Low Back Pain

A Path Analysis of the Effects of the Doctor-patient Encounter and Expectancy in an Open-label Randomized Trial of Spinal Manipulation for the Care of Low Back Pain

The Chiro.Org Blog

SOURCE:   BMC Complement Altern Med. 2014 (Jan 13); 14: 16

Mitchell Haas, Darcy Vavrek, Moni B Neradilek, and
Nayak Polissar

Center for Outcomes Studies,
University of Western States,
2900 NE 132nd Ave,
Portland, OR, USA.

BACKGROUND:   The doctor-patient encounter (DPE) and associated patient expectations are potential confounders in open-label randomized trials of treatment efficacy. It is therefore important to evaluate the effects of the DPE on study outcomes.

METHODS:   Four hundred participants with chronic low back pain (LBP) were randomized to four dose groups: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for six weeks. They received light massage control at visits when manipulation was not scheduled. Treating chiropractors were instructed to have equal enthusiasm for both interventions. A path analysis was conducted to determine the effects of dose, patient expectations of treatment success, and DPE on LBP intensity (100-point scale) at the end of care (6 weeks) and primary endpoint (12 weeks). Direct, indirect, and total standardized effects (βtotal) were computed. Expectations and DPE were evaluated on Likert scales. The DPE was assessed as patient-rated perception of chiropractor enthusiasm, confidence, comfort with care, and time spent.

RESULTS:   The DPE was successfully balanced across groups, as were baseline expectations. The principal finding was that the magnitude of the effects of DPE on LBP at 6 and 12 weeks (|β|total = 0.22 and 0.15, p < .05) were comparable to the effects of dose of manipulation at those times (|β|total = 0.11 and 0.12, p < .05). In addition, baseline expectations had no notable effect on follow-up LBP. Subsequent expectations were affected by LBP, DPE, and dose (p < .05).

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Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute and Subacute Low Back Pain: A Randomized Clinical Trial

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SOURCE:   Spine (Phila Pa 1976). 2015 (Feb 15); 40 (4): 209–217

Schneider, Michael DC, PhD, Haas, Mitchell DC, MA
Glick, Ronald MD, Stevans, Joel DC, Landsittel, Doug PhD

School of Health and Rehabilitation Sciences,
Clinical and Translational Science Institute,
University of Pittsburgh,
Pittsburgh, PA

STUDY DESIGN:   Randomized controlled trial with follow-up to 6 months.

OBJECTIVE:   This was a comparative effectiveness trial of manual-thrust manipulation (MTM) versus mechanical-assisted manipulation (MAM); and manipulation versus usual medical care (UMC).

SUMMARY OF BACKGROUND DATA:   Low back pain (LBP) is one of the most common conditions seen in primary care and physical medicine practice. MTM is a common treatment for LBP. Claims that MAM is an effective alternative to MTM have yet to be substantiated. There is also question about the effectiveness of manipulation in acute and subacute LBP compared with UMC.

METHODS:   A total of 107 adults with onset of LBP within the past 12 weeks were randomized to 1 of 3 treatment groups: MTM, MAM, or UMC. Outcome measures included the Oswestry LBP Disability Index (0-100 scale) and numeric pain rating (0-10 scale). Participants in the manipulation groups were treated twice weekly during 4 weeks; subjects in UMC were seen for 3 visits during this time. Outcome measures were captured at baseline, 4 weeks, 3 months, and 6 months.

RESULTS:   Linear regression showed a statistically significant advantage of MTM at 4 weeks compared with MAM (disability = –8.1, P = 0.009; pain = –1.4, P = 0.002) and UMC (disability = –6.5, P = 0.032; pain = –1.7, P < 0.001). Responder analysis, defined as 30% and 50% reductions in Oswestry LBP Disability Index scores revealed a significantly greater proportion of responders at 4 weeks in MTM (76%; 50%) compared with MAM (50%; 16%) and UMC (48%; 39%). Similar between-group results were found for pain: MTM (94%; 76%); MAM (69%; 47%); and UMC (56%; 41%). No statistically significant group differences were found between MAM and UMC, and for any comparison at 3 or 6 months.

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Assessment of Chiropractic Treatment for Active Duty, U.S. Military Personnel with Low Back Pain: Study Protocol for a Randomized Controlled Trial

The Chiro.Org Blog

SOURCE:   Trials. 2016 (Feb 9);   17 (1):   70 ~ FULL TEXT

Christine M. Goertz, Cynthia R. Long, Robert D. Vining, Katherine A. Pohlman, Bridget Kane, Lance Corber, Joan Walter, and Ian Coulter

Palmer College of Chiropractic,
Palmer Center for Chiropractic Research,
741 Brady Street,
Davenport, IA, 52803, USA.

BACKGROUND:   Low back pain is highly prevalent and one of the most common causes of disability in U.S. armed forces personnel. Currently, no single therapeutic method has been established as a gold standard treatment for this increasingly prevalent condition. One commonly used treatment, which has demonstrated consistent positive outcomes in terms of pain and function within a civilian population is spinal manipulative therapy provided by doctors of chiropractic. Chiropractic care, delivered within a multidisciplinary framework in military healthcare settings, has the potential to help improve clinical outcomes for military personnel with low back pain. However, its effectiveness in a military setting has not been well established. The primary objective of this study is to evaluate changes in pain and disability in active duty service members with low back pain who are allocated to receive usual medical care plus chiropractic care versus treatment with usual medical care alone.

METHODS/DESIGN:   This pragmatic comparative effectiveness trial will enroll 750 active duty service members with low back pain at three military treatment facilities within the United States (250 from each site) who will be allocated to receive usual medical care plus chiropractic care or usual medical care alone for 6 weeks. Primary outcomes will include the numerical rating scale for pain intensity and the Roland-Morris Disability Questionnaire at week 6. Patient reported outcomes of pain, disability, bothersomeness, and back pain function will be collected at 2, 4, 6, and 12 weeks from allocation.

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Deconstructing Chronic Low Back Pain in the Older Adult – Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment.
Part V: Maladaptive Coping

The Chiro.Org Blog

SOURCE:   Pain Medicine 2016 (Jan); 17 (1): 64-73 ~ FULL TEXT

Elizabeth A. DiNapoli, Michael Craine, Paul Dougherty,
Angela Gentili, Gary Kochersberger, Natalia E. Morone,
Jennifer L. Murphy, Juleen Rodakowski, Eric Rodriguez,
Stephen Thielke, Debra K. Weiner

Mental Illness Research, Education & Clinical Center,
VA Pittsburgh Healthcare System, Pittsburgh,
Pennsylvania Geriatric Research,
Education & Clinical Center,
VA Pittsburgh Healthcare System, Pittsburgh, PA

This is just one from a series of 10 articles titled:

Deconstructing Chronic Low Back Pain in the Older Adult

OBJECTIVE:   As part of a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults, this article focuses on maladaptive coping – a significant contributor of psychological distress, increased pain, and heightened disability in older adults with CLBP.

METHODS:   A modified Delphi technique was used to develop a maladaptive coping algorithm and table providing the rationale for the various components of the algorithm. A seven-member content expert panel and a nine-member primary care panel were involved in the iterative development of the materials. While the algorithm was developed keeping in mind resources available within the Veterans Health Administration (VHA) facilities, panelists were not exclusive to the VHA, and therefore, materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors’ clinical practice.

RESULTS:   We present a treatment algorithm and supporting table to be used by providers treating older adults who have CLBP and engage in maladaptive coping strategies. A case of an older adult with CLBP and maladaptive coping is provided to illustrate the approach to management.

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