Low Back Pain

Cortical Changes in Chronic Low Back Pain

By Frank M. Painter|July 3, 2017|Cortical Changes, Low Back Pain|

Cortical Changes in Chronic Low Back Pain: Current State of the Art and Implications for Clinical Practice

SOURCE: Man Ther. 2011 (Feb); 16 (1): 15-20

Benedict Martin Wand, Luke Parkitny,
Neil Edward O’Connell, Hannu Luomajoki,
James Henry McAuley, Michael Thacker,
G. Lorimer Moseley

School of Health Sciences,
The University of Notre Dame Australia,
Fremantle, WA, Australia

There is increasing evidence that chronic pain problems are characterised by alterations in brain structure and function. Chronic back pain is no exception. There is a growing sentiment, with accompanying theory, that these brain changes contribute to chronic back pain, although empirical support is lacking. This paper reviews the structural and functional changes of the brain that have been observed in people with chronic back pain. We cast light on the clinical implications of these changes and the possibilities for new treatments but we also advise caution against concluding their efficacy in the absence of solid evidence to this effect.

From the Full-Text Article:

Introduction

Chronic musculoskeletal pain is almost by definition a problem for which previous treatment has been unsuccessful. The clinical stories of patients with problems such as chronic low back pain (CLBP), fibromyalgia, and late whiplash associated disorder are usually ones of confusing and conflicting diagnoses and multiple treatment failures. Diagnosis and treatment has traditionally focused on what Robinson and Apkarian (2009) have called ‘end organ dysfunction’. That is, clinicians and researchers have looked to structural and functional abnormalities within the musculoskeletal system for a driver of the clinical condition and treatment has sought to normalise peripheral pathology and mechanics (stretch it, splint it, remove it, anaesthetise or denervate it). In general terms the ‘end organ dysfunction’ approach might be considered to have proven unsuccessful for these conditions (see for e.g. van Tulder et al., 2006a; van Tulder et al., 2006b). Neuroimaging studies have revealed numerous structural and functional changes within the brains of people with chronic musculoskeletal pain and there is growing opinion that these changes may contribute to the development and maintenance of the chronic pain state (Apkarian et al., 2009; Tracey and Bushnell, 2009). In this model of chronic pain the brain is seen as an explicit target for treatment and several treatment strategies have been developed and modified to fit this aim. Although there are data available on a range of chronic painful disorders, we will focus here on the cortical changes observed in patients with CLBP and the possible clinical implications for this population.

Brain changes in people with CLBP

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Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain

By Frank M. Painter|June 30, 2017|Low Back Pain|

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis

The Chiro.Org Blog

SOURCE: JAMA. 2017 (Apr 11); 317 (14): 1451–1460

Neil M. Paige, MD, MSHS, Isomi M. Miake-Lye, BA,
Marika Suttorp Booth, MS, Jessica M. Beroes, BS,
Aram S. Mardian, MD, Paul Dougherty, DC,
Richard Branson, DC, Baron Tang, PT, DPT,
Sally C. Morton, PhD, Paul G. Shekelle, MD, PhD

West Los Angeles Veterans Affairs Medical Center,
Los Angeles, California

This is just one article from a series of 5:

The Non-pharmacologic Therapies Low Back Pain

Commentary from the Illinois Chiropractic Society

JAMA Endorses Spinal Manipulation

For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1] On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.

The authors concluded:

“Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

This study comes on the heels of a February 2017 Clinical Practice Guideline from the American College of Physicians recommending spinal manipulation for acute, sub-acute, and chronic low back pain (LBP). [2]

These high-quality studies in respected medical journals add to a growing list of scientific support for spinal manipulation therapy (SMT). So why are our offices not flooded with medical referrals? An editorial accompanying the JAMA study provides perspective as to why some medical providers may be reluctant to refer to chiropractic physicians:

“Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors. Chiropractic therapy is not widely accepted by some traditional health care practitioners. This may be, at least in part, because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.

However, chiropractic care is popular today with the US public. According to a 2012 report, among patients with back or neck pain, approximately 30% sought care from a chiropractor. In a 2013 survey by Consumer Reports magazine involving 14,000 subscribers with low back pain, chiropractic care had the largest proportion of “highly satisfied” patients. Among approximately 4000 respondents who had seen a chiropractor, 59% were highly satisfied compared with 55% who saw a physical therapist and 34% who saw a primary care physician.

“Serious complications (related to SMT) are extremely rare… if spinal manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for patients with uncomplicated low back pain”. [3]

The emerging health care model dictates that all providers embrace proven clinically effective treatments, regardless of long-standing philosophical bias. If we expect medical providers to advance their thinking to accept validated chiropractic therapies, we must first be willing to reciprocate. By working together to provide evidence-based patient-centric care, we can advance our profession to become the undeniable first choice for both patients and providers.

References:

Paige NM, Miake-Lye IM, Booth MS, et al.
Association of Spinal Manipulative Therapy With Clinical Benefit and Harm
for Acute Low Back Pain; Systematic Review and Meta-analysis
JAMA. 2017 (Apr 11); 317 (14): 1451–1460
Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee
of the American College of Physicians.
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Ann Intern Med. 2017 (Apr 4); 166 (7): 514–530
Deyo RA.
The Role of Spinal Manipulation in the Treatment of Low Back Pain
JAMA. 2017 (Apr 11); 317 (14): 1418-1419

The Abstract:

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Take the Guideline Challenge

By Frank M. Painter|May 16, 2017|Clinical Guidelines, Low Back Pain|

Take the Guideline Challenge

The Chiro.Org Blog

SOURCE: ACA News ~ May 15, 2017

By Christine Goertz, DC, PhD

Dr. Goertz is senior scientific advisor for the ACA. She also serves as vice chancellor for research and health policy at Palmer College of Chiropractic and is the CEO of the Spine Institute for Quality (Spine IQ)

In my last blog post, I talked about the unprecedented opportunity the chiropractic profession has to make a critical difference in areas of great public health impact, such as low back pain. I strongly believe that if we do the right thing right now, the chiropractic profession is uniquely positioned to significantly impact the quality of spine care delivery, increasing access to chiropractic care for millions of patients who desperately need conservative treatment for spine-related conditions. The flipside is that if we don’t take right action now, chiropractic risks becoming a marginalized profession that’s on the outside looking in as other health care providers take ownership of musculoskeletal conditions and spinal manipulation.

So what is right action? Recently, I asked this question of several of my colleagues who influence policy at the highest levels of research and/or health care delivery in the United States. One of those people was Francis Collins, MD, PhD, director of the National Institutes of Health. [1] Dr. Collins responded by saying:

Chiropractic’s commitment to evidence-based practice and to addressing gaps in the scientific basis of chiropractic care is vital for the progress of the field. Robust research on the safety and effectiveness of chiropractic therapies in the management of common musculoskeletal complaints must continue to be a high priority for the profession. Advancing evidence-based chiropractic care will further the integration of chiropractic into medical systems at a time when the need for effective approaches to improve outcomes for patients with chronic pain could not be more pressing.

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Elevated Production of Nociceptive CC-chemokines

By Frank M. Painter|April 22, 2017|Low Back Pain, Spinal Joint Pain|

Elevated Production of Nociceptive CC-chemokines and sE-selectin in Patients with Low Back Pain and the Effects of Spinal Manipulation: A Non-randomized Clinical Trial

The Chiro.Org Blog

SOURCE: Clin J Pain. 2017 (Apr 19) [Epub]

Julita A. Teodorczyk-Injeyan, PhD,
Marion McGregor, PhD, DC,
John J. Triano, DC, PhD,
H. Stephen Injeyan, PhD, DC

Graduate Education and Research Programs,
Canadian Memorial Chiropractic College,
Toronto, Ontario, Canada

BACKGROUND: The involvement of inflammatory components in the pathophysiology of low back pain is poorly understood. It has been suggested that spinal manipulative therapy (SMT) may exert anti-inflammatory effects.

PURPOSE: To determine the involvement of inflammation-associated chemokines (CC series) in the pathogenesis of non-specific low back pain and to evaluate the effect of SMT on that process.

METHODS: Patients presenting with non-radicular, non-specific low back pain (minimum pain score 3 on 10 point visual analogue scale, VAS) were recruited according to stringent inclusion criteria. They were evaluated for appropriateness to treat using a high velocity low amplitude manipulative thrust (HVLT) in the lumbar-lumbosacral region. Blood samples were obtained at baseline and following the administration of a series of 6 HVLTs on alternate days over the period of two weeks. The in vitro levels of CC chemokines (CCL2, CCL3 and CCL4) production and plasma levels of an inflammatory biomarker, soluble E-selectin, were determined at baseline and at the termination of treatments two weeks later.

RESULTS: Compared with asymptomatic controls baseline production of all chemokines was significantly elevated in acute (P=0.004 – <0.0001), and that of CCL2 and CCL4 in chronic LBP patients (P<0.0001). Furthermore, CCL4 production was significantly higher (P<0.0001) in the acute versus chronic LBP group. sE-selectin levels were significantly higher (P=0.003) in chronic but not in acute LBP patients. Following SMT, patient reported outcomes showed significant (P<0.0001) improvements in VAS and ODI scores. This was accompanied by a significant decline in CCL 3 production (P<0.0001) in both groups of patients. Change scores for CCL4 production differed significantly (P<0.0001) only for the acute LBP cohort, and no effect on the production of CCL2 or plasma sE-selectin levels was noted in either group.

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Do Older Adults with Chronic Low Back Pain Differ

By Frank M. Painter|April 11, 2017|Chiropractic Care, Low Back Pain|

Do Older Adults with Chronic Low Back Pain Differ from Younger Adults in Regards to Baseline Characteristics and Prognosis?

The Chiro.Org Blog

SOURCE: Eur J Pain. 2017 (Mar 14) [Epub]

Manogharan S, Kongsted A, Ferreira ML, Hancock MJ.

Faculty of Medicine and Health Science,
Macquarie University,
Sydney, NSW, Australia

BACKGROUND: Low back pain (LBP) in older adults is poorly understood because the vast majority of the LBP research has focused on the working aged population. The aim of this study was to compare older adults consulting with chronic LBP to middle aged and young adults consulting with chronic LBP, in terms of their baseline characteristics, and pain and disability outcomes over 1 year.

METHODS: Data were systematically collected as part of routine care in a secondary care spine clinic. At initial presentation patients answered a self-report questionnaire and underwent a physical examination. Patients older than 65 were classified as older adults and compared to middle aged (45-65 years old) and younger adults (17-44 years old) for 10 baseline characteristics. Pain intensity and disability were collected at 6 and 12 month follow-ups and compared between age groups.

RESULTS: A total of 14,479 participants were included in the study. Of these 3,087 (21%) patients were older adults, 6,071 (42%) were middle aged and 5,321 (37%) were young adults. At presentation older adults were statistically different to the middle aged and younger adults for most characteristics measured (e.g. less intense back pain, more leg pain and more depression); however, the differences were small. The change in pain and disability over 12 months did not differ between age groups.

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Pain Location Matters: The Impact of Leg Pain on Health Care Use, Work Disability and Quality of Life in Patients with Low Back Pain

By Frank M. Painter|April 5, 2017|Low Back Pain, Outcome Assessment, Sciatica|

Pain Location Matters: The Impact of Leg Pain on Health Care Use, Work Disability and Quality of Life in Patients with Low Back Pain

The Chiro.Org Blog

SOURCE: Eur Spine J. 2015 (Mar); 24 (3): 444–451

Samantha L. Hider, David G. T. Whitehurst,
Elaine Thomas, Nadine E. Foster

Arthritis Research UK Primary Care Centre,
Keele University, Keele,
Staffordshire, ST5 5BG, UK.

PURPOSE: In low back pain (LBP) patients, those with radiating leg pain or sciatica have poorer pain and disability outcomes. Few studies have assessed the effect of leg pain on health care use and quality of life.

METHODS: Prospective cohort study of 1,581 UK LBP primary care consulters. Back pain, employment, health care utilisation, and quality of life (EQ-5D) data were collected at baseline, 6 and 12 months. At baseline, patients were classified as reporting

(1) LBP only

(2) LBP and leg pain above the knee only (LBP + AK) or

(3) LBP and leg pain extending below the knee (LBP + BK).

RESULTS: Self-reported leg pain was common; at baseline 645 (41%) reported LBP only, 392 (25%) reported LBP + AK and 544 (34%) reported LBP + BK. Patients with LBP + BK, compared to those with LBP only, were significantly more likely to be unemployed, take time off work, consult their family doctor, receive physical therapy, or be referred to other health care practitioners. There were statistically significant decrements in EQ-5D scores for LBP + AK compared to LBP only, and for LBP + BK compared to LBP + AK (p ≤ 0.05 for all comparisons).

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