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.

Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Risk of Adverse Drug Events

Objectives

Mortality rates due to adverse drug events (ADEs) are escalating in the United States. Analgesics are among the drug classes most often associated with occurrence of an ADE. Utilization of nonpharmacologic chiropractic services for treatment of low back pain could lead to reduced risk of an ADE. The objective of this investigation was to evaluate the association between utilization of chiropractic services and likelihood of an ADE.

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative

Objective

The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

Comparing the Recruitment of Research Participants With Chronic Low Back Pain Using Amazon Mechanical Turk With the Recruitment of Patients From Chiropractic Clinics: A Quasi-Experimental Study

ObjectiveThe purpose of this study was to compare the crowdsourcing platform Amazon Mechanical Turk (MTurk) with in-person recruitment and web-based surveys as a method to (1) recruit study participants and (2) obtain low-cost data quickly from chiropractic patients with chronic low back pain in the United States.MethodsIn this 2-arm quasi-experimental study, we used in-person clinical sampling and web-based surveys from a separate study (RAND sample, n = 1677, data collected October 2016 to January 2017) compared with MTurk (n = 310, data collected November 2016) as a sampling and data collection tool. We gathered patient-reported health outcomes and other characteristics of adults with chronic low back pain receiving chiropractic care. Parametric and nonparametric tests were run. We assessed statistical and practical differences based on P values and effect sizes, respectively.ResultsCompared with the RAND sample, the MTurk sample was statistically significantly younger (mean age 35.4 years, SD 9.7 vs 48.9, SD 14.8), made less money (24% vs 17% reported less than $30,000 annual income), and reported worst mental health than the RAND sample. Other differences were that the MTurk sample had more men (37% vs 29%), fewer White patients (87% vs 92%), more Hispanic patients (9% vs 5%), fewer people with a college degree (59% vs 68%), and patients were more likely to be working full time (62% vs 58%). The MTurk sample was more likely to have chronic low back pain (78% vs 66%) that differed in pain frequency and duration. The MTurk sample had less disability and better global health scores. In terms of efficiency, the surveys cost $2.50 per participant in incentives for the MTurk sample. Survey development took 2 weeks and data collection took 1 month.ConclusionOur results suggest that there may be differences between crowdsourcing and a clinic-based sample. These differences range from small to medium on demographics and self-reported health. The low incentive costs and rapid data collection of MTurk makes it an economically viable method of collecting data from chiropractic patients with low back pain. Further research is needed to explore the utility of MTurk for recruiting clinical samples, such as comparisons to nationally representative samples.     

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.

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.     

Correlation of Body Composition and Low Back Pain Severity in a Cross-Section of US Veterans

Objective

Back pain is more prevalent in the obese, but whether back pain severity is directly correlated to obesity in veterans is unknown. We sought to determine if there was a correlation between body composition and low back pain severity in a sample of veterans. The hypothesis was that veterans with higher body mass index values would report higher low back pain severity scores.

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.     

A Pilot Randomized Controlled Trial of Flexion-Distraction Dosage for Chiropractic Treatment of Lumbar Spinal Stenosis

Objective

The purpose of this pilot clinical trial was to assess the feasibility of recruiting older adults with lumbar spinal stenosis (LSS) into a clinical trial that used different dosages of flexion-distraction manipulation.

Methods

This randomized controlled trial used a 4-group design. Three groups consisted of chiropractic flexion-distraction manipulation applied at different dosages (8, 12, or 18 treatments). The fourth group was given 8 treatments of placebo care. Feasibility measures included recruitment goals, adherence to various treatment schedules, credibility of the placebo treatment, and rates of adverse events. The primary outcome measure was the Swiss Spinal Stenosis Questionnaire, a validated self-report of LSS symptom severity and physical function.

Results

The recruitment and adherence goals of the study were met with a total of 60 subjects randomized (n = 15 per group) and most subjects attending at least 75% of their scheduled visits. No adverse events were reported by any of the subjects in the trial. Our placebo treatment did not appear to be credible; most subjects correctly guessed that they were receiving a placebo treatment. Between-group effect size estimates were small, indicating larger samples are needed for future studies.

Conclusion

This pilot study showed that it is feasible to recruit patients with LSS and that most subjects will adhere to a 6-week treatment schedule. The information gained from this trial will be useful to inform the design of larger trials.     

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.     

The influence of a chiropractic manipulation on lumbar kinematics and electromyography during simple and complex tasks: a case study

OBJECTIVE: To investigate whether a more sophisticated and detailed analysis of both simple and complex tasks may yield more information regarding the short-term influence of an adjustment on spine biomechanics. METHODS: The study used a single-subject, before-after design. Three-dimensional spine kinematics and trunk muscle electromyography were assessed during a variety of tasks performed by a professional golfer exhibiting non-specific, chronic, low back pain. The patient received a right-to-left and left-to-right spinous pull adjustment. RESULTS: After the adjustment, changes were seen in all 3 axes of motion during a golf swing, with concomitant muscle responses. In addition, changes in the off axes of motion were seen during simple movement tasks. CONCLUSIONS: A more detailed spine kinematic analysis, specifically analysis of motion in the nonprincipled axes, yielded more information regarding the short-term influence of an adjustment on lumbar spine motion and muscle function.     

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process

Objective

The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities.

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.

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.     

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations

ObjectiveThe purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use.MethodsA systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists.ResultsOf the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus–level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings.ConclusionThe absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.     

The DonTigny Low Back Pain Management Program

Abstract

A guide for understanding, relief and prevention of low back pain caused by dysfunction, injury or instability of the sacroiliac joints is presented. This article is intended to be used as an educational tool to enhance patient understanding and compliance for successful results.     

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.