Nonoperative treatments for sciatica: a pilot study for a randomized clinical trial

OBJECTIVES: To assess the feasibility of patient recruitment, the ability of patients and clinicians to comply with study protocols, and the use of data collection instruments to collect cost-effectiveness data, and to obtain variability estimates for sample-size calculations for a full-scale trial. STUDY DESIGN: Prospective, observer-blinded, pilot randomized clinical trial. SETTING: Primary contact chiropractic and medical clinics. PATIENTS: Ages 20 to 65 years, with low back-related radiating leg pain (sciatica). OUTCOME MEASURES: Self-report questionnaires were administered at baseline and 3 and 12 weeks after randomization. The measures included leg and back pain severity, frequency and bothersomeness of symptoms, leg/back disability, medication use, global improvement, satisfaction, and health care utilization. INTERVENTIONS: Medical care, chiropractic care, and epidural steroid injections. RESULTS: A total of 706 persons were screened by phone to determine initial eligibility. Of these, over 90% of those persons contacted did not meet the entrance criteria. The most common reason for disqualification was that the duration of the complaint was longer than 3 months. Twenty patients were randomized into the study. All 3 groups showed substantial improvements in the main patient-rated outcomes at the end of the 12-week intervention phase. For leg pain, back pain, frequency and bothersomeness of leg symptoms, and Roland-Morris disability score, the percent improvement varied from 50% to 84%, and the corresponding effect sizes ranged from 0.8 to 2.2. Bothersomeness of leg symptoms was the most responsive outcome associated with the largest magnitude of effect size. All within-group changes from baseline were statistically significant (P <.01). No between-group comparisons were planned or performed because of the insufficient sample size and high risk of committing type I and type II errors. CONCLUSIONS: Pilot studies such as these are important for the determination of the feasibility of conducting costly, larger scale trials. Recruitment for a full-scale study of sciatica of 2 to 12 weeks duration is not feasible, given the methods used in this pilot study. Our results do indicate, however, that there are substantial numbers of patients with sciatica more chronic in nature who would be interested in participating in a similar study. In addition, collaboration with a local health maintenance organization would likely facilitate clinician referrals and optimize the recruitment process. Patient and provider compliance was high in the pilot study, which indicates that most study protocols are feasible. Additionally, we were able to collect complete outcomes data, including those regarding health care use. A suggested modification by investigators and outside consultants has resulted in the replacement of the medication group with a minimal intervention control group (ie, self-care advice). As a result, a second pilot study of patients with sciatica of more than 4 weeks duration has been planned before a full-scale trial is attempted.     

Exploring Patient Satisfaction: A Secondary Analysis of a Randomized Clinical Trial of Spinal Manipulation,Home Exercise,and Medication for Acute and Subacute Neck Pain

Objective

The purpose of this study was to assess satisfaction with specific aspects of care for acute neck pain and explore the relationship between satisfaction with care, neck pain, and global satisfaction.

Methods

This study was a secondary analysis of patient satisfaction from a randomized trial of spinal manipulation therapy (SMT) delivered by doctors of chiropractic, home exercise and advice (HEA) delivered by exercise therapists, and medication (MED) prescribed by a medical doctors for acute/subacute neck pain. Differences in satisfaction with specific aspects of care were analyzed using a linear mixed model. The relationship between specific aspects of care and (1) change in neck pain (primary outcome of the randomized trial) and (2) global satisfaction were assessed using Pearson's correlation and multiple linear regression.

Results

Individuals receiving SMT or HEA were more satisfied with the information and general care received than MED group participants. Spinal manipulation therapy and HEA groups reported similar satisfaction with information provided during treatment; however, the SMT group was more satisfied with general care. Satisfaction with general care (r = − 0.75 to − 0.77; R² = 0.55-0.56) had a stronger relationship with global satisfaction compared with satisfaction with information provided (r = − 0.65 to 0.67; R² = 0.39-0.46). The relationship between satisfaction with care and neck pain was weak (r = 0.17-0.38; R² = 0.08-0.21).

Conclusions

Individuals with acute/subacute neck pain were more satisfied with specific aspects of care received during spinal manipulation therapy or home exercise interventions compared to receiving medication. The relationship between neck pain and satisfaction with care was weak.     

Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation.

OBJECTIVE: To compare needle acupuncture, medication (tenoxicam with ranitidine), and spinal manipulation for managing chronic (>13 weeks duration) spinal pain syndromes. DESIGN: Prospective, randomized, independently assessed preintervention and postintervention clinical pilot trial. SETTING: Specialized spinal pain syndrome out-patient unit at Townsville General Hospital, Queensland, Australia. SUBJECTS: Seventy-seven patients (without contraindication to manipulation or medication) were recruited. INTERVENTIONS: One of three separate, clearly defined intervention protocols: needle acupuncture, nonsteroidal anti-inflammatory medication, or chiropractic spinal manipulation. MAIN OUTCOME MEASURES: Main outcome measures were changes (4 weeks vs. initial visit) in the scores of the (1) Oswestry Back Pain Disability Index, (2) Neck Disability Index, and (3) three visual analogue scales of local pain intensity. RESULTS: Randomization was successful. After a median intervention period of 30 days, spinal manipulation was the only intervention that achieved statistically significant improvements (all expressed as percentages of the original scores) with (1) a reduction of 30.7% on the Oswestry scale, (2) an improvement of 25% on the neck disability index, and (3) reductions on the visual analogue scale of 50% for low back pain, 46% for upper back pain, and 33% for neck pain (all P<.001). Neither of the other interventions showed any significant improvement on any of the outcome measures. CONCLUSIONS: The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine.     

A feasibility study of chiropractic spinal manipulation versus sham spinal manipulation for chronic otitis media with effusion in children.

BACKGROUND: Pediatric otitis media with effusion is a common and costly condition. Although chiropractors have anecdotally claimed success in treating otitis media, there is little research to support their claims. OBJECTIVE: A pilot study was undertaken for the purpose of assessing the feasibility of conducting a full-scale randomized clinical trial investigating the efficacy of chiropractic spinal manipulative therapy (SMT) for children with chronic otitis media with effusion. METHODS: This study was a prospective, parallel-group, observer-blinded, randomized feasibility study. Twenty-two patients, ages 6 months to 6 years, received either active chiropractic SMT or placebo chiropractic SMT. Otoscopy and tympanometry were used to create a middle ear status profile, and daily diaries were collected. RESULTS: Five newspaper advertisements over 6 months generated 105 responses. Twenty patients subsequently qualified and were randomized into the study. Collection of tympanometric and otoscopic data proved to be challenging. Compliance with the treatment and evaluation protocols and daily diaries was excellent. There were no reports of serious side effects as a result of either the active or placebo chiropractic treatments. CONCLUSION: Recruitment for a randomized controlled trial is feasible and could be enhanced by medical collaboration. Patients and parents are able and willing to participate in a study comparing active SMT and placebo SMT. Parents were extremely compliant with the daily diaries, suggesting that similar quality-of-life and functional status measures can be successfully used in a larger trial. We found the objective outcomes assessment involving tympanometry and otoscopy extremely challenging and should be performed by experienced examiners in future studies.     

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.     

Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study

BACKGROUND: Minor side effects associated with chiropractic are common. However, little is known about their predictors or the effects of reactions on satisfaction and clinical outcomes. OBJECTIVE: The objectives of this study are to compare the relative effects of cervical spine manipulation and mobilization on adverse reactions and to estimate the effects of adverse reactions on satisfaction and clinical outcomes among patients with neck pain. METHODS: Neck pain patients were randomized to receive cervical spine manipulation or mobilization. At 2 weeks, subjects were queried about possible treatment-related adverse reactions and followed for 6 months with assessments for pain and disability at 2, 6, 13, and 26 weeks. Numerical rating scales and the Neck Disability Index were used to measure pain and disability. Perceived improvement and satisfaction with care were assessed at 4 weeks. RESULTS: Of 960 eligible patients, 336 enrolled and 280 responded to the adverse event questionnaire. Thirty percent of respondents reported at least 1 adverse symptom, most commonly increased pain and headache. Patients randomized to manipulation were more likely than those randomized to mobilization to report an adverse reaction (adjusted odds ratio = 1.44, 95% confidence interval = 0.85, 2.43). Subjects reporting adverse reactions were less satisfied with care and less likely to have clinically meaningful improvements in pain and disability. CONCLUSIONS: Adverse reactions are more likely to be reported following cervical spine manipulation than mobilization. Chiropractors may reduce iatrogenesis and increase satisfaction and perhaps clinical outcomes by mobilizing rather than manipulating their neck pain patients.     

Perceptions of Chiropractic Care Among Women With Migraine: A Qualitative Substudy Using a Grounded-Theory Framework

ObjectiveThe purpose of this study was to characterize expectations, attitudes, and experiences of individuals with migraine who were randomly assigned to receive chiropractic care delivered within a randomized controlled trial in a hospital-based integrative care center.MethodsThis qualitative substudy was conducted as a part of a 2-arm pilot pragmatic randomized controlled trial investigating a multimodal model of chiropractic care for women with episodic migraine (4-13 migraines per month). Women were randomly assigned to chiropractic care (10 sessions over 14 weeks) plus enhanced usual care vs enhanced usual care alone. Semistructured interviews were conducted at baseline and 14-week follow-up with 15 randomly selected participants from the 29 participants randomized to the chiropractic group. Qualitative analysis was performed by 2 independent reviewers using a constant comparative method of analysis for generating grounded theory.ResultsIntegrating baseline and follow-up interviews, 3 themes emerged: over the course of treatment with chiropractic care, participants became more aware of the role of musculoskeletal tension, pain, and posture in triggering migraine; participants revised their prior conceptions of chiropractic care beyond spinal manipulation; and participants viewed the chiropractor–patient relationship as an essential and valuable component to effectively managing their migraines.ConclusionIn this qualitative study, women with episodic migraine after receiving comprehensive chiropractic care described chiropractic as a multimodal intervention where they learned about musculoskeletal contributions to migraine, discovered new ways to affect their symptoms, and developed a collaborative patient–practitioner relationship. The results of this study provide insights into perceptions of chiropractic care among women with migraine and suggestions for future trials.     

Issues in planning a placebo-controlled trial of manual methods: results of a pilot study

OBJECTIVE: There are fundamental differences between the administration of medications and the application of manual procedures, such as those used by chiropractors. The objective of this study was to gather preliminary information on how to address these differences in the design of a multisite, randomized placebo-controlled trial of chiropractic care for women with chronic pelvic pain (CPP). DESIGN: Pilot study for a multisite, randomized, placebo-controlled clinical trial. SETTING: Three chiropractic research clinics in the midwest United States. SUBJECTS: Thirty-nine (39) women with CPP of at least 6 months' duration, diagnosed by board-certified gynecologists. INTERVENTIONS: The active intervention consisted of the chiropractic technique, lumbar spine flexion-distraction, combined with manual Trigger Point Therapy. The placebo intervention consisted of a sham chiropractic procedure performed with an instrument combined with effleurage (light massage). OUTCOME MEASURES: The primary outcome measure was the change in the Pain Disability Index (PDI) from baseline to the end of treatment (6 weeks), assessed by group and site. If the change score was in the same direction at all sites, the results were to be combined to estimate treatment effect size. RESULTS: Patient characteristics were similar to those of patients with CPP in other studies. Recruitment methods, particularly in respect to the eligibility criteria and screening protocols, would require modification in order to recruit an adequate sample for the planned randomized controlled trial. Clinicians followed standardized procedures with apparently minimal deviation, patients in both groups were satisfied with their care and blinding appeared to be successful. PDI change scores were not consistent across sites and so results were not combined and overall treatment effect sizes were not estimated. CONCLUSIONS: The technical and personnel resources required to achieve adequate standardization of procedures at multiple sites may make a placebo-controlled trial unfeasible, given our current lack of knowledge about the active agent in manual chiropractic procedures.     

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.     

Naprapathic manual therapy or evidence-based care for back and neck pain: a randomized, controlled trial

OBJECTIVES: To compare naprapathic manual therapy with evidence-based care for back or neck pain regarding pain, disability, and perceived recovery. Naprapathy that is common in the Nordic countries and in some states in the United States is characterized by manual manipulations with a focus on soft and connective tissues, aiming to decrease pain and disability in the musculoskeletal system. METHODS: Four hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks, recruited at 2 large public companies in Sweden in 2005, were included in this randomized controlled trial. The 2 interventions were naprapathy, including spinal manipulation/mobilization, massage, and stretching (Index Group) and support and advice to stay active and how to cope with pain, according to the best scientific evidence available, provided by a physician (Control Group). Pain, disability, and perceived recovery were measured by questionnaires at baseline and after 3, 7, and 12 weeks. RESULTS: At 7-week and 12-week follow-ups, statistically significant differences between the groups were found in all outcomes favoring the Index Group. At 12-week follow-up, a higher proportion in the naprapathy group had improved regarding pain [risk difference (RD)=27%, 95% confidence interval (CI): 17-37], disability (RD=18%, 95% CI: 7-28), and perceived recovery (RD=44%, 95% CI: 35-53). Separate analysis of neck pain and back pain patients showed similar results. DISCUSSION: This trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.     

Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?

This synopsis provides an overview of the benign and serious risks associated with chiropractic care for subjects with neck or low-back pain. Most adverse events associated with spinal manipulation are benign and self-limiting. The incidence of severe complications following chiropractic care and manipulation is extremely low. The best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.     

The effect of manipulation on pain and range of motion in the cervical spine: a pilot study.

OBJECTIVE: The objective of this pilot study was to determine the number of patients required for a randomized controlled trial of spinal manipulation for neck pain and to determine if there is a relationship between pain and range of motion (ROM) in the cervical spine. DESIGN: Fifty consecutive outpatients were studied in a pretest-posttest design without long-term follow-up. SETTING: The patients were taken from a primary cae outpatient teaching clinic specializing in back pain. PATIENTS: All patients had unilateral neck pain without neurological deficit. The patients were selected as a consecutive sample. INTERVENTION: All the patients received a single cervical manipulation. MAIN OUTCOME MEASURES: Prior to and immediately after the treatment, cervical ROM was recorded on a goniometer, and pain intensity was rated on the 101-point numerical rating scale. RESULTS: The results show an increase in all planes of post-treatment ROM and a decrease in post-treatment pain scores. Partial correlations between post-treatment ROM and 101-point numerical rating scale scores reveal a significant relationship between a decrease in pain and an increase in cervical rotation (p < .005). CONCLUSIONS: Since the results of this pilot study are not controlled, they cannot be seen as proof supporting the clinical efficacy of manipulation for neck pain. However, the correlation between an increase in cervical rotation and a decrease in pain is clinically instructive. In addition, the outcome measures used in this study could prove to be useful in the design of future randomized controlled trials of cervical manipulation.     

Chiropractic treatment of postsurgical neck syndrome with mechanical force, manually assisted short-lever spinal adjustments

OBJECTIVE: To describe a case of postsurgical neck pain, after multiple spinal surgeries, that was successfully treated by chiropractic intervention with instrumental adjustment of the cervical spine. CLINICAL FEATURES: A 35-year-old woman had chronic neck pain for over 5 years after two separate surgeries of the cervical spine: a diskectomy at C3/4 and a fusion at C5/6. Surgeries were performed 6 months apart in an attempt to resolve persistent neck pain and spasm of the cervical musculature. Neither surgery was effective in relieving the patient's pain. Five years after the second surgery, a third surgery was recommended by the patient's physicians to alleviate the chronic pain. The patient sought chiropractic evaluation of her condition to avoid further surgical intervention. INTERVENTION AND OUTCOME: The patient was treated with conservative instrumental chiropractic manipulation, consisting of mechanical force, manually assisted short-lever spinal adjustments rendered with an Activator Adjusting Instrument (AAI) II. She comfortably tolerated the treatment and responded favorably to this therapy. All chronic symptoms had resolved within 30 days of instituting the chiropractic instrumental adjustments with an AAI. More interestingly, longitudinal examination over the next 2 years showed that the patient experienced no residual effects or further recurrences of her previous chronic problem after her initial course of chiropractic care. CONCLUSION: Chiropractic treatment of postsurgical neck syndrome may be effectively treated, in certain cases, by mechanical force, manually assisted adjusting procedures with an AAI. The use of instrumental adjustment methodology may provide chiropractic physicians with an effective alternative to manual manipulation in those cases in which the patient's surgical history or presenting symptoms make forceful manipulation of the spine, particularly performed at end range, inappropriate. This approach may be contemplated by physicians faced with managing this type of condition. Further study should be made in this regard, in an academic research setting, to determine the safest and most effective approaches to managing postsurgical patients in a chiropractic setting.     

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 patients in Denmark: a short description of basic characteristics

BACKGROUND: The vast majority of information on chiropractic and chiropractic patients originates from English-speaking countries. Lately, however, reports describing chiropractic patients and practice in other European countries have emerged. OBJECTIVE: To describe basic characteristics of Danish chiropractic patients. DESIGN: Survey questionnaire. All chiropractic clinics in Denmark were asked to collect information on new patients during 1 randomly assigned week in 1999. SETTING: Private chiropractic practice and a nonprofit research institution. OUTCOME MEASURES: Age and sex, location and duration of chief complaint, pain intensity, limitation of activities of daily living from chief complaint, and mode of referral. RESULTS: Eighty-eight percent of all chiropractic clinics in Denmark participated in the study. Out of 2020 patients from the participating clinics, 1897 (94%) filled out a self-administered questionnaire. The mean age of participants was 42 years, and slightly more women than men returned the questionnaire. By far the most frequent area of complaint was pain related to the lower back (50%) followed by pain related to the neck (15%). The majority of patients had complaints in the subacute or chronic category (duration 1-6 months). Patients with sciatica had significantly higher pain scores and limitation in activities of daily living (ADL) than any other group, whereas patients with neck pain tended to score lower. Patients in the subacute category had the highest pain scores and limitation in ADL. For complaints lasting more than 6 months, limitation in ADL remained constant at a low level. Twenty-three percent of all patients were referred to the chiropractor, most frequently by a general medical practitioner. More than half of all patients had previously been treated for the same or similar problems, most frequently by a chiropractor. Fifty-one percent had also received chiropractic care for other types of problems. CONCLUSIONS: Most Danish chiropractic patients complain of pain related to the low back or neck of between 1 and 6 months' duration. This study confirms that chiropractic is fairly well integrated in the Danish primary health care system. There are differences between the chiropractic patient population in Denmark compared with that of Sweden and Holland.     

Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study

Objective

The purpose of this preliminary study was to assess whether the dual somatosensory evoked potential (SEP) technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck or upper extremity pain and, if so, whether changes are associated with changes in pain scores.

Predictors of participation in primary care group-format back pain self-care interventions

OBJECTIVE: The goal of this study was to explain how primary care back pain patients who volunteer for a group-format self-care intervention differ from nonvolunteers. This is relevant to the generalizability of studies that rely on volunteers as well as the characteristics of patients who do not seek out self-care interventions. SETTING: This study was conducted at a large health maintenance organization in western Washington state. PATIENTS: "Volunteers" (n = 481) were primary care back pain patients participating in randomized trials of a self-management intervention who were recruited through passive nonintensive means (a mailed invitation). "Nonvolunteers" (n = 967) consisted of a representative sample of consecutive back pain patients. We compared the baseline characteristics of these two groups. RESULTS: The relatively small percentage (8%) of primary care back pain patients who volunteered for, and ultimately participated in, group self-management classes tended to be white, older, better educated, and more likely to be retired than nonvolunteers. The two groups did not differ significantly on most clinical measures, including pain intensity and persistence. Patients experiencing the highest (and lowest) levels of pain-related activity interference were less likely to volunteer than those with moderate activity limitations, however. CONCLUSIONS: Those individuals volunteering to participate in a group-format self-care intervention in a primary care setting differed from nonvolunteers primarily on demographic measures as opposed to clinical measures. Back pain patients experiencing the highest levels of activity limitations were somewhat less likely to participate than those with moderate activity limitations. Recruitment for effective self-care interventions is an important issue in determining their impact on a population basis.     

Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial.

The revised Oswestry Low Back Pain Questionnaire (ROLBPQ) and Roland-Morris Activity Scale (RMAS) were compared in a randomized controlled trial of chiropractic manipulation, stroking massage, corset and transcutaneous muscular stimulation (TMS). This trial employed specific inclusion and exclusion criteria, including nonspecific low back pain for a duration of 3 wk to 6 months and ages between 18 and 55. We had the opportunity to ask 85 patients to answer the questionnaires. Sixty-three patients, who completed the initial and final evaluations, were used for data analysis. Both ROLBPQ and RMAS showed good internal consistency with alpha coefficients ranging from .77 to .93. Both instruments showed a significant difference between the chiropractic manipulation and massage groups (p less than .05). RMAS was able to further show significant differences between the chiropractic manipulation and TMS groups, and between the corset and massage groups, but the ROLBPQ failed to do so. RMAS also showed that chiropractic manipulation had a better but nonsignificant result than corset, possibly due to insufficient sample size and/or duration of treatment. We conclude that both instruments are reliable for measuring low back pain disability, and chiropractic manipulation has a superior short-term benefit when compared to stroking massage and TMS in subacute low back pain patients. In addition, it appears that RMAS is preferable in a clinical trial situation for subacute low back pain because it is more sensitive than ROLBPQ to detect changes.     

Patient satisfaction,characteristics, radiology,and complications associated with attending a specialized government-funded multidisciplinary spinal pain unit

OBJECTIVE: To prospectively document the satisfaction of a random sample of patients attending a specialized multidisciplinary spinal pain unit in the Australian public health care system and to collect associated data on patient characteristics, radiological findings, treatment modalities used, and any significant complications.Design and setting Spinal pain syndrome patients attended the specialized Multidisciplinary Spinal Pain Unit at Townsville General Hospital and the Kirwan Community Health Centre (Queensland, Australia) for diagnosis and management (ie, chiropractic spinal manipulation, medication, or needle acupuncture). A patient satisfaction questionnaire was sent to a random sample of patients in this Queensland Government funded service that was approved by the health authority's Ethics Committee. RESULTS: A total of 1775 new patients (949 men, 826 women; aged 10 to 91 years; average age = 43 years) visited the unit. Medical referral accounted for 40% of patients, chiropractic for 2%, osteopathy for 1%, and other referrals for 0.7%; 40.3% were self-referred and 16% were specifically referred for a medicolegal consultation and examination following work-related or motor vehicle accident injuries. Thirty-nine patients (2.2%) were found to have acute pain (< 28 days). Of 941 patients who could accurately recall when symptoms first began, 69 (7.3%) presented with subacute pain (4 to 12 weeks duration), and 872 (92.7%) presented with chronic spinal pain syndrome (>12 weeks duration). Following extensive investigations, 1474 patients (83%) had radiologically identifiable abnormalities, including osseous or soft tissue anomalies. There was only 1 significant complication (pneumothorax) out of 7831 acupuncture treatment sessions, representing 0.01% of patients and 0.006% of a total of 16,936 examinations and treatments administered at the unit. The patient satisfaction questionnaire resulted in an extremely high satisfaction score. CONCLUSION: A public hospital or community health center based specialized spinal pain syndrome unit is useful for referring clinicians who wish to obtain a further opinion for challenging spinal pain syndrome patients in the lower socioeconomic group that cannot afford private health care.     

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.