and home exercise over home exercise alone. Group differences at other time points ranged from 0 to 6 percentage points with no consistent pattern favoring one treatment. One-year post-treatment pain reductions diminished in all three groups. Secondary self-report outcomes followed a similar pattern with no important group differences, except satisfaction with care, where the two combination groups were consistently superior to home exercise alone.

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Spinal Manipulation and Exercise for Low Back Pain in Adolescents

By |March 22, 2019|Exercise and Chiropractic|

Spinal Manipulation and Exercise for Low Back Pain in Adolescents: A Randomized Trial

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SOURCE:   Pain. 2018 (Jul); 159 (7): 1297–1307

Roni Evans, Mitchell Haas, Craig Schulz, Brent Leininger, Linda Hanson, and Gert Bronfort

Integrative Health & Wellbeing Research Program,
Earl E. Bakken Center for Spirituality and Healing,
University of Minnesota,
Minneapolis, MN, USA.



Low back pain (LBP) is common in adolescence, but there is a paucity of high-quality research to inform care. We conducted a multicenter randomized trial comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to ET alone.

Participants were 185 adolescents aged 12 to 18 years with chronic LBP.

The primary outcome was LBP severity at 12, 26, and 52 weeks. Secondary outcomes included disability, quality of life, medication use, patient- and caregiver-rated improvement, and satisfaction. Outcomes were analyzed using longitudinal linear mixed effect models. An omnibus test assessing differences in individual outcomes over the entire year controlled for multiplicity.

Of the 185 enrolled patients, 179 (97%) provided data at 12 weeks and 174 (94%) at 26 and 52 weeks. Adding SMT to ET resulted in a larger reduction in LBP severity over the course of 1 year (P = 0.007). The group difference in LBP severity (0–10 scale) was small at the end of treatment (mean difference = 0.5; P = 0.08) but was larger at weeks 26 (mean difference = 1.1; P = 0.001) and 52 (mean difference = 0.8; P = 0.009). At 26 weeks, SMT with ET performed better than ET alone for disability (P = 0.04) and improvement (P = 0.02). The SMT with ET group reported significantly greater satisfaction with care at all time points (P ≤ 0.02). There were no serious treatment-related adverse events.

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A Meta-analysis of Core Stability Exercise

By |May 1, 2018|Exercise and Chiropractic|

A Meta-analysis of Core Stability Exercise versus General Exercise for Chronic Low Back Pain

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SOURCE:   PLoS One. 2012; 7 (12): e52082


Xue-Qiang Wang, Jie-Jiao Zheng, Zhuo-Wei Yu, 2 Xia Bi, Shu-Jie Lou, Jing Liu, et. al.

Department of Sport Rehabilitation,
Shanghai University of Sport,
Shanghai, China.


OBJECTIVE:   To review the effects of core stability exercise or general exercise for patients with chronic low back pain (LBP).

SUMMARY OF BACKGROUND DATA:   Exercise therapy appears to be effective at decreasing pain and improving function for patients with chronic LBP in practice guidelines. Core stability exercise is becoming increasingly popular for LBP. However, it is currently unknown whether core stability exercise produces more beneficial effects than general exercise in patients with chronic LBP.

METHODS:   Published articles from 1970 to October 2011 were identified using electronic searches. For this meta-analysis, two reviewers independently selected relevant randomized controlled trials (RCTs) investigating core stability exercise versus general exercise for the treatment of patients with chronic LBP. Data were extracted independently by the same two individuals who selected the studies.

RESULTS:   From the 28 potentially relevant trials, a total of 5 trials involving 414 participants were included in the current analysis. The pooling revealed that core stability exercise was better than general exercise for reducing pain [mean difference (-1.29); 95% confidence interval (-2.47, -0.11); P = 0.003] and disability [mean difference (-7.14); 95% confidence interval (-11.64, -2.65); P = 0.002] at the time of the short-term follow-up. However, no significant differences were observed between core stability exercise and general exercise in reducing pain at 6 months [mean difference (-0.50); 95% confidence interval (-1.36, 0.36); P = 0.26] and 12 months [mean difference (-0.32); 95% confidence interval (-0.87, 0.23); P = 0.25].

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Manual Therapy and Exercise for Neck Pain

By |March 14, 2018|Exercise and Chiropractic, Pain Management|

Manual Therapy and Exercise for Neck Pain: A Systematic Review

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SOURCE:   Man Ther. 2010 (Aug); 15 (4): 334–354


Jordan Miller, Anita Gross, Jonathan D’Sylva, Stephen J. Burnie, Charles H. Goldsmith, Nadine Graham, Ted Haines, Gert Brønfort, Jan L. Hoving

School of Rehabilitation Science,
McMaster University,
Hamilton, Canada


Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy.

Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias.

Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI: -1.69, -0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment.

High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI: -0.76, -0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache.

Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash.

Evidence regarding radiculopathy was sparse. Specific research recommendations are made.


From the Database of Abstracts of Reviews of Effects (DARE) review

CRD summary

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A Tailored Exercise Program Versus General Exercise

By |February 24, 2018|Exercise and Chiropractic|

A Tailored Exercise Program Versus General Exercise for a Subgroup of Patients with Low Back Pain and Movement Control Impairment: A Randomised Controlled Trial with One-year Follow-up

The Chiro.Org Blog


SOURCE:   Man Ther. 2015 (Oct); 20 (5): 672–679


Jeannette Saner, Jan Kool, Judith M. Sieben, Hannu Luomajoki, Carolien HG. Bastiaenen, Rob A. de Bie

Zurich University of Applied Sciences ZHAW,
School of Health Professions,
Institute of Physiotherapy,
Technikumstrasse 71,
Postfach 8401, Winterthur, Switzerland


BACKGROUND:   Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown.

OBJECTIVES:   The effectiveness of a specific exercise treatment to improve movement control was tested in this study.

METHODS:   Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted movement control impairment (MCI) (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC = 52; GE = 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS).

RESULTS:   The Patient Specific Function Scale (PSFS) showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year.

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