Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain

Objectives

Chronic low back pain (CLBP) and chronic neck pain (CNP) are the most common types of chronic pain, and chiropractic spinal manipulation is a common nonpharmacologic treatment. This study presents the characteristics of a large United States sample of chiropractic patients with CLBP and CNP.

A Longitudinal Observational Clinical Study of Neurophysiological and Patient-Reported Responses to a Program of Physiotherapy for Acute and Subacute Low Back Pain

Objectives

The purpose of this study was to document the baseline neurophysiological status (skin conductance activity levels) of patients presenting for physiotherapy with acute and subacute low back pain (symptoms of up to 12 weeks’ duration) and to observe the magnitude and direction of sympathetic nervous system (SNS) changes (skin conductance responses [SCRs]) occurring as a result of receiving guideline-endorsed physiotherapy treatment.

Trunk Neuromuscular Responses to a Single Whole-Body Vibration Session in Patients With Chronic Low Back Pain: A Cross-Sectional Study

Objective

Whole-body vibration (WBV) exercise is progressively adopted as an alternative therapeutic modality for enhancing muscle force and muscle activity via neurogenic potentiation. So far, possible changes in the recruitment patterns of the trunk musculature after WBV remain undetermined. The main objective of this study was to evaluate the short-term effects of a single WBV session on trunk neuromuscular responses in patients with chronic low back pain (cLBP) and healthy participants.

Methods

Twenty patients with cLBP and 21 healthy participants performed 10 trunk flexion-extensions before and after a single WBV session consisting of five 1-minute vibration sets. Surface electromyography (EMG) of erector spinae at L2-L3 and L4-L5 and lumbopelvic kinematic variables were collected during the trials. Data were analyzed using 2-way mixed analysis of variance models.

Results

The WBV session led to increased lumbar EMG activity during the flexion and extension phases but yielded no change in the quiet standing and fully flexed phases. Kinematic data showed a decreased contribution to the movement of the lumbar region in the second extension quartile. These effects were not different between patients with cLBP and healthy participants.

Conclusions

Increased lumbar EMG activity after a single WBV session most probably results from potentiation effects of WBV on lumbar muscles reflex responses. Decreased EMG activity in full trunk flexion, usually observed in healthy individuals, was still present after WBV, suggesting that the ability of the spine stabilizing mechanisms to transfer the extension torque from muscles to passive structures was not affected.     

An Exploration of Maitland's Concept of Pain Irritability in Patients with Low Back Pain

Maitland''s construct of musculoskeletal pain irritability is widely used by physical therapists for making decisions about the vigor of examination and treatment, but this construct has not been defined to the extent that its measurement properties can be tested. The purposes of this study were to 1) determine if physical therapists utilize low back pain (LBP) irritability judgments to make treatment decisions, 2) identify LBP characteristics appropriate for an LBP irritability construct, and 3) develop a measurement construct of LBP irritability. Physical therapists evaluated and treated 183 subjects with LBP. The therapists judged the subjects'' LBP as irritable or non-irritable, and recorded treatments provided at the initial visit. A principal-components analysis (PCA) was performed on 14 patient-reported LBP characteristics to identify potential components of a measurement construct of LBP irritability. The therapists'' irritability judgments were found to be associated with the types of treatments prescribed. Five dimensions of LBP irritability were identified by the PCA from the 14 LBP characteristics considered. Four of these dimensions were associated with the therapists'' LBP irritability judgments. The Roland-Morris Disability Questionnaire, presence of distal symptoms, and forward bending tolerance were found to have a stronger association with the irritability judgments than the dimensions of irritability identified in this study. Validated measures of LBP characteristics in current clinical use may adequately capture Maitland''s concept of irritability.     

Utilization of Low Back Pain Patient Reported Outcome Measures Within Chiropractic Literature: A Descriptive Review

Objective

The purpose of this review was to determine the most commonly reported and utilized low back pain (LBP) Patient Reported Outcome Measures (PROMs) within the chiropractic literature and to investigate their temporal and methodological publication characteristics.

Relationship Between Hip Extensor Strength and Back Extensor Length in Patients With Low Back Pain: A Cross-Sectional Study

ObjectiveThe purpose of this study was to examine the relationship between hip extensor strength and back extensor length in patients with low back pain (LBP) and healthy controls.MethodsIn 266 patients with LBP and 215 matched controls, back extensor length and hip extensor strength were measured and compared in the 2 groups using an independent t test. The Pearson correlation coefficient was used to determine correlation between these 2 variables. Multivariate logistic regression was used to test the risk of sustaining LBP with having these muscle insufficiencies.ResultsA significant difference in hip extensor strength was found between patients with LBP and controls (P < .001). Back extensor length was different in healthy men compared with the patients with LBP (P < .001) but was not significant between women with and without LBP (P = .34). The results showed a significant relationship between back extensor length and hip extensor strength in men with LBP (r = 0.6, P = .01). Multivariate logistic regression revealed that having a weak hip extensor (P = .001) or shortened back extensor (P = .01) could increase the risk of LBP occurrence.ConclusionThe findings support the assumptions of the presence of muscle imbalance of hip extensor weakness and back extensor tightness in male patients with LBP and that each muscle impairment may contribute to LBP.     

The Effect of 2 Different Exercise Programs on Pain Intensity and Muscle Dimensions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial

Objectives

The purpose of this study was to compare the effect of 2 exercise programs combined with electrotherapy on pain intensity and lumbar stabilizer muscles dimensions in patients with nonspecific chronic low back pain.

The Association Among Overweight,Obesity, and Low Back Pain in U.S. Adults: A Cross-Sectional Study of the 2015 National Health Interview Survey

Objective

The purpose of this study was to explore the association between obesity (via body mass index [BMI]) and presence of low back pain (LBP) in a representative sample of US adults, aged ≥18 years.

Interaction Between Thoracic Movement and Lumbar Spine Muscle Activation Patterns in Young Adults Asymptomatic for Low Back Pain: A Cross-Sectional Study

ObjectiveThe purpose of this study was to investigate the interaction between thoracic movement and lumbar muscle co-contraction when the lumbar spine was held in a relatively neutral posture.MethodsThirty young adults, asymptomatic for back pain, performed 10 trials of upright standing, maximum trunk range of motion, and thoracic movement tasks while lumbar muscle activation was measured. Lumbar co-contraction was calculated, compared between tasks, and correlated to thoracic angles.ResultsMovement tasks typically exhibited greater co-contraction than upright standing. Co-contraction in the lumbar musculature was 67%, 45%, and 55% greater than upright standing for thoracic flex, thoracic bend, and thoracic twist, respectively. Generally, the thoracic movement task demonstrated greater co-contraction than the maximum task in the same direction. Co-contraction was also correlated to thoracic angles in each movement direction.ConclusionTasks with thoracic movement and a neutral lumbar spine posture resulted in increases in co-contraction within the lumbar musculature compared with quiet standing and maximum trunk range-of-motion tasks. Findings indicated an interaction between the 2 spine regions, suggesting that thoracic posture should be accounted for during the investigation of lumbar spine mechanics.     

Influence of Foot Orthotics Upon Duration of Effects of Spinal Manipulation in Chronic Back Pain Patients: A Randomized Clinical Trial

Objective

The purpose of this study was to investigate the effects of 4 weeks of custom foot orthotics on pain, disability, recurrence of spinal fixation, and muscle dysfunction in adult low back pain patients receiving limited chiropractic care.

Methods

Adult volunteers with low back pain of greater than or equal to 1 month's duration were randomized to receive custom orthotics (group A) or a flat insole sham (group B) with limited chiropractic care in 5 visits over 4 weeks. Primary outcome measures are as follows: Quadruple Numerical Pain Rating Scale (for back), the Roland-Morris Disability Questionnaire, the number of muscles grade 4 or lower on manual muscle testing, and the number of spinal fixations detected by motion palpation and vertebral challenge at intake (B1), 2 weeks later before treatment began and orthotic use was initiated (B2) and before each subsequent treatment at approximately days 3, 10, 17, and 24 after B2. Secondary outcome measures are correlations of all primary outcomes.

Results

Both groups improved on all Numerical Pain Rating Scale, Roland-Morris Disability Questionnaire, and the number of muscles from intake (B1) to final visit. Only group B yielded significant improvements in the number of spinal fixations. No outcome measures showed statistical difference between groups at any time point; however, those who wore custom orthotics longer each day showed trends toward greater improvements in some outcome measures.

Conclusions

Both groups improved with chiropractic care including spinal manipulation; however, there were no statistical differences shown between sham and custom orthotic groups. Future studies should formally measure the time that orthotics or shams are worn in a weight-bearing capacity each day.     

Procedure Selection and Patient Positioning Influence Spine Kinematics During High-Velocity,Low-Amplitude Spinal Manipulation Applied to the Low Back

Objectives

This investigation compared indirect 3-dimensional angular kinematics (position, velocity, and acceleration) of the lumbar spine for 2 different high-velocity, low-amplitude (HVLA) spinal manipulation procedures (lumbar spinous pull or push), and altered initial patient lower limb posture.

An Exploratory Analysis of Gender as a Potential Modifier of Treatment Effect Among Patients in a Randomized Controlled Trial of Integrative Acupuncture and Spinal Manipulation for Low Back Pain

ObjectiveTo identify the potential association of self-reported gender on pain and disability among patients in a randomized controlled trial of integrative acupuncture and spinal manipulation therapy (SMT) for low back pain (LBP).MethodsIn the original study, 100 participants with LBP were randomized to receive acupuncture, SMT, or both combined. Eighty completed treatment and were followed for 60 days. Primary outcome measures were the Roland-Morris Disability Questionnaire and numeric pain scales. This study was a secondary analysis and used regression models to estimate and test for gender-specific differences in outcomes from baseline through end of treatment.ResultsWomen assigned to acupuncture averaged a 3.8-point reduction in highest LBP vs 2.0 points for SMT, whereas men assigned to SMT averaged a 3.5-point reduction vs 1.8 points for acupuncture (P for interaction = .04). There was a trend toward the same for disability (P for interaction = .12). For women, acupuncture alone led to better outcomes without SMT, and for men, SMT alone led to better outcomes without acupuncture. Women who received acupuncture were more likely to experience 50% or greater reductions in disability and pain, whereas men who received SMT were more likely to experience 50% or greater reductions in disability and pain.ConclusionAn association was found between self-reported gender and response to LBP treatment. Women demonstrated a greater reduction in pain and disability with acupuncture and men with SMT. Future clinical trials should consider sex as a potential determinant of treatment outcomes for LBP.     

The Risk of Bias and Sample Size of Trials of Spinal Manipulative Therapy for Low Back and Neck Pain: Analysis and Recommendations

Objective

The purpose of this study was to evaluate changes in methodological quality and sample size in randomized controlled trials (RCTs) of spinal manipulative therapy (SMT) for neck and low back pain over a specified period. A secondary purpose was to make recommendations for improvement for future SMT trials based upon our findings.

Methods

Randomized controlled trials that examined the effect of SMT in adults with neck and/or low back pain and reported at least 1 patient-reported outcome measure were included. Studies were identified from recent Cochrane reviews of SMT, and an update of the literature was conducted (March 2013). Risk of bias was assessed using the 12-item criteria recommended by the Cochrane Back Review Group. In addition, sample size was examined. The relationship between the overall risk of bias and sample size over time was evaluated using regression analyses, and RCTs were grouped into periods (epochs) of approximately 5 years.

Results

In total, 105 RCTs were included, of which 41 (39%) were considered to have a low risk of bias. There is significant improvement in the mean risk of bias over time (P < .05), which is the most profound for items related to selection bias and, to a lesser extent, attrition and selective outcome reporting bias. Furthermore, although there is no significant increase in sample size over time (overall P = .8), the proportion of studies that performed an a priori sample size calculation is increasing statistically (odds ratio, 2.1; confidence interval, 1.5-3.0). Sensitivity analyses suggest no appreciable difference between studies for neck or low back pain for risk of bias or sample size.

Conclusion

Methodological quality of RCTs of SMT for neck and low back pain is improving, whereas overall sample size has shown only small and nonsignificant increases. There is an increasing trend among studies to conduct sample size calculations, which relate to statistical power. Based upon these findings, 7 areas of improvement for future SMT trials are suggested.     

Cost Analysis Related to Dose-Response of Spinal Manipulative Therapy for Chronic Low Back Pain: Outcomes From a Randomized Controlled Trial

Objective

The purpose of this analysis is to report the incremental costs and benefits of different doses of spinal manipulative therapy (SMT) in patients with chronic low back pain (LBP).

Methods

We randomized 400 patients with chronic LBP to receive a dose of 0, 6, 12, or 18 sessions of SMT. Participants were scheduled for 18 visits for 6 weeks and received SMT or light massage control from a doctor of chiropractic. Societal costs in the year after study enrollment were estimated using patient reports of health care use and lost productivity. The main health outcomes were the number of pain-free days and disability-free days. Multiple regression was performed on outcomes and log-transformed cost data.

Results

Lost productivity accounts for most societal costs of chronic LBP. Cost of treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were greater age (P = .03), greater disability (P = .01), lower quality-adjusted life year scores (P = .01), and higher costs in the period preceding enrollment (P < .01). Pain-free and disability-free days were greater for all SMT doses compared with control, but only SMT 12 yielded a statistically significant benefit of 22.9 pain-free days (P = .03) and19.8 disability-free days (P = .04). No statistically significant group differences in quality-adjusted life years were noted.

Conclusions

A dose of 12 SMT sessions yielded a modest benefit in pain-free and disability-free days. Care of chronic LBP with SMT did not increase the costs of treatment plus lost productivity.     

A Qualitative Study of Doctors of Chiropractic in a Nova Scotian Practice-based Research Network: Barriers and Facilitators to the Screening and Management of Psychosocial Factors for Patients With Low Back Pain

Objectives

This study aimed to assess chiropractors’ awareness of clinical practice guidelines for low back pain and to identify barriers and facilitators to the screening and management of psychosocial factors in patients with low back pain.

The Effectiveness of Hollowing and Bracing Strategies With Lumbar Stabilization Exercise in Older Adult Women With Nonspecific Low Back Pain: A Quasi-Experimental Study on a Community-based Rehabilitation

Objective

The purpose of this study was to explore the therapeutic effectiveness of hollowing lumbar stabilization exercise (HLSE) and bracing lumbar stabilization exercise (BLSE) for older adult women with nonspecific low back pain (NSLBP) in community welfare centers.

Sensorimotor Cortical Activity in Acute Low Back Pain: A Cross-Sectional Study

Sensorimotor cortical activity is altered in both the immediate acute and chronic stages of musculoskeletal pain. However, these changes are opposite, with decreased cortical activity reported in experimentally induced acute pain (lasting minutes to hours), and increased cortical activity in chronic, clinical pain (lasting >6 months). It is unknown whether sensorimotor cortical activity is altered in acute, clinical musculoskeletal pain (lasting <4 weeks). In 36 individuals with acute, nonspecific, clinical low back pain (LBP) and 36 age- and sex-matched, pain-free controls, we investigated the processing of non-noxious afferent inputs using sensory evoked potentials (SEPs), as well as corticomotor excitability and organization of the primary motor cortex using transcranial magnetic stimulation. Processing of non-noxious sensory inputs was lower (smaller area of the N₈₀–N₁₅₀–P₂₆₀ SEP complex) in acute LBP (F_1,70 = 45.28, P < .01). The examination of specific SEP components revealed a smaller area of the N₁₅₀ and P₂₆₀ SEP components in acute LBP, although interindividual variability was high. Motor cortical map volume was lower in acute LBP (F_1,70 = 5.61, P = .02). These findings demonstrate that acute LBP is characterized by lower sensorimotor cortical activity at the group level. However, individual variation was high, suggesting individual adaptation of cortical plasticity in acute pain.PerspectiveThis is the first study to examine sensorimotor cortical activity in the acute stage of clinical LBP. This information is critical for understanding the neurophysiology of acute LBP.     

Coping and Management Techniques Used by Chronic Low Back Pain Patients Receiving Treatment From Chiropractors

ObjectivesThe purpose of this study was to describe coping strategies (eg, mechanisms, including self-treatment) that a person uses to reduce pain and its impact on functioning as reported by patients with chronic low back pain who were seen by doctors of chiropractic and how these coping strategies vary by patient characteristics.MethodsData were collected from a national sample of US chiropractic patients recruited from chiropractic practices in 6 states from major geographical regions of the United States using a multistage stratified sampling strategy. Reports of coping behaviors used to manage pain during the past 6 months were used to create counts across 6 domains: cognitive, self-care, environmental, medical care, social activities, and work. Exploratory analyses examined counts in domains and frequencies of individual items by levels of patient characteristics.ResultsA total of 1677 respondents with chronic low back pain reported using an average of 9 coping behaviors in the prior 6 months. Use of more types of behaviors were reported among those with more severe back pain, who rated their health as fair or poor and who had daily occurrences of pain. Exercise was more frequent among the healthy and those with less pain. Female respondents tended to report using more coping behaviors than men, and Hispanics more than non-Hispanics.ConclusionPersons with chronic back pain were proactive in their coping strategies and frequently used self-care coping strategies like those provided by chiropractors in patient education. In alignment with patients’ beliefs that their condition was chronic and lifelong, many patients attempted a wide range of coping strategies to relieve their pain.     

Outcomes for Chronic Neck and Low Back Pain Patients After Manipulation Under Anesthesia: A Prospective Cohort Study

Background

The purpose of this study was to investigate outcomes of chronic patients unresponsive to previous spinal manipulative therapy subsequently treated with manipulation under anesthesia (MUA).

Methods

A prospective outcome cohort study was performed on 30 patients who had not improved with previous treatment and who underwent a single MUA by a doctor of chiropractic. The numeric rating scale for pain (NRS) and Bournemouth Questionnaire (BQ) were collected at 2 weeks and 1 day before MUA. At 2 and 4 weeks after MUA, the Patient's Global Impression of Change, NRS, and BQ were collected. The intraclass correlation coefficient evaluated stability before treatment. Percentage of patients “improved” was calculated at 2 and 4 weeks. Wilcoxon test compared pretreatment NRS and BQ scores with posttreatment scores. Mann-Whitney U test compared individual questions on the BQ between improved and not improved patients. Logistic regression compared BQ questions to “improvement.”

Results

Good stability of NRS and BQ scores before MUA (intraclass correlation coefficient = 0.46-0.95) was found. At 2 weeks, 52% of the patients reported improvement with 45.5% improved at 4 weeks. Significant reductions in NRS scores at 4 weeks (P = .01) and BQ scores at 2 (P = .008) and 4 weeks (P = .001) were reported. Anxiety/stress levels were significantly different at 2 and 4 weeks between improved and not improved patients (P = .007). None of the BQ questions were predictive of improvement.

Conclusion

Approximately half of patients previously unresponsive to conservative treatment reported clinically relevant improvement at 2 and 4 weeks post-MUA.