Multimodale Verfahren – auf die Mischung kommt es an!

In the last 50 years conventional treatments have not been able to slow down the expanding chronic low back pain problem. However, nowadays health care has changed according to a broad biopsychosocial model of health, the positive effect of activity on health and healing, emphasis on function rather than pain or impairment, and reliance upon clinical evidence. In search for new solutions "functional restoration" (FR) programs have been developed. They include multidisciplinary treatment of patients in groups, consisting of 6-8 h of treatment a day, lasting 3 to 6 weeks and usually integrating intense physical and ergonomic training, psychological (behavioral) therapy, patient education, and instruction in social- and work-related issues. FR programs have yet to demonstrate their effectiveness in several countries. Controlled studies in the USA were very positive regarding the return-to-work rate, whereas studies in Scandinavian countries did not demonstrate similar results. Possible reasons for the different results concerning back-to-work ratios might be that study design, patient population, content of the program, and other external factors are different and studies as well as effects are therefore not directly comparable. According to several well-controlled studies, the most probable reason for this different effect may be that social and security (health care) systems and cultures differ among countries and that patients with chronic low back pain respond differently to this combination. Sick absenteeism and inability to work may be influenced by many factors besides pain that cannot be addressed by intervention or prevention programs, e.g., job satisfaction, education level, and the compensation systems. It may be that the lower economic benefit during sick leave in the United States leads to favorable results from functional restoration programs. Concerning the prediction of success, several studies have shown that medical background, diagnosis and physical impairment as well as physical variables (mobility, strength) have limited predictive value. Return to work and pain reduction are much better predicted by length of absence from work, application for pension, and the patients' disability in daily-life activities. In the last five years another important variable of success has been identified: avoidance behavior has been suspected to be a major contributor to the initiation and maintenance of chronic low back pain. The perpetuation of avoidance behavior beyond normal healing time subsequently leads to negative consequences such as "disuse syndrome", which is associated with physical deconditioning, sick role behavior, psychosocial withdrawal and negative affect. Accordingly, fear-avoidance beliefs were strongly related to absenteeism from work due to back pain and were the best predictors of therapy outcome in 300 acute low back pain patients. In a prospective study on 87 patients with chronic low back pain (CLBP) we demonstrated that fear-avoidance beliefs were the strongest predictors of return to work after a functional restoration treatment program. Although nonspecific mechanisms such as emotional disturbance, helplessness, pain anticipation, disability, and job circumstances could be identified as influencing the chronic pain process, we have to remember that long-lasting experience of pain is usually a very individual process in which several conditions may work together in a unique combination. Treatment procedures must consider this variability by focusing on general mechanisms, as well as on individual conditions and deficits. FR treatment strongly depends on behavioral principles that rule the whole therapeutic process: Adequate information is necessary to overcome unhelpful beliefs; information has to be related to the patients' daily experiences and their mental capability to understand them. Pacing, goal-setting, graded exposure with exercise quotas and permanent feedback as well as contingent motivation characterize the training procedures. Training procedures must incorporate the patients' daily activities early on. The patients' efficacy expectations are the most potent determinants of change in the training process. Exacerbation of pain is not taken as a failure of the therapeutic concept, but as a challenge to self-management. However, the important principle in managing chronic low back pain is "treating patients rather than spines."     

A psychosocial risk factor--targeted intervention for the prevention of chronic pain and disability following whiplash injury

BACKGROUND AND PURPOSE: The objective of this study was to determine whether the addition of a psychosocial intervention improved return-to-work rates beyond those associated with participation in a functional restoration physical therapy intervention. Subjects who had sustained whiplash injuries participated in the Progressive Goal Attainment Program (PGAP), which is a 10-week psychosocial intervention program that aims to increase activity involvement and minimize psychological barriers to rehabilitation progress. SUBJECTS AND METHODS: A sample of 60 subjects enrolled in a functional restoration physical therapy intervention were used as a historical cohort comparison group. Subjects who received the functional restoration physical therapy intervention were compared with a sample of 70 subjects who received PGAP in addition to physical therapy. RESULTS: Participation in PGAP plus physical therapy resulted in a higher return-to-work rate (75%) than participation in physical therapy alone (50%). Differences between treatment conditions were most pronounced for the subgroup of subjects who had the largest number of psychosocial risk factors. DISCUSSION AND CONCLUSION: The findings suggest that a psychosocial risk reduction intervention can be an effective means of improving function and facilitating return to work in people who are at risk for prolonged pain-related disability.     

Effekte eines interdisziplinären Functional-restoration-Behandlungsprogramms mit kognitiv-behavioraler Therapie beim chronischen Rückenschmerz

Introduction

The efficacy of functional restoration programs for the treatment of chronic back pain is well documented. Nevertheless, there are only a few such centres in Germany and few trials have been conducted in German-speaking regions to demonstrate that implementing such programs in everyday clinical settings with large numbers of patients is just as effective as in a research setting. The present study examined whether the positive effects of such programs can also be observed in the clinically relevant context of a standardized day clinic treatment regimen.

Material and methods

A total of 681 back pain patients in 2 German cities were examined at 4 measurement points (before and immediately after the program, as well as 6 and 12 months after treatment) using a comprehensive questionnaire on perceived pain and symptoms of anxiety and depression, as well as the work situation.

Results

In both cities significant and long-term improvements in back pain, pain-related impairment and degree of chronification were observed, as well as a high return-to-work rate after treatment. Hence, the quality of such programs was also confirmed for a large patient population.     

Return to work of 87 severely impaired low back pain patients two years after a program of intensive functional restoration

Return to work is the main long-term objective of rehabilitation programs for patients with chronic low back pain (LBP).ObjectivesEvaluation of work status and number of sick leaves in 87 severely impaired LBP patients 2 years after a functional restoration program.Patients and methodsOpen prospective study. Population: 87 chronic LBP patients. Intervention: multidisciplinary functional restoration program. Ergonomic advice on the workplace was performed for 53 patients. Outcome: work status and number of sick leaves due to LBP.ResultsThe characteristics of the 26 patients lost to follow-up did not differ significantly from the rest of the population before the program. In the 61 remaining patients, 48 (78%) were at work at 2 years, 43 full-time and 22 at the same job. Nineteen worked in a different environment. Sick leaves were reduced by 60% compared to the 2 years prior to the program: 128 days (± 200 days) versus 329 days (± 179 days); p < 0.005.ConclusionSick leaves remained significantly reduced and the number of workers who were at work significantly increased at 2 years after an intensive program.     

Use of epidural corticosteroids in low back pain

OBJECTIVE: To review the literature regarding the safety and efficacy of epidural corticosteroid injections in the treatment of low back pain (LBP) of various etiologies. DATA SOURCES: A MEDLINE search (1966-February 1999) of English-language literature pertaining to the use of epidural corticosteroids in LBP was performed. Additional literature was obtained from reference lists of pertinent articles identified through the search. STUDY SELECTION AND DATA EXTRACTION: All articles were considered for the review. The clinical trials included are those that enrolled a larger patient population and were primarily controlled clinical trials. The authors selected pertinent information for further discussion. DATA SYNTHESIS: Nerve root compression and inflammation are thought to be factors contributing to LBP. Corticosteroids act to decrease inflammation and may be of benefit in relieving LBP, especially if administered directly to the affected area via the epidural route. However, data on the efficacy of various corticosteroid agents administered via this route are limited. In addition, there have been reports of significant adverse reactions, thought to be due primarily to the preservative components in the corticosteroid preparations. Therefore, the role of these agents in the therapy of LBP remains to be determined. CONCLUSIONS: Based on the studies reviewed, epidural corticosteroids may be an effective treatment for LBP. Their use is warranted in patients who have failed conservative therapy. Although they contain preservatives, it appears that these agents are relatively safe and do not cause significant neurotoxicities.     

Multimodale Schmerztherapie bei chronischen und chronifizierenden Rückenschmerzen

Objectives

In recent years, multimodal treatment programs for chronic lower back pain (LBP) have been successfully established, however, the availability of such programs is limited. The aim of this study was to determine the predictors of success in a multimodal pain treatment program.

Methods

The study included 408 patients with chronic lower back or neck pain, who were admitted to a multimodal treatment program over 3 weeks. The German pain questionnaire was used for initial evaluation. Pain intensity was measured via VAS at the beginning of treatment and 6 months after therapy. The items on the pain questionnaire were tested by studying variance and regression analyses for their ability to predict treatment outcome (change of pain intensity).

Results

The following items could predict treatment outcome: duration of current pain episode, application for pension, pain intensity and job satisfaction. Age, sex, pain location (neck pain versus LBP) and chronicity stage according to MPSS were not found to be significant predictors.

Conclusions

According to our data, patients suffering from LBP or neck pain for less than 3 years, regardless of the stage of chronicity, can be expected to have a good outcome (pain reduction) after admission to a multimodal treatment program. Job satisfaction is a further predictor of good outcome. Predictors for a bad treatment outcome are: pain intensity less than 30/100 (VAS), pain duration longer than 3 years, and application for pension.     

The Effects of the Nintendo Wii Exercise Program on Chronic Work-related Low Back Pain in Industrial Workers

[Purpose] The purpose of this study was to investigate the effects of a Nintendo Wii exercise program on chronic work-related LBP compared with stability exercise. [Methods] Twenty-four workers participated in this study. All of the participants were diagnosed with chronic LBP by a physician. Participants were randomly assigned to three groups: a control group (CG), lumbar stabilization exercise group (LSE), and Nintendo Wii exercise group (NWE). Participants were treated 3 times a week for 8 weeks. Each session lasted 30 minutes. [Results] The results demonstrated that exercise programs improved significantly physical functions related to LBP. In health-related QOL, the Nintendo Wii exercise program significantly improved both the mental and physical health composites, but other groups had significant improvement only in the physical health composite. [Conclusion] The Nintendo Wii exercise program could be a biopsychosocial intervention for work-related LBP in factory workers.Key words: Low back pain, Exercise, Nintendo Wii     

Changes in disability following physical therapy intervention for patients with low back pain: dependence on symptom duration

OBJECTIVES: To assess the impact of symptom duration on functional outcome, functional improvement, pain, and patient perception of recovery after a physical therapy (PT) program for low back pain (LBP) and to determine what variables are significantly associated with improved function. DESIGN: Retrospective case series. SETTING: Outpatient setting at a tertiary care facility. PARTICIPANTS: Patients (N=130) who were seen for PT between June 2003 and November 2004. INTERVENTIONS: A customized rehabilitation program was developed for each patient based on examination findings and included a combination of the following interventions: mobilization/manipulation, flexibility exercises, strengthening exercises, endurance exercises, massage techniques, and heat and cold modalities. MAIN OUTCOME MEASURES: Functional outcome, functional improvement, perceived pain, and perceived improvement scores in the CareConnections Outcomes System (formerly TAOS) database. RESULTS: Persons whose symptom duration was greater than 6 months had significantly less functional improvement than persons whose symptom duration was less than 1 month. The median percentage improvement score for perceived recovery was also significantly lower for the chronic group than for the acute group. There was no significant difference in the percentage decrease in pain among the acute, subacute, and chronic groups. In regression analyses, a model with age (P=.001), symptom duration (P=.002), and inclusion of strengthening, flexibility, and mobilization and manipulation exercises (P=.001) fit the data well and explained 55.5% of the variance in functional improvement score for all 3 groups combined. CONCLUSIONS: Patients showed improvements in function following a rehabilitation program for LBP. The functional improvement score is influenced by age, symptom duration, and inclusion of mobilization/manipulation and strengthening and flexibility exercises.     

Impact of functional restoration programs on fears, avoidance and beliefs in chronic low back pain patients]

OBJECTIVE: To assess the impact of functional restoration programs on fears, avoidance and beliefs in chronic low back pain. METHODS: Open prospective study in eight spine centers. Seventy patients enrolled in several restoration programs were evaluated before and at the end of the program. Variables recorded were pain (VAS), disability (Quebec back pain disability scale), handicap (VAS), anxiety and depression (HAD scale), and fears, avoidance and beliefs (FABQ). RESULTS: All variables recorded significantly improved at the end of the programs except for fears about professional activities (FABQ1) and lumbar mobility. Fears about physical activities (FABQ2) significantly decreased after these programs. Variations in FABQ1 and FABQ2 scores were not correlated with variations in scores of outcome measures assessing impairment, disability, and handicap. CONCLUSION: Functional restoration programs in their current form in France do not decrease fears and beliefs about professional activities in chronic low back pain patients. Adding psychosocial intervention at the work place to the functional restoration programs may lead to a better impact on fears about work thus reducing work loss.     

A prospective short-term study of chronic low back pain patients utilizing novel objective functional measurement

The present study utilized recently developed diagnostic tests that permit recognition of functional deficits in spine mobility, trunk strength, endurance, coordination, and dynamic lifting capacity. Changes in these tests were compared to changes in psychological functioning (e.g., self-report of pain) as well as to outcome criteria such as return-to-work and resolution of litigation. The study utilized these tests repeatedly during a new treatment approach to feed back objective information of the patient's functional capacity, not amenable to simple visual inspection, to both the patient and the surgeon. The program itself integrated a low back physical rehabilitation program with a multimodal pain management program and was guided by repeated functional capacity measurements. A total of 66 patients were evaluated. Results demonstrated significant improvement in physical function in these patients, which was also accompanied by changes in self-report of pain complaints. Moreover, an 82% return-to-work rate was achieved in this sample which was initially 92% unemployed. These results indicate that the physician dealing with chronic low back dysfunction can employ objective measures of functional capacity as an alternative to the sole reliance on pain patient self-report or structured tests, such as radiographic imaging, which merely document a universal, progressive degenerative process.     

Multimodal—was ist das überhaupt?

In chronic pain syndromes multimodal treatment has proved its efficacy. However, multimodal treatment does not mean randomly combining different interventions in a potpourri of methods. Multimodal treatment must closely follow a well-proved conceptual framework. Those concepts may be well illustrated by therapy of back pain. The most elaborate model for understanding the transition from acute to chronic pain is fear avoidance. Based on this model chronic pain status is understood as a learned consequence, which resulted from patients’ anxious avoidance of body movements. In these cases, treatment of a physical pathology is not the main aim of therapy but rather functional restoration. Those multimodal programs meanwhile have demonstrated their effectiveness. However, good results not only depend on recognition of imperative elements in therapy but also on adhering to essential principles (avoidance of negative anticipation, adequate information with assurance techniques, no training of avoidance, recognition of elements of fear therapy).     

Die Multimodale Schmerztherapie Dachau (MSD)

Background

Data on the efficacy of the Dachau multidisciplinary treatment program for chronic pain is presented. The treatment is administered in a primary care day clinic and the treatment period is 5 weeks plus 5 booster days 6 months later. The program is characterized by high treatment intensity (122.5 h over 5 weeks) and is aimed at patients where outpatient pain therapy proved to be insufficient. The treatment plan is applicable to different types of chronic pain and the main treatment objective is functional restoration.

Methods

Outcome criteria were pain intensity, disability, vitality, depression, catastrophizing, and employment status. The data was assessed at the beginning of treatment, after 5 weeks and 6 months after therapy. The patient population consisted of 189 chronic pain patients.

Results

All outcome criteria showed a significant and stable improvement over 6 months. Effect sizes demonstrated medium and high treatment effects. The back to work rate was 63% at 6 months follow-up.

Discussion

The Dachau multidisciplinary treatment for chronic pain achieved significant improvements which remained stable for 6 months after treatment.     

Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: a prospective study.

Low back pain (LBP) is a major problem of public health. Chronic pain is the most difficult to treat and the most expensive. The way patients cope with their pain may influence its outcome. AIM: To identify coping strategies of LBP patients, and their influence on LBP evolution. METHODS: Ninety nine patients were assessed just after an acute LBP episode and one year later. Assessment tools included medical and social reports, scales of anxiety, depression, quality of life, locus of control (LOC), social support and coping strategies. RESULTS: One year after the initial episode, 67% of patients have improved and 33% had a chronic pain. A principal components analysis showed that two main dimensions might be identified inside the outcome: functional and emotional non-adjustment. Functional non-adjustment was predicted by male gender, reduction of activity, and history of trauma over one year. Emotional non-adjustment was only predicted by trait-depression. Reactions to pain were structured in four factors: distraction-praying, helplessness-hopelessness, cognitive restructuration and perceived control. Two of these factors predicted adjustment one year later: distraction-praying had a direct effect on functional non-adjustment, and helplessness-hopelessness on emotional issue. CONCLUSIONS: Besides somatic factors, psychosocial predictors of LBP chronic evolution may be identified. Both aspects must be taken into account in order to prevent chronic pain. Perhaps cognitive-behavior therapy may help LBP patients to cope with pain in a better way.     

Physical activity and low back pain: A critical narrative review

BackgroundNon-specific low back pain (LBP) is the leading cause of years lived with disability worldwide. Physical activity is an integral part of LBP treatment.ObjectiveTo critically review available evidence regarding the efficacy of physical activity for people with LBP.MethodsUp to date critical narrative review of the efficacy of physical activity for the managment LBP. The process of article selection was unsystematic; articles were selected based on authors’ expertise, self-knowledge and reflective practice.ResultsTherapeutic physical activity for LBP includes a wide range of non-specific and specific activities. The efficacy of physical activity on pain and activity limitations has been widely assessed. In acute and subacute LBP, exercise did not reduce pain compared to no exercise. In chronic low back pain (CLBP), exercise reduced pain at the earliest follow-up compared with no exercise. In a recent systematic review, exercise improved function both at the end of treatment and in the long-term compared with usual care. Exercice also reduced work disability in the long-term. We were unable to establish a clear hierarchy between different exercise modalities. Multidisciplinary functional programs consistently improved pain and function in the short- and long-term compared with usual care and physiotherapy and improved the long-term likelihood of returning to work compared to non-multidisciplinary programs.ConclusionPhysical activity of all types is an effective treatment for CLBP.     

Spinal Manipulative Therapy for Acute Low Back Pain: A Clinical Perspective

Low back pain (LBP) is an extremely common cause of pain and disability. While many treatments for acute LBP exist, one of the most widely used, but also most controversial, is spinal manipulative therapy (SMT). This therapy includes both high-velocity manipulative techniques and low-velocity mobilization techniques. The literature regarding the use of SMT is often conflicting, which explains the difference in recommendations regarding SMT in international LBP guidelines. The lack of a clear tissue diagnosis in the majority of patients with LBP combined with the unknown mechanism of action of SMT adds to the difficulty for clinicians in providing SMT in a logical and effective manner. Despite these limitations, the existing literature does provide some assistance to clinicians on when to provide SMT and how to provide it in an optimal way. This review aims to summarize the key research literature investigating SMT in LBP in order to help clinicians make informed decisions about the use of SMT for their patients with acute LBP.KEYWORDS: Clinical Decision Making, Clinical Prediction Rules, Screening, Spinal ManipulationLow back pain (LBP) is the most prevalent musculoskeletal condition and a leading cause of disability¹. In developed countries such as the United States and Australia, LBP prevalence ranges from 26–80%, with 12–33% of people reporting LBP on any given day^2,3. In the US, back pain has been reported as the second most common reason for consulting a general practitioner⁴. LBP is extremely costly and places a great burden on the health system. A recent Australian health report listed back pain as the most expensive musculoskeletal health condition behind osteoarthritis⁵. Yet despite decades of research, we remain unsure about how best to classify the condition or how best to treat patients.Acute LBP is widely defined as pain lasting less than 6 weeks^6,7. While it is commonly believed that the majority of people with acute LBP recover with or without treatment within 4 to 6 weeks, recent evidence does not support this view^8,9. A recent stufy of nearly 1000 primary care patients receiving care at the discretion of their clinician, found that only 39% were fully recovered by 6 weeks. The results of this study, and others like it⁸, suggest that there is substantial scope for improving the outcome of acute LBP and that careful consideration of the types of treatment provided is necessary. While many treatments for acute LBP exist, one of the most widely used, but also most controversial, is spinal manipulative therapy (SMT). This term is applied to a group of treatments that includes both high-velocity manipulative techniques and low-velocity mobilization techniques.This review aims to summarize the key research literature investigating the use of SMT in acute LBP in order to help clinicians make informed decisions about the use of SMT for their patients. The following issues are covered:

• LBP guideline recommendations regarding SMT
• Screening for precautions/contraindications to SMT
• The efficacy of SMT
• Optimal delivery of SMT (determining level, technique, force, frequency, etc)
• Which patients benefit most from SMT
• Directions for future research

     

Training programs in stroke patients: literature review]

INTRODUCTION: An increased number of physical retraining programs are available for the rehabilitation of stroke patient; generally positive results are observed, but no consensus in methodology exists (program characteristics, intensity, duration, frequency, etc.). OBJECTIVE: To review the literature about training program characteristics for stroke patients and describe their efficacy, limits, and results. METHODS: A search of the Medline database revealed 97 references, including 53 clinical studies examining protocols of physical training and 15 meta-analyses and literature reviews of physical training. RESULTS: Three physical training protocols were found (walking, neuromuscular and 'force' training). Each training had specific effects: cardiovascular, functional, and muscular. DISCUSSION-CONCLUSION: To obtain positive cardiovascular effects and/or walking improvement, classical rehabilitation and physical training programs need to be associated for rehabilitation of the stroke patient.     

Midocalm in complex therapy of chronic low back pain syndrome

The aim of the study was to determine whether application of midocalm is appropriate in patients with chronic low back pain (LBP) from the point of view of quality of life (QL), efficacy and tolerance. The subjects were 50 patients with chronic LBP associated with spinal osteochondrosis, who underwent clinical examination and were questioned using four QL questionnaires: Health Assessment Questionnaire (HAQ), Womac osteoarthritis index Womac osteoarthritis index, Oswestry Low Back Pain Disability Questionnaire, and The 36-Item Short-Form Health Survey (SF-36). The subjects were divided into two groups. The 25 patients of Group I were administered nise in a dose of 100 mg twice a day during 10 days, the 25 patients of Group II--nise in a dose of 100 mg twice a day plus midocalm in a dose of 150 mg per day during the first two days and 450 mg per day from the third day through the tenth day. The study showed high efficacy of midocalm in complex therapy of patients with chronic LBP, as well as low rate of adverse reactions and high treatment tolerance. QL of the patients improved. Combining midocalm therapy with nise allows quicker positive effect in patients with chronic LBP and lowers need for long application of non-steroid antiinflammatory drugs.     

Comprehensive multidisciplinary treatment of chronic pain: a follow-up study of treated and non-treated groups

There are relatively few outcome studies of multidisciplinary chronic pain programs which have utilized no-treatment comparison groups. The present study compared a group of chronic pain patients (N = 42) treated in a comprehensive multidisciplinary pain program with a group of patients (N = 15) who were evaluated but not treated. Comparisons were made at evaluation and at a follow-up period averaging 11 months later. From evaluation to discharge, the treated group showed significant increases in physical functioning. From evaluation to long-term follow-up, both the treated and non-treated groups showed significant decreases in self-report pain ratings and interference with activities ratings. However, only the treated group showed a significant decrease in addictive medication use and increase in work functioning. The return-to-work rate for the treated group was 48% with an additional 28% of the patients being returned to vocational rehabilitation. None of the non-treated group returned to work or vocational rehabilitation. Results are discussed in terms of their support for the conclusion that comprehensive multidisciplinary pain programs produce marked subjective and functional changes.     

Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program

OBJECTIVE: To develop a clinical prediction rule to predict treatment response to a stabilization exercise program for patients with low back pain (LBP). DESIGN: A prospective, cohort study of patients with nonradicular LBP referred to physical therapy (PT). SETTING: Outpatient PT clinics. PARTICIPANTS: Fifty-four patients with nonradicular LBP. INTERVENTION: A standardized stabilization exercise program. MAIN OUTCOME MEASURE: Treatment response (success or failure) was categorized based on changes in the Oswestry Disability Questionnaire scores after 8 weeks. RESULTS: Eighteen subjects were categorized as treatment successes, 15 as treatment failures, and 21 as somewhat improved. After using regression analyses to determine the association between standardized examination variables and treatment response status, preliminary clinical prediction rules were developed for predicting success (positive likelihood ratio [LR], 4.0) and failure (negative LR, .18). The most important variables were age, straight-leg raise, prone instability test, aberrant motions, lumbar hypermobility, and fear-avoidance beliefs. CONCLUSIONS: It appears that the response to a stabilization exercise program in patients with LBP can be predicted from variables collected from the clinical examination. The prediction rules could be used to determine whether patients with LBP are likely to benefit from stabilization exercises.     

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.