Treating Chronic Back Pain With Chiropractic

Low back pain is a very common condition, and one that is very expensive for our health care system. Experts estimate that chronic back pain costs the US about $100 billion each year in direct and indirect costs. As the authors of a new study write:

“One factor explaining these enormous costs is the high rate of recurrence and chronic disability related to low-back disorders…It has been suggested that only 10% of LBP patients generate more than 80% of the total costs related to LBP.”

Because of the enormous costs of treating chronic back pain, prevention is an important goal. This current study set out to examine the role of chiropractic in treating chronic low back pain. The authors studied 30 patients who had back pain for at least six months. All patients were subjected to a one-month control period that consisted of no treatment. This was included so that the researchers could observe the natural course of the back pain symptoms.

After this baseline period, half of the patients (Group 1) received intensive chiropractic treatment consisting of 12 treatments in one month, then no treatments for nine months. The other half of the patients (Group 2) received the same intensive treatment, but also received maintenance chiropractic treatments every 3 weeks for nine months. At the end of the nine-month period, both groups were again examined.

After analyzing the results, the authors found the following:

  • Pain levels were reduced in both groups of patients. The intensive month of chiropractic adjustments reduced pain, even without follow-up care.
  • Disability levels, however, showed a different response. For the patients with no continuing treatment, the disability levels returned to their pretreatment levels on the Oswestry. The Group 2 patients – who received maintenance care – continued to see improvement in disability scores over the whole nine months.

The following graph illustrates the differences between the two groups on disability levels:

Chronic pain and chiropractic

The authors conclude:

“This study appears to confirm previous reports showing that LBP and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment. Maintenance chiropractic care involving spinal manipulation combined with other treatment modalities (exercises, pain management program) should be investigated. Such combined interventions may have a critical influence on pain, disability, and return to work.”

Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. Journal of Manipulative and Physiological Therapeutics 2004;27:509-514.

Treating Chronic Back Pain With Chiropractic

Low back pain is a very common condition, and one that is very expensive for our health care system. Experts estimate that chronic back pain costs the US about $100 billion each year in direct and indirect costs. As the authors of a new study write:

“One factor explaining these enormous costs is the high rate of recurrence and chronic disability related to low-back disorders…It has been suggested that only 10% of LBP patients generate more than 80% of the total costs related to LBP.”

Because of the enormous costs of treating chronic back pain, prevention is an important goal. This current study set out to examine the role of chiropractic in treating chronic low back pain. The authors studied 30 patients who had back pain for at least six months. All patients were subjected to a one-month control period that consisted of no treatment. This was included so that the researchers could observe the natural course of the back pain symptoms.

After this baseline period, half of the patients (Group 1) received intensive chiropractic treatment consisting of 12 treatments in one month, then no treatments for nine months. The other half of the patients (Group 2) received the same intensive treatment, but also received maintenance chiropractic treatments every 3 weeks for nine months. At the end of the nine-month period, both groups were again examined.

After analyzing the results, the authors found the following:

  • Pain levels were reduced in both groups of patients. The intensive month of chiropractic adjustments reduced pain, even without follow-up care.
  • Disability levels, however, showed a different response. For the patients with no continuing treatment, the disability levels returned to their pretreatment levels on the Oswestry. The Group 2 patients – who received maintenance care – continued to see improvement in disability scores over the whole nine months.

The following graph illustrates the differences between the two groups on disability levels:

Chronic pain and chiropractic

The authors conclude:

“This study appears to confirm previous reports showing that LBP and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment. Maintenance chiropractic care involving spinal manipulation combined with other treatment modalities (exercises, pain management program) should be investigated. Such combined interventions may have a critical influence on pain, disability, and return to work.”

Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. Journal of Manipulative and Physiological Therapeutics 2004;27:509-514.

Treating Chronic Back Pain With Chiropractic

Low back pain is a very common condition, and one that is very expensive for our health care system. Experts estimate that chronic back pain costs the US about $100 billion each year in direct and indirect costs. As the authors of a new study write:

“One factor explaining these enormous costs is the high rate of recurrence and chronic disability related to low-back disorders…It has been suggested that only 10% of LBP patients generate more than 80% of the total costs related to LBP.”

Because of the enormous costs of treating chronic back pain, prevention is an important goal. This current study set out to examine the role of chiropractic in treating chronic low back pain. The authors studied 30 patients who had back pain for at least six months. All patients were subjected to a one-month control period that consisted of no treatment. This was included so that the researchers could observe the natural course of the back pain symptoms.

After this baseline period, half of the patients (Group 1) received intensive chiropractic treatment consisting of 12 treatments in one month, then no treatments for nine months. The other half of the patients (Group 2) received the same intensive treatment, but also received maintenance chiropractic treatments every 3 weeks for nine months. At the end of the nine-month period, both groups were again examined.

After analyzing the results, the authors found the following:

  • Pain levels were reduced in both groups of patients. The intensive month of chiropractic adjustments reduced pain, even without follow-up care.
  • Disability levels, however, showed a different response. For the patients with no continuing treatment, the disability levels returned to their pretreatment levels on the Oswestry. The Group 2 patients – who received maintenance care – continued to see improvement in disability scores over the whole nine months.

The following graph illustrates the differences between the two groups on disability levels:

Chronic pain and chiropractic

The authors conclude:

“This study appears to confirm previous reports showing that LBP and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment. Maintenance chiropractic care involving spinal manipulation combined with other treatment modalities (exercises, pain management program) should be investigated. Such combined interventions may have a critical influence on pain, disability, and return to work.”

Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. Journal of Manipulative and Physiological Therapeutics 2004;27:509-514.

Treating Chronic Back Pain With Chiropractic

Low back pain is a very common condition, and one that is very expensive for our health care system. Experts estimate that chronic back pain costs the US about $100 billion each year in direct and indirect costs. As the authors of a new study write:

“One factor explaining these enormous costs is the high rate of recurrence and chronic disability related to low-back disorders…It has been suggested that only 10% of LBP patients generate more than 80% of the total costs related to LBP.”

Because of the enormous costs of treating chronic back pain, prevention is an important goal. This current study set out to examine the role of chiropractic in treating chronic low back pain. The authors studied 30 patients who had back pain for at least six months. All patients were subjected to a one-month control period that consisted of no treatment. This was included so that the researchers could observe the natural course of the back pain symptoms.

After this baseline period, half of the patients (Group 1) received intensive chiropractic treatment consisting of 12 treatments in one month, then no treatments for nine months. The other half of the patients (Group 2) received the same intensive treatment, but also received maintenance chiropractic treatments every 3 weeks for nine months. At the end of the nine-month period, both groups were again examined.

After analyzing the results, the authors found the following:

  • Pain levels were reduced in both groups of patients. The intensive month of chiropractic adjustments reduced pain, even without follow-up care.
  • Disability levels, however, showed a different response. For the patients with no continuing treatment, the disability levels returned to their pretreatment levels on the Oswestry. The Group 2 patients – who received maintenance care – continued to see improvement in disability scores over the whole nine months.

The following graph illustrates the differences between the two groups on disability levels:

Chronic pain and chiropractic

The authors conclude:

“This study appears to confirm previous reports showing that LBP and disability scores are reduced after spinal manipulation. It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment. Maintenance chiropractic care involving spinal manipulation combined with other treatment modalities (exercises, pain management program) should be investigated. Such combined interventions may have a critical influence on pain, disability, and return to work.”

Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. Journal of Manipulative and Physiological Therapeutics 2004;27:509-514.

Predicting Outcomes in Low Back Pain Patients

Low back pain is a common problem seen in clinical practice, and one that can be difficult to treat. One patient may have an acute case of back pain that resolves on its own in a few days, while the next may suffer for years with chronic pain.

Being able to predict which patients are the best candidates for chiropractic would be useful for optimizing care and resources. A new study looks at how effective the Bournemouth Questionnaire (BQ), a new 7-item questionnaire, is as a tool for measuring outcomes during the treatment of lower back pain when compared with the Oswestry Questionnaire, a well-known standard tool.

The study was conducted by 7 chiropractors and an experienced researcher as part of a larger multi-center, multi-clinic study on low back pain (LBP). Each chiropractor studied 10 consecutive patients with low back pain, with the current problem present for a minimum of 14 days. The patient could not have received treatment for the last 6 months prior to entering the study.

The Oswestry and Bournemouth Questionnaires were conducted at the first treatment, at the fourth treatment (or before, if treatment was concluded), at 3 months, and at 12 months. At the 12-month follow up, additional assessment questions were given to discern the total number of days with LBP and total number of days off from work during the past year due to LBP.

Only 4 of the 7 items on the BQ accurately predicted specific outcomes. The following items on the BQ accurately predicted outcomes:

Question 2: Over the past few days, how much has your LBP interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?

Question 3: Over the past few days, how much has your LBP interfered with your ability to take part in recreational, social and family activities?

Question 6: How have you felt that your work (both inside and outside the home) these last few days has affected (or would affect) your LBP? (Patients with a low score on this question were unlikely to take sick leave during the next year.)

Question 7: Over the past few days, how much have you been able to control (reduce/help) your LBP on your own? (Those who do not have control over their pain are likely to have reoccurrence of LBP within the next year.)

The BQ is able to predict fairly accurately which patients will (or will not) take more than 30 days of sick leave and which ones will (or will not) not report more than 30 days of disability during the next 12 months, based on three of the items noted above: questions 2, 3, and 7. Three of the items in the BQ were of little value in predicting outcomes: pain, anxiety and depression.

Daily activities and own pain control were two of the highest predictors of patient outcomes.

Based on a comparison of results, and predictive accuracy, the study authors conclude that the shorter Bournemouth Questionnaire is not as good than the Oswestry questionnaire (the tool considered to be the “gold standard”) for predicting patient outcomes a year after the beginning of chiropractic treatment. Two items on the BQ questionnaire (anxiety and depression) were found to be irrelevant in predicting patient outcomes. There was also poor agreement between the two questionnaires, especially in patient populations experiencing greater pain, which makes the BQ relatively unreliable during baseline assessment and at later intervals if pain has reoccurred.

The authors found that:

“…by asking up to 3 simple but relevant questions from the BQ, it was possible to predict outcome already in approximately 65% of chiropractic patients with persistent LBP. If these questions are asked again at the fourth visit and the mean value calculated for these…this percentage will increase to approximately 70%.”

Larsen K, Leboeuf-Yde C. The Bournemouth Questionnaire: can it be used to monitor and predict treatment outcome in chiropractic patients with persistent low back pain? Journal of Manipulative and Physiological Therapeutics 2005;28:219-227.

Chiropractic Treatment of Back Pain

Back pain is a common problem seen in daily practice, and a great deal has been written about it. Unfortunately, there is little consensus about types of treatment are most effective. A new study indicates that a multi-disciplinary approach—one that combines medical care, exercise, and chiropractic—may be the best way to reduce long-term disability in patients with low back pain.

This large study from the UK examined 1,334 patients with back pain who sought treatment at 181 general practices throughout the country. The patients were divided into randomized treatment groups: “Of six groups of participants, one received only best care in general practice. The other five received best care plus an intervention—exercise, manipulation in private or NHS premises, or manipulation in private or NHS premises followed by exercise.”

The study participants were given a wide variety of surveys to complete, and they were retested three months after the beginning of treatment, and again at 12 months.

Here’s what the analysis of the data found:

  • All of the patients improved from baseline. For instance, the Roland Disability score at the beginning of the study was 9 for all groups. The following graph illustrates the gains experienced by all of the study subjects:
  • Pain levels in the “medical treatment plus manipulation” dropped from about 61 before treatment (on a scale of 0 to 100) to 41 after treatment—a significant decrease.

The authors conclude with following key findings:

  • “…Exercise improves back function by a small, but statistically significant, margin at three months; it also achieves sustained reductions in disability and pain, and in adverse beliefs about back pain.”
  • “Manipulation improves back function by a small to moderate margin at three months and a small but significant margin at 12 months; it also achieves sustained improvements in disability and pain, adverse back beliefs, and general physical health.”
  • “Combined treatment improves back function by a moderate margin at three months and a small but significant margin at 12 months; generally it achieves little more than manipulation, except for much greater improvements in beliefs about back pain and fear avoidance.”

This study illustrates that the most effective treatment for back pain is one that involves medical and chiropractic professionals. When medical care is combined with an exercise program and spinal manipulation, the authors found a reduction in disability and an improvement in general health that lasted at least 12 months after initial treatment.

UK Beam Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 2004;329;1377.

Chiropractic, Back Pain, Patient Satisfaction

This study conducted in the United Kingdom looked at factors that influence patient satisfaction after chiropractic treatment. The study looked at 965 new patients seeking chiropractic treatment for lower back pain who received a questionnaire at the time of initial treatment, and again six weeks later.

Members of the Great Britain Chiropractic Association were sent study packets and follow-up questionnaires, and asked to enroll 10 eligible clients from their practice. Eligible study participants were literate, new to chiropractic, seeking treatment for lower back pain, and had no recent back surgery or serious underlying pathology. The average age for participants was 45-47 years old, with equal rates of both genders represented. Most were employed.

During the study, the Bournemouth Questionnaire was given to subjects at their first visit to the chiropractor. The Bournemouth asked each subject to self-report using an 11-point scale on the following factors:

  • Level of pain
  • Degree of anxiety
  • Effect on normal activity
  • Effect of work on complaint
  • Degree of depression
  • Ability to control (reduce) pain
  • Effect on lifestyle (social life)

The following two factors were added for assessment at 6 weeks, using a 7-point scale (-3 was the greatest deterioration and +3 was the greatest improvement):

  • Satisfaction with care
  • Overall improvement or deterioration over the care period

A correlation between the first 7 factors noted above, and satisfaction with treatment was present, but weak at the six-week follow up. Reduced pain level, reduced effect of work on pain, and the improved ability to control pain were the factors most strongly related to satisfaction and outcomes at 6 weeks. These 3, plus activity, were highly significant predictors of patient satisfaction with care.

A perception of overall improvement was highly related to improved treatment satisfaction scores (60%).

Overall improvement was most highly related (60%) to patient satisfaction with chiropractic care, with improved physical functioning (reduced pain, improved ability to work, and the ability to control pain) the next highest correlation (27%).

The study authors note that the ability of a chiropractor to reorient pain experience into a more positive framework may play a role in higher satisfaction ratings, and this component of treatment needs further study.
Physical functionality (increased activity/decreased pain) correlated more closely to satisfaction ratings for treatment than affective (emotional) improvements such as reducing anxiety or depression. But other unknown factors, which were unable to be measured with the tools in this study, also appeared to contribute to both patient improvement and satisfaction scores.

The study authors note that even though physical factors were more significant than emotional ones in satisfaction with treatment, that it is important to not ignore affective (emotional) factors in treatment, since other studies have shown that palliative coping (rest and nurturing) was related to more positive pain perception in clients when recent life stresses were high.

Interestingly, the study showed that in the U.K., patients are seeking chiropractic care for complaints much sooner than they did two decades ago; nearly half (47%) now seek initial care for a musculoskeletal complaint within a month of onset, compared to waiting over a year before seeking care in the 1970’s.

Breen A, Breen R. Back pain and satisfaction with chiropractic treatment: what role does the physical outcome play? The Clinical Journal of Pain 2003;19:263-268.

Chiropractic and Back Pain

Back pain is a difficult and expensive health problem. Finding the most effective treatment for patients with back pain is a priority in this age of managed care.

This new study, conducted in Australia, was designed to look at the long-term effectiveness of three different treatment modalities in 62 patients. Subjects were evenly divided between men (53.2%) and woman (47%), with an average age of 39 (range 29-46).

The study was a randomized, clinical trial that divided subjects into one of 3 exclusive, standardized treatment protocols:

Medication: (19 subjects originally; 12 sought other treatment, with 7 subjects at final follow-up). This group was given Celebrex 200 – 400 mg/day, unless this medication had been previously tried; the next medication regime of choice was Vioxx 12.5 -25 mg/day; followed by Acetaminophen 500 mg, 2-6/day.

Acupuncture: (20 subjects originally; 6 sought other treatment with 14 subjects at final follow-up). This was performed with Chinese acupuncture needles during 20-minute appointments.

Spinal Manipulation: (23 subjects originally; 4 sought other treatment with 19 subjects at final follow-up). High-velocity, low amplitude spinal manipulative thrust to a joint was performed by a chiropractor during two 20-minute visits a week, until pain relief or lack of symptoms was achieved.

Extensive subjective follow-up questionnaires were administered to assess the effectiveness of treatment. These included the Visual Analogue Scale (VAS) for pain intensity; the Owestry questionnaire for low-back and thoracic spinal pain; the Neck Disability Index for neck pain; and the Short Form-36 Health Survey Questionnaire.

The overall results of the extended study tend to favor spinal manipulation in its effectiveness as a treatment modality for chronic spinal pain, followed by needle acupuncture, when neither is contraindicated. Both seemed to achieve long-term benefits for those treated, unlike medication alone, which did not provide these benefits.

Below is a table that summarizes the long-term effectiveness of the 3 types of treatment:

Group Effectiveness

Percent who Sought Other Treatment

Medication Deterioration seen in 2 out of 7 variables (pain frequency, neck and VAS pain scale, neck); improvement seen in 1 variable (SF-36 indicator of General Health)

81.2

Acupuncture Improvement in all 7 variables

53.3

Spinal Manipulation Improvement in all 7 variables

38.7

This is also shown by the large dropout rate from the group treated alone by medication, who pursued additional forms of treatment, while the spinal manipulation group had the lowest percentage of those seeking additional treatment modalities (and by inference, appeared to experience the highest satisfaction).

The medication-only group actually saw deterioration in several variables; the improvement in the General Health variable seen in this group could be related to their not being required to come in for weekly or bi-weekly clinic visits, as the other treatment groups had to.

The study authors conclude, “Overall, patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes. For patients receiving acupuncture, improvements were also observed, although without reaching statistical significance (with a single exception). For patients receiving medication, the findings were less favorable.”

This study is extremely relevant for clinicians working with patients with chronic pain, especially after the recently uncovered problems associated with Cox-2 inhibitors, such as Celebrex and Vioxx. This study shows that chiropractic can be an effective, safe treatment for these patients.

Muller R, Giles LGF. Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes.  Journal of Manipulative and Physiological Therapeutics 2005; 28(1):3-11.

Chiropractic, Neck Pain, Back Pain

This RAND review of the literature analyzed 1,457 studies related to manipulation of the cervical spine. Only sixty-seven of these were used in the final analysis, as they were the only ones that specifically addressed the effectiveness of treatment.

“Analysis of the existing data has led the authors to conclude that 1) mobilization is probably of at least short-term benefit for patients with acute neck pain; 2) manipulation is probably slightly more effective than mobilization or physical therapy for some patients with subacute or chronic neck pain (and all three treatments are probably superior to usual medical care); and 3) manipulation and/or mobilization may be beneficial for muscle tension headache.”

In terms of adverse complications as a result of chiropractic manipulation, the authors state, “The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.” [This is a rate between 0.0000005 and 0.000001.]

Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine 1996;21(15):1746-1760.

Integrated Care More Cost-Effective for Low Back Pain

Low back pain and chiropracticLow back pain can have a detrimental impact on productivity in the workplace, and for many patients, ineffective treatment can slow down recovery and further prolong a person’s return to work after an injury. Two recent studies investigate ways that employers and health care professionals can assist in a patient’s recovery.

A study in the UK looked at how patients with low back pain modify their work environments to reduce absences and disability. Interviews with 25 workers suffering from low back pain revealed that although many attempt to make changes in their workplace to accommodate their injury, they often encounter insufficient support and expertise among their managers for creating these adjustments. Modifications are often made informally, rather than coordinated with an occupational health department within the company. This lack of support can result in a slower return to pre-injury productivity levels, and in some cases lead patients to leave the workplace altogether.

A second study, this one a controlled trial published in the British Medical Journal, found that for patients with chronic low back pain, a treatment plan that incorporated integrated care was most cost-effective when compared with standard clinical procedures.

The researchers for this study assigned 134 patients to one of two treatment groups. Patients who received integrated care worked with an occupational physician and a team of healthcare professionals, including a manual therapist, and coordinated with the patient’s supervisor at work to collectively plot a treatment plan that incorporated workplace adaptations, ergonomics, behavioral approaches, and a gradual return to work. Patients in the control group received standard treatment through their general practitioner.

At the end of the treatment, the total cost of traditional treatment was significantly higher, both to the individual and to society in the loss of productivity, when compared to the more cost-effective integrated treatment. These results confirm that taking an integrated approach to the treatment of low back pain can result in lower costs and a faster return to work.

Chiropractic is an important aspect of integrated treatment, offering a noninvasive alternative to pain medication that has been proven effective for many people suffering from low back pain. As these studies show, it can also be a cost-effective solution that promotes a quicker return to overall health. Crafting a treatment plan that considers a patient’s life and workplace needs is increasingly being shown to be an important key to recovery.

Coole C, Watson PJ, Drummond A. Low back pain patients’ experiences of work modifications; a qualitative study. BMC Musculoskeletal Disorders 2010, 11:277

Lambeek LC, Bosmans JE, van Royen BJ, van Tulder MW, van Mechelen W, Anema JR. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial. British Medical Journal. 2010; 341:c6414.