Low Back Pain

Spinal Manipulation Compared with Back School and with Individually Delivered Physiotherapy

By Frank M. Painter|January 30, 2014|Chiropractic Care, Evidence-based Medicine, Low Back Pain, Outcome Assessment|

Spinal Manipulation Compared with Back School and with Individually Delivered Physiotherapy for the Treatment of Chronic Low Back Pain: A Randomized Trial with One-year Follow-up

SOURCE: Clinical Rehabilitation 2010 (Jan); 24 (1): 26–36

Francesca Cecchi, Raffaello Molino-Lova, Massimiliano Chiti,
Guido Pasquini, Anita Paperini, Andrea A Conti, and Claudio Macchi

Fondazione Don Carlo Gnocchi,
Scientific Institute,
Florence, Italy.
francescacecchi2002@libero.it

FROM: Health Insights Today

A randomized trial by researchers at an outpatient rehabilitation department in Italy involving 210 patients with chronic, nonspecific low back pain compared the effects of spinal manipulation, physiotherapy and back school. The participants were 210 patients (140 women and 70 men) with chronic, non-specific low back pain, average age 59. Back school and individual physiotherapy were scheduled as 15 1-hour-sessions for 3 weeks. Back school included group exercise and education/ergonomics. Individual physiotherapy included exercise, passive mobilization and soft-tissue treatment. Spinal manipulation included 4-6 20-minute sessions once-a-week.

Outcome measures were the Roland Morris Disability Questionnaire (scoring 0-24) and Pain Rating Scale (scoring 0-6), assessed at baseline, discharge, and at 3, 6, and 12 months. 205 patients completed the study.

At discharge, disability score decreased by:

3.7 +/- 4.1 for back school,4.4 +/- 3.7 for individual physiotherapy, and

6.7 +/- 3.9 for manipulation.

The pain score reduction was 0.9 +/- 1.1, 1.1 +/- 1.0, 1.0 +/- 1.1, respectively. At 12 months, disability score reduction was 4.2 +/- 4.8 for back school, 4.0 +/- 5.1 for individual physiotherapy, 5.9 +/- 4.6 for manipulation; pain score reduction was 0.7 +/- 1.2, 0.4 +/- 1.3, and 1.5 +/- 1.1, respectively.

Spinal manipulation was associated with higher functional improvement and long-term pain relief than back school or individual physiotherapy, but received more further treatment at follow-ups;

pain recurrences and drug intake were also reduced compared to back school or individual physiotherapy.

The difference in their improved scores is quite dramatic:

After 12 months

Intervention	Disability Score	Pain Rating
At Discharge
Spinal Manipulation	6.7 +/- 3.9	1.0 +/- 1.1
Individual Physiotherapy	4.4 +/- 3.7	1.1 +/- 1.0
Back School	3.7 +/- 4.1	0.9 +/- 1.1
Spinal Manipulation	5.9 +/- 4.6	1.5 +/- 1.1
Individual Physiotherapy	4.0 +/- 5.1	0.4 +/- 1.3
Back School	4.2 +/- 4.8	0.7 +/- 1.2

NOTE: These numbers indicate the reductions in scores on the Roland Morris Disability Questionnaire and the Pain Rating Scale.

The Abstract:

OBJECTIVE: To compare spinal manipulation, back school and individual physiotherapy in the treatment of chronic low back pain.

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Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain:

By Frank M. Painter|January 19, 2014|Depression Screening, Low Back Pain, Outcome Assessment|

Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity

The Chiro.Org Blog

Chiropractic & Manual Therapies 2014 (Jan 17); 22: 4

Alice Kongsted, Benedicte Aambakk, Sanne Bossen and Lise Hestbaek

The Nordic Institute of Chiropractic and Clinical Biomechanics,
Campusvej 55,
5230 Odense, M, Denmark

Background Depression is an important prognostic factor in low back pain (LBP) that appears to be infrequent in chiropractic populations. Identification of depression in few patients would consequently implicate screening of many. It is therefore desirable to have brief screening tools for depression. The objective of this study was to investigate if one or two items from the Major Depression Inventory (MDI) could be a reasonable substitute for the complete scale.

Methods The MDI was completed by 925 patients consulting a chiropractor due to a new episode of LBP. Outcome measures were LBP intensity and activity limitation at 3-months and 12-months follow-up. Single items on the MDI that correlated strongest and explained most variance in the total score were tested for associations with outcome. Finally, the predictive capacity was compared between the total scale and the items that showed the strongest associations with outcome measures.

Results In this cohort 9% had signs of depression. The total MDI was significantly associated with outcome but explained very little of the variance in outcome. Four single items performed comparable to the total scale as prognostic factors. Items 1 and 3 explained the most variance in all outcome measures, and their predictive accuracies in terms of area under the curve were at least as high as for the categorised complete scale.

Conclusions Baseline depression measured by the MDI was associated with a worse outcome in chiropractic patients with LBP. A single item (no. 1 or 3) was a reasonable substitute for the entire scale when screening for depression as a prognostic factor.

From the FULL TEXT Article:

Introduction

Pain and depression often co-exist [1-3] , and although the causal relation between the two is not clear, [4, 5] evidence suggests that pain negatively affects outcome in depression as well as vice versa [6].

Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health [7] for which the risk of a poor prognosis is increased in the presence of depression [8, 9] . It is a condition for which there is no generally effective treatment, but non-pharmacological treatment addressing psychological symptoms in addition to the physical symptoms has been demonstrated to improve outcome in LBP patients with high scores on psychological questions [10].

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Elimination of Intermittent Chronic Low Back Pain in a Recreational Golfer Following Improvement of Hip Range of Motion Impairments

By Frank M. Painter|November 30, 2013|Low Back Pain|

Elimination of Intermittent Chronic Low Back Pain in a Recreational Golfer Following Improvement of Hip Range of Motion Impairments

The Chiro.Org Blog

SOURCE: J Bodywork and Movement Ther 2013; 17 (4): 448-52

Peter M. Lejkowski, Erik Poulsen

Faculty of Undergraduate Education,
Canadian Memorial Chiropractic College,
Toronto, ON, Canada

BACKGROUND: The biomechanical relationship between the hip and low back is well described and impairment of hip range of motion is thought to affect lumbar spine function, possibly leading to increased loading and subsequent symptoms. However therapy for low back pain (LBP) patients is commonly directed solely to the low back area overlooking possible hip impairment.

CASE DESCRIPTION: A 56-year-old male recreational golfer presented with a chronic golf-related low back complaint. Previous conservative therapy targeting the spine did not result in complete symptom relief. A working diagnosis of L4-S1 facet joint irritation and lower lumbar segmental instability secondary to bilateral hip ROM impairment was established. A trial of therapy strictly addressing the hip ROM impairments was initiated and following 2 treatment sessions, a complete resolution of symptoms was achieved and maintained at a 2-month follow-up.

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Dose-response and Efficacy of Spinal Manipulation for Care of Chronic Low Back Pain: A Randomized Controlled Trial

By Frank M. Painter|October 29, 2013|Chiropractic Care, Low Back Pain|

Dose-response and Efficacy of Spinal Manipulation for Care of Chronic Low Back Pain: A Randomized Controlled Trial

The Chiro.Org Blog

SOURCE: Spine J. 2014 (Jul 1); 14 (7): 1106–1116

Mitchell Haas, DC, Darcy Vavrek, ND, David Peterson, DC,
Nayak Polissar, PhD, Moni B. Neradilek, MS

Center for Outcomes Studies,
University of Western States,
2700 NE 132nd Ave., Portland, OR 97230, USA.
haasmitch@comcast.net

BACKGROUND CONTEXT: There have been no full-scale trials of the optimal number of visits for the care of any condition with spinal manipulation.

PURPOSE: To identify the dose-response relationship between visits to a chiropractor for spinal manipulation and chronic low back pain (cLBP) outcomes and to determine the efficacy of manipulation by comparison with a light massage control.

STUDY DESIGN/SETTING: Practice-based randomized controlled trial.

PATIENT SAMPLE: Four hundred participants with cLBP.

OUTCOME MEASURES: The primary cLBP outcomes were the 100-point modified Von Korff pain intensity and functional disability scales evaluated at the 12- and 24-week primary end points. Secondary outcomes included days with pain and functional disability, pain unpleasantness, global perceived improvement, medication use, and general health status.

METHODS: One hundred participants with cLBP were randomized to each of four dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for 6 weeks. At sessions when manipulation was not assigned, they received a focused light massage control. Covariate-adjusted linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 18, 24, 39, and 52 weeks.

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Prognosis in Patients with Recent Onset Low Back Pain in Australian Primary Care

By Frank M. Painter|September 17, 2013|Low Back Pain, Prognosis|

Prognosis in Patients with Recent Onset Low Back Pain in Australian Primary Care: Inception Cohort Study

The Chiro.Org Blog

British Medical Journal 2008 (Jul 7); 337: a171

Henschke N, Maher CG, Refshauge KM, Herbert RD,
Cumming RG, Bleasel J, York J, Das A, McAuley JH.

Musculoskeletal Division,
The George Institute for International Health,
Sydney, Australia.

This BMJ study contradicts previous Clinical Practice Guidelines that suggest that recovery from an episode of recent onset low back pain is usually rapid and complete. Their findings with 973 consecutive primary care patients was that recovery was slow for most patients, and almost 1/3 of patients did not recover within one year (when following standard medical recommendations).

OBJECTIVE: To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.

DESIGN: Cohort study with one year follow-up.

SETTING: Primary care clinics in Sydney, Australia.

PARTICIPANTS: An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.

MAIN OUTCOME MEASURES: Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.

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An Evidence-based Diagnostic Classification System For Low Back Pain

By Frank M. Painter|September 14, 2013|Evidence-based Medicine, Low Back Pain|

An Evidence-based Diagnostic Classification System For Low Back Pain

The Chiro.Org Blog

SOURCE: J Can Chiropr Assoc. 2013 (Sep); 57 (3): 189–204

Robert Vining, DC, Eric Potocki, DC, MS, Michael Seidman, MSW, DC, A. Paige Morgenthal, DC, MS

Palmer College of Chiropractic, Palmer Center for Chiropractic Research, 5433 Bryant Ave, South Minneapolis, MS 55419; dr.potocki@yahoo.com

INTRODUCTION: While clinicians generally accept that musculoskeletal low back pain (LBP) can arise from specific tissues, it remains difficult to confirm specific sources.

METHODS: Based on evidence supported by diagnostic utility studies, doctors of chiropractic functioning as members of a research clinic created a diagnostic classification system, corresponding exam and checklist based on strength of evidence, and in-office efficiency.

RESULTS: THE DIAGNOSTIC CLASSIFICATION SYSTEM CONTAINS ONE SCREENING CATEGORY, TWO PAIN CATEGORIES: Nociceptive, Neuropathic, one functional evaluation category, and one category for unknown or poorly defined diagnoses. Nociceptive and neuropathic pain categories are each divided into 4 subcategories.

CONCLUSION: This article describes and discusses the strength of evidence surrounding diagnostic categories for an in-office, clinical exam and checklist tool for LBP diagnosis. The use of a standardized tool for diagnosing low back pain in clinical and research settings is encouraged.

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From the FULL TEXT Article:

Introduction

Health professionals across such disciplines as orthopedics, physical therapy, and chiropractic have shared the goal of categorizing patients with musculoskeletal low back pain (LBP) according to evidence-based classification systems. [1, 2] To this end, several investigators have generated classification systems for LBP diagnosis and treatment. [3–8] Identifying specific pathophysiology causing LBP has the potential to positively impact clinical research and practice by providing opportunities to test, validate or reject treatments targeted at specific diagnoses. [1,2] Clinical prediction rules [4,6] and symptom or treatment-based classification systems [7,8] lack the pathophysiological component(s) clinicians sometimes use to better understand a condition and make clinical decisions. Patho-anatomic diagnoses address pain arising from more specific anatomic structures or pathological processes. However, definitively confirming pain sources for LBP continues to be a challenge.

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