A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up

OBJECTIVE: This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain (LBP) and assesses the influence of doctor type and pain duration on clinical outcomes. DESIGN: Prospective, longitudinal, nonrandomized, practice-based, observational study. SETTING: Fifty-one chiropractic and 14 general practice community clinics. SUBJECTS: A total of 2870 acute and chronic ambulatory patients with LBP of mechanical origin. METHODS: Sixty chiropractic (DC) and 111 general practice (MD) physicians participated. Primary outcomes were pain, using a 100-point visual analogue scale (VAS), and functional disability, using the Revised Oswestry Disability Questionnaire. These were measured at baseline and 8 time points. Regression analysis compared acute and chronic DC and MD patients after correcting for baseline differences in the 4 cohorts. RESULTS: Most improvement was seen by 3 months and sustained for 1 year; exacerbation was seen thereafter. Acute patients demonstrated greater relief at all time points. A clinically important advantage for chiropractic patients was seen in chronic patients in the short-term (>10 VAS points), and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year (P<.000). The advantage for DC care was prominent for chronic patients with leg pain below the knee (P<.001). More than 50% of chronic patients had over 50 days of pain in the third year. CONCLUSION: Study findings were consistent with systematic reviews of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP. Patient choice and interdisciplinary referral should be prime considerations by physicians, policymakers, and third-party payers in identifying health services for patients with LBP.     

Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians

BACKGROUND: Few studies exist on the prognostic value of demographic, clinical, or psychosocial factors on long-term outcomes for patients with chronic low back pain. OBJECTIVE: This study reports on long-term pain and disability outcomes for patients with chronic low back pain, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome. METHODS: Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based, observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at 6 months and 12 months, were pain (by using the Visual Analog Scale), and functional disability (by using the Revised Oswestry Disability Questionnaire). Satisfaction was a secondary outcome. RESULTS: Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study. CONCLUSION: Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes. Further study is required to explore the advantage seen for chiropractic care in patients with leg pain below the knee and in the area of patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.     

Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis

BACKGROUND: Evidence suggests that spinal manipulation is an effective treatment for mechanical neck and low-back pain (LBP). Treatment efficacy is important to establish for these symptoms because combined they account for a considerable amount of disability and substantial associated direct and indirect costs to society. OBJECTIVE: The purpose of this study was to examine the outcome of patients undergoing chiropractic treatment for mechanical neck or LBP. Design and Setting: A retrospective, outcome-based analysis was done for patients seeking care at a private chiropractic practice over a 1-year period. A total of 512 files were reviewed, with 119 patients selected for inclusion. Patients were included if their chief symptom was uncomplicated mechanical neck or LBP. Diagnoses included cervical, lumbar, or sacroiliac joint sprain/strain (International Code of Diagnostics version 9 [ICD-9] code: 847.1, 847.3, 846.1, respectively), discogenic LBP (ICD-9: 722.1), and headaches (ICD-9: 784.0) because many patients with neck pain presented with concomitant headaches. Disability and pain were measured with the modified Oswestry scale (for the patients with LBP), Neck Disability Index, and an 11-box visual analogue pain scale before and after treatment. Treatment consisted of spinal manipulation, various soft-tissue techniques, home-care instructions, and ergonomic and return-to-activity advice, including rehabilitative exercises. Patients received an average of 12 treatments over a 4-week period. Statistical analysis was performed on pretreatment and posttreatment values for both disability and pain. Stratification was based on duration (acute/subacute, chronic, acute exacerbation of a chronic condition) and severity (mild, moderate, or severe) of symptoms. RESULTS: Statistically significant reductions in disability and pain scores were achieved in all groups. An average 52.5% and 52.9% reduction in pain and disability, respectively, was achieved in the low-back group. The chronic LBP group realized a less statistically significant reduction of pain and disability (19.7% and 19.8%, respectively) than the acute/subacute (66.8% and 62.5%) or the chronic/recurrent group (56. 5% and 63.4%). The differences were statistically significant. Patients with neck pain had an average 53.8% and 48.4% reduction in their pain and disability, respectively. Patients with concomitant neck pain and headaches had statistically significant higher pretreatment and posttreatment disability and pain scores than those with only neck pain. There was no statistically significant difference in outcomes between groups stratified according to pain intensity. CONCLUSIONS: Patients attending a private chiropractic clinic for treatment of mechanical neck pain or LBP had statistically significant reductions in their pain-related disability after treatment. These results indicate that chiropractic manipulation is beneficial for the treatment of mechanical neck pain and LBP. However, care must be taken when drawing conclusions from these outcomes. The study design does not account for the natural history of low back- or neck pain-related disability and therefore does not allow for claims of treatment efficacy. In addition, it has been suggested that patients presenting to medical doctors with these symptoms have significant overlying comorbidity when compared with patients presenting to a chiropractor.     

Second Prize: The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: findings from the UCLA low back pain study

BACKGROUND: Although chiropractors often use physical modalities with spinal manipulation, evidence that modalities yield additional benefits over spinal manipulation alone is lacking. OBJECTIVE: The purpose of the study was to estimate the net effect of physical modalities on low back pain (LBP) outcomes among chiropractic patients in a managed-care setting. METHODS: Fifty percent of the 681 patients participating in a clinical trial of LBP treatment strategies were randomized to chiropractic care with physical modalities (n = 172) or without physical modalities (n = 169). Subjects were followed for 6 months with assessments at 2, 4, and 6 weeks and at 6 months. The primary outcome variables were average and most severe LBP intensity in the past week, assessed with numerical rating scales (0-10), and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire. RESULTS: Almost 60% of the subjects had baseline LBP episodes of more than 3 months' duration. The 6-month follow-up was 96%. The adjusted mean differences between groups in improvements in average and most severe pain and disability were clinically insignificant at all follow-up assessments. Clinically relevant improvements in average pain and disability were more likely in the modalities group at 2 and 6 weeks, but this apparent advantage disappeared at 6 months. Perceived treatment effectiveness was greater in the modalities group. CONCLUSIONS: Physical modalities used by chiropractors in this managed-care organization did not appear to be effective in the treatment of patients with LBP, although a small short-term benefit for some patients cannot be ruled out.     

Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians

BACKGROUND: Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. OBJECTIVES: To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. METHODS: A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians' practice activities; and low back complaint status at 1 year. RESULTS: Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. CONCLUSIONS: Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.     

Chiropractic and a new taxonomy of primary care activities

OBJECTIVE: To specify the procedural and cognitive content of primary care and to discuss potential chiropractic primary care roles. Data Collection: Data were collected through use of two expert panels and a consensus process to create a list of primary care activities. The first panel was an interdisciplinary mix of physicians, mainly allopathic ones; most of the members of the second panel were chiropractors. Each panel rated primary care activities across a number of dimensions, such as importance for good health, frequency in a typical office-based practice, necessity for medical doctor involvement in the activity, competence of the majority of chiropractic physicians, and interest among chiropractors in performing the activity. RESULTS: There was no real difference between the panels in terms of taxonomy scope or importance of the activities for good health. Many of the activities are performed more frequently in a typical medical office than in a typical chiropractic office. With respect to a set of primary care activities that occur daily in medical offices, chiropractors are able to make diagnoses in 92% of the activities and to make therapeutic contributions in more than 50% of the activities. Medical doctor involvement was perceived as required more frequently by the chiropractic panel than by the interdisciplinary panel. Moreover, chiropractors' interests and self-assessments of competence showed some limits with regard to their assumption of total care for some frequently occurring primary care activities. CONCLUSIONS: The most important finding of this activity is the overriding sense of agreement between allopathic and chiropractic physicians in terms of the scope of primary care activities, suggesting that there is opportunity for chiropractors and medical doctors to work together on patient care and organizational strategy. However, the levels of self-assessed competence and interest on the part of chiropractors for many frequently occurring primary care activities reveal some important limits for assumption of total primary care.     

The treatment of neck and low back pain: who seeks care? who goes where?

BACKGROUND: Neck and low back pain are leading causes of morbidity and health care utilization. However, little is known about the characteristics that differentiate those who seek from those who do not seek health care for their pain. OBJECTIVES: The objectives of this study were to: 1) describe health care utilization for neck and back pain; 2) determine the characteristics of individuals seeking health care for neck and back pain; and 3) identify the characteristics of patients who consult medical doctors, chiropractors, or both. DESIGN: Population-based cross-sectional mailed survey. SUBJECTS: Subjects were randomly selected adults from the Saskatchewan Health Insurance and Registration File. MEASURES: Demographic, socio-economic, general health, comorbidity, health-related-quality-of-life, pain severity and health care utilization data were collected. The main outcome was whether subjects with prevalent neck or low back pain visited a health care provider in the previous month. RESULTS: Twenty-five percent of individuals with neck or low back pain visited a health care provider. Seeking health care was associated with disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning. Compared with medical patients, fewer chiropractic patients lived in rural areas or reported arthritis, but they reported better social and physical functioning. More patients consulting both providers reported disabling neck or back pain. CONCLUSIONS: Individuals seeking care for neck or back pain have worse health status than those who do not seek care. Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors.     

Chronic pediatric asthma and chiropractic spinal manipulation: a prospective clinical series and randomized clinical pilot study

OBJECTIVES: The first objective was to determine if chiropractic spinal manipulative therapy (SMT) in addition to optimal medical management resulted in clinically important changes in asthma-related outcomes in children. The second objective was to assess the feasibility of conducting a full-scale, randomized clinical trial in terms of recruitment, evaluation, treatment, and ability to deliver a sham SMT procedure. STUDY DESIGN: Prospective clinical case series combined with an observer-blinded, pilot randomized clinical trial with a 1-year follow-up period. SETTING: Primary contact, college outpatient clinic, and a pediatric hospital. PATIENTS: A total of 36 patients aged 6 to 17 years with mild and moderate persistent asthma were admitted to the study. OUTCOME MEASURES: Pulmonary function tests; patient- and parent- or guardian-rated asthma-specific quality of life, asthma severity, and improvement; am and pm peak expiratory flow rates; and diary-based day and nighttime symptoms. INTERVENTIONS: Twenty chiropractic treatment sessions were scheduled during the 3-month intervention phase. Patients were randomly assigned to receive either active SMT or sham SMT in addition to their standardized ongoing medical management. RESULTS: It is possible to blind the participants to the nature of the SMT intervention, and a full-scale trial with the described design is feasible to conduct. At the end of the 12-week intervention phase, objective lung function tests and patient-rated day and nighttime symptoms based on diary recordings showed little or no change. Of the patient-rated measures, a reduction of approximately 20% in beta(2) bronchodilator use was seen (P =.10). The quality of life scores improved by 10% to 28% (P <.01), with the activity scale showing the most change. Asthma severity ratings showed a reduction of 39% (P <.001), and there was an overall improvement rating corresponding to 50% to 75%. The pulmonologist-rated improvement was small. Similarly, the improvements in parent- or guardian-rated outcomes were mostly small and not statistically significant. The changes in patient-rated severity and the improvement rating remained unchanged at 12-month posttreatment follow-up as assessed by a brief postal questionnaire. CONCLUSION: After 3 months of combining chiropractic SMT with optimal medical management for pediatric asthma, the children rated their quality of life substantially higher and their asthma severity substantially lower. These improvements were maintained at the 1-year follow-up assessment. There were no important changes in lung function or hyperresponsiveness at any time. The observed improvements are unlikely as a result of the specific effects of chiropractic SMT alone, but other aspects of the clinical encounter that should not be dismissed readily. Further research is needed to assess which components of the chiropractic encounter are responsible for important improvements in patient-oriented outcomes so that they may be incorporated into the care of all patients with asthma.     

The impact of psychosocial factors on neck pain and disability outcomes among primary care patients: results from the UCLA Neck Pain Study

Purpose. The purpose of this study is to estimate the associations of psychosocial factors with pain and disability outcomes among neck-pain patients enrolled in a randomized clinical trial of chiropractic treatments.

Methods. Neck-pain patients were randomized to one of 8 modes of chiropractic treatment. Health status and psychosocial variables were measured at baseline. Changes in neck pain severity and disability from baseline to 6 months were the primary outcome variables. Multivariable regression models were used to estimate effects of psychosocial variables adjusted for potential confounders.

Results. Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.

Conclusions. We found some evidence that certain coping strategies and types of social support are associated with pain and disability outcomes in this population of largely subacute and chronic neck-pain patients.     

Comparison of work and time estimates by chiropractic physicians with those of medical and osteopathic providers.

BACKGROUND: Resource-based relative value scales (RBRVS) have become a standard method for identifying costs and determining reimbursement for physician services. Development of RBRVS systems and methods are reviewed, and the RBRVS concept of physician "work" is defined. OBJECTIVE: Results of work and time inputs from chiropractic physicians are compared with those reported by osteopathic and medical specialties. Last, implications for reimbursement of chiropractic fee services are discussed. METHODS: Total work, intraservice work, and time inputs for clinical vignettes reported by chiropractic, osteopathic, and medical physicians are compared. Data for chiropractic work and time reports were drawn from a national random sample of chiropractors conducted as part of a 1997 workers' compensation chiropractic fee schedule development project. Medical and osteopathic inputs were drawn from RBRVS research conducted at Harvard University under a federal contract reported in 1990. Both data sets used the same or similar clinical vignettes and similar methods. Comparisons of work and time inputs are made for clinical vignettes to assess whether work reported by chiropractors is of similar magnitude and variability as work reported by other specialties. RESULTS: Chiropractic inputs for vignettes related to evaluation and management services are similar to those reported by medical specialists and osteopathic physicians. The range of variation between chiropractic work input and other specialties is of similar magnitude to that within other specialties. Chiropractors report greater work input for radiologic interpretation and lower work input for manipulation services. CONCLUSIONS: Chiropractors seem to perform similar total "work" for evaluation and management services as other specialties. No basis exists for excluding chiropractors from using evaluation and management codes for reimbursement purposes on grounds of dissimilar physician time or work estimates. Greater work input by chiropractors in radiology interpretation may be related to a greater importance placed on findings in care planning. Consistently higher reports for osteopathic work input on manipulation are likely attributable to differences in reference vignettes used in the respective populations. Research with a common reference vignette used for manipulation providers is recommended, as is development of a single generic approach to coding for manipulation services.     

Views on radiography use for patients with acute low back pain among chiropractors in an Ontario community

BACKGROUND: Recent studies suggest that chiropractors continue to widely use radiography for assessing patients with acute low back pain. This practice is contrary to growing evidence that suggests only a small percentage of patients with acute low back pain require radiographic evaluation. OBJECTIVES: To assess quantitatively and qualitatively the views of chiropractors in a selected community in Ontario on the use of radiography for evaluating patients with acute low back pain. Study Design: Mailed surveys and focus group interview. METHOD: Surveys were mailed to all chiropractors (N = 26) in a selected community in Ontario, followed by a focus group session with local chiropractors (n = 7). Surveys requested information on personal and practice characteristics and the management of low back pain, including the use of radiography. The focus group, led by a facilitator, discussed issues surrounding practice guidelines and radiography use. RESULTS: There was a 76% response rate to the mailed surveys. Of those who responded, 63% stated they would use radiography on patients with uncomplicated acute low back pain lasting 1 week; 68% stated that radiographs were useful in the diagnostic evaluation of patients with acute low back pain lasting less than 1 month. Most reasons given for use of radiography in this patient population are not supported by existing evidence. CONCLUSIONS: There appears to be a high rate of radiographic use by chiropractors in the study community, which is consistent with findings in previous studies. Many of the reasons given for use of radiography are not supported by existing evidence and may contribute to the gap between current chiropractic practice and available evidence with respect to use of radiography for acute low back pain.     

A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: part I

OBJECTIVE: To investigate the primary care, health promotion activities associated with what has historically been called "maintenance care" (MC) as used in the practice of chiropractic in the United States. This includes issues such as investigating the purpose of MC, what conditions and patient populations it best serves, how frequently it is required, what therapeutic interventions constitute MC, how often it is recommended, and what percent of patient visits are for prevention and health promotion services. It also investigates the economic impact of these services. DESIGN: Postal survey of a randomized sample of practicing US chiropractors. The questionnaire was structured with a 5-point ordinal Likert scale (28 questions) and brief fill-in questionnaire (12 questions). The 40-question survey was mailed to 1500 chiropractors selected at random from a pool of chiropractors with active practices in the United States. The National Directory of Chiropractic database was the source of actively practicing chiropractors from which doctor selection was made. The sample was derived by using the last numbers composing the zip codes assigned by the US Postal Service. This sampling method assured potential inclusion of chiropractors from all 50 states, from rural areas and large cities, and assured a sample weighting based on population density that might not have been afforded by a simple random sample. RESULTS: Six hundred and fifty-eight (44%) of the questionnaires were completed and returned. US chiropractors agreed or strongly agreed that the purpose of MC was to optimize health (90%), prevent conditions from developing (88%), provide palliative care (86%), and minimize recurrence or exacerbations (95%). MC was viewed as helpful in preventing both musculoskeletal and visceral health problems. There was strong agreement that the therapeutic composition of MC placed virtually equal weight on exercise (96%) and adjustments/manipulation (97%) and that other interventions, including dietary recommendations (93%) and patient education about lifestyle changes (84%), shared a high level of importance. Seventy-nine percent of chiropractic patients have MC recommended to them and nearly half of those (34%) comply. The average number of recommended MC visits was 14.4 visits per year, and the total revenue represents an estimated 23% of practice income. CONCLUSIONS: Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.     

The impact of psychosocial factors on neck pain and disability outcomes among primary care patients: Results from the UCLA Neck Pain Study

Purpose. The purpose of this study is to estimate the associations of psychosocial factors with pain and disability outcomes among neck-pain patients enrolled in a randomized clinical trial of chiropractic treatments.

Methods. Neck-pain patients were randomized to one of 8 modes of chiropractic treatment. Health status and psychosocial variables were measured at baseline. Changes in neck pain severity and disability from baseline to 6 months were the primary outcome variables. Multivariable regression models were used to estimate effects of psychosocial variables adjusted for potential confounders.

Results. Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.

Conclusions. We found some evidence that certain coping strategies and types of social support are associated with pain and disability outcomes in this population of largely subacute and chronic neck-pain patients.     

Evaluation of chiropractic management of pediatric patients with low back pain: a prospective cohort study

BACKGROUND: Recent epidemiologic studies have estimated that the lifetime prevalence of low back pain (LBP) in children is approximately 50%, with almost 15% of children experiencing frequent or continual pain. A literature search revealed no published studies addressing conservative treatment of childhood LBP. OBJECTIVE: To describe chiropractic management of LBP in patients between the ages of 4 and 18 years, as well as outcomes and factors associated with the outcomes. METHODS: Prospective cohort study of consecutive pediatric patients with LBP seeing randomly selected chiropractors within the cities of Calgary, Alberta, and Toronto, Ontario, Canada. Follow-up data collection included the type and extent of treatment rendered and its outcome, which was measured with a 5-point subjective rating scale and a self-report pediatric visual analogue scale. RESULTS: Fifteen chiropractors provided data on 54 consecutive pediatric patients with LBP. The average age of the patients was 13.1 years, 57% were male, 61% were acute, with 47% attributing onset to a traumatic event (most commonly sports-related); 24% reported an episode duration of greater than 3 months. Almost 90% of cases presented with uncomplicated mechanical LBP, most frequently diagnosed as lumbar facet dysfunction or subluxation. Patients were managed with manipulation, with a minority (7.7%) receiving some form of active management. "Important" improvement was seen in 62% and 87% on the visual analogue and subjective scales, respectively, within a 6-week course of management (Kaplan-Meier survival analysis). Patients with chronic LBP were less likely to respond within the median number of treatments (relative risk = 2.1). CONCLUSIONS: Patients responded favorably to chiropractic management, and there were no reported complications. Future investigations should establish the natural history and compare chiropractic management with other forms of treatment to gain knowledge about the effectiveness of chiropractic in managing pediatric LBP.     

Chiropractic Care for Adults With Pregnancy-Related Low Back,Pelvic Girdle Pain,or Combination Pain: A Systematic Review

ObjectiveThe purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of chiropractic care options commonly used for pregnancy-related low back pain (LBP), pelvic girdle pain (PGP), or combination pain for both experienced practitioners and students of chiropractic.MethodsWe included procedures that were commonly used by chiropractors and not requiring additional certifications. Outcomes were self-reported changes in pain or disability. We used the Scottish Intercollegiate Guideline Network checklists to assess outcomes. For strength of evidence, we used the adapted version of the US Preventive Services Task Force criteria as described in the UK report.ResultsFifty articles were included from 18 SRs, 30 randomized controlled trials (RCTs), and 2 cohort studies. Pregnancy LBP (7 SRs and 12 RCTs): moderate, favorable evidence for electrotherapy and osteopathic manipulative therapy; inconclusive, favorable strength for chiropractic care, exercise, and support devices; and inconclusive, unclear strength for spinal manipulative therapy. Pregnancy PGP (4 SRs and 4 RCTs): inconclusive, favorable strength for exercise; and inconclusive, unclear evidence for patient education, information, and support devices. Pregnancy LBP or PGP (13 SRs and 12 RCTs): moderate, unclear evidence for complementary and alternative medicine; moderate, unclear evidence for exercise; inconclusive, favorable evidence for multimodal care, patient education, and physiotherapy; and inconclusive, unclear strength for spinal manipulative therapy, osteopathic manipulative therapy, and support devices.ConclusionAlthough there is a lack of conclusive evidence, many of the interventions have moderate or unclear but favorable evidence.     

Back pain and satisfaction with chiropractic treatment: what role does the physical outcome play?

OBJECTIVES: This study sought to determine what functional and affective outcomes had the most predictive value for overall satisfaction and improvement in patients seeking chiropractic treatment of low back pain. METHOD: Baseline questionnaires were completed by 965 patients seeking chiropractic help for low back pain, with blinded follow-up at 6 weeks. Patients were asked about effects on pain, anxiety, normal activity, work, depression, lifestyle, satisfaction, and overall improvement. Stepwise multiple regression analyses were used to evaluate the contribution of change scores to overall improvement and satisfaction. A 2-stage block regression was conducted to find out what additional factors besides overall improvement predicted patient satisfaction. RESULTS: There were weak to moderate, but highly significant, relationships between the change scores and both improvement and satisfaction. However, most of the variance (57%) in the latter was explained by overall improvement and a very small amount (0.5%) by improvements in activity, leaving nearly 43% unexplained by any of the variables. Pain, work, and ability to control pain together predicted 27% of the variance in overall improvement. No other variables predicted this, leaving 73% of the variance unexplained. DISCUSSION: Pragmatic rather than affective variables played some part in predicting satisfaction through global improvement in these patients. This should help to inform future interpretation of clinical trials of chiropractic treatments for back pain. However, the nature of the "unknown" components needs further investigation. There are initial indications in the literature that information giving, and the reconfiguration of patients' perceptions of the problem, may contribute to patient satisfaction generally. Further work is needed to confirm this and to establish where such interventions can also contribute to overall improvement.