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 and Exercise

Staying active helps recover from back painIt is well known that staying active is an important way to quickly recover from an episode of low back pain. Other studies have shown that chiropractic care is also effective at helping patients with back pain.

This current study was conducted over a 10-week period in Sweden, and it looked at the effectiveness of traditional stay-active treatment for lower back pain, versus that of stay active-care combined with manual therapy that included stretching and manipulation.

160 study subjects aged 20 to 55 years of age, employed, and with lower back pain of 3 months duration or less and no other significant medical conditions or complications entered the clinical trial. Subjects were randomly assigned to one of two groups, with 45% assigned to the reference (stay-active care) group, and 55% assigned to the experimental (stay-active care + manual therapy) group.

Stay-active treatment was given by 2 orthopedic surgeons and 8 physiotherapists to the reference group. This treatment consisted of:

  • Patient education to encourage taking part in physical activities to stay fit.
  • Prescribing sick leaves as short as possible, with medications prescribed when indicated.
  • Offering muscle stretching and matching home exercises (41% received stretching).

The experimental group (stay-active therapy + manual care) received treatment from 2 GPs and 9 physiotherapists who had previously received 12 days of training in administering manual therapy. They used the stay-active approach noted above, and added manual therapy to their treatment, which included:

  • Muscular Energy Technique (MET) diagnostic items included in the physical exam.
  • Mobilization for pelvic dysfunction, with a lock maneuver administered gently according to MET procedure.
  • Treatment with specific mobilization or lumbar thrust techniques based on exam results.

Steroid injections were allowed in 50% of the patients based on specific findings, with soft tissue stretching after parasacrococcygeal injections (injections to the base of the spine near the rectum). Auto-traction was used when indicated for cases of herniated disc.

Outcomes for both pain and 15 disability variables were measured using visual analog scales that rated pain or disability from none (0 mm) to maximum (100 mm). 12 of the disability items formed the Disability Rating Index, which measured such items as the ability to lift heavy items, to do heavy or light physical work, ability to participate in sports, to run, to get up from a sitting position, to dress (without help), to bend over a sink, to carry a bag, to climb stairs, to make a bed, to walk outdoors. The other 3 disability variables measured the ability to lie still, and to drive or ride in a car. The questionnaire also asked about medications taken.

A baseline measurement was obtained when patients entered the study, and outcomes were measured at 5 weeks and 10 weeks after treatment started. Treatment staff was blinded to the outcomes during the study period.

At the beginning of the study, the baseline results were the same for both groups.Pain scores decreased significantly with treatment over time for both groups. But because the experimental group had a slightly greater degree of baseline pain, when adjustments for herniations, age and sex were made, the experimental group experienced a faster rate in the decrease of pain during the last week of the study. The use of pain medication and nonsteroidal anti-inflammatory medications decreased at a similar rate in both groups over the period of the study.

At baseline, the experimental group tended to have slightly higher initial disability scores for all 15 variables than the reference group. By 5 and 10 weeks, the experimental group tended to have lower scores on all disability variables, and to have experienced a faster rate of improvement in the Disability Rating index, than the reference group.

Stay-active care combined with manual therapy provided greater pain relief during the last week of treatment and improved disability scores at 5 and 10 weeks, when compared with stay-active care alone. These study results are consistent with previous studies that have shown the higher effectiveness of manual treatment when compared with stay-active care treatment. The study authors theorize that this effectiveness is due to extension of the muscle spindles resetting input into the proprioreceptive system within the lower back, although the true mechanism is still unknown and needs further study.

The improved results with manual therapy would indicate that it should become a more generally used treatment option in the treatment of lower back pain than stay-active care alone.

Grunnesjo MI, Bogefeldt JP, Svardsudd KF, Blomberg SIE. A randomized controlled clinical trial of stay-active care versus manual therapy in addition to stay-active care: functional variables and pain. Journal of Manipulative and Physiological Therapeutics 2004;27:431-441.

Side Effects of Chiropractic Treatment

An increasing number of studies have been done in the last few years on both the effectiveness and safety of chiropractic manipulation:

“It is now documented that spinal manipulation may have a positive effect on some back problems. Consequently, its use has been recommended as a clinically effective and economically useful method of treatment. The rate of serious accidents after spinal manipulation performed by chiropractors has been reported in the literature as very low. The most serious accidents are those affecting the cerebral blood supply, because they can have serious, permanent or even lethal consequences. American insurance data2 indicates that the incidence of stroke is one per 2 million treatments of the neck, whereas a Danish study3 using several sources for ascertainment arrived at an estimate of one irreversible cerebrovascular accident per 1.3 million treatments of the neck.” 1

This study1 set out to assess the “common” and “abnormal” side effects following spinal manipulation. The researchers recorded the “self-reported unpleasant reactions” of 625 patients (1,858 visits), as well as the time of onset, duration, and severity of the symptoms.

In all, about half of the patients reported some type of symptom. “Reactions to spinal manipulation are common and benign. They typically arise and disappear shortly after treatment (usually gone the day after treatment). The most common reactions are local discomfort in the area of treatment (two thirds of reactions), followed by pain in areas other than that of treatment, fatigue or headache (10% each). Nausea, dizziness or ‘other” reactions are uncommonly reported (<5% of reactions).”

  1. Leboeuf-Yde C, Hennius B, Rudberg E, et al. Side effects of chiropractic treatment: a prospective study. Journal of Manipulative and Physiological Therapeutics 1997;20(8):511-515.
  2. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice. Part I: The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988. Journal of Manipulative and Physiological Therapeutics 1996;19:371-377.
  3. Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics 1995;18:530-536.

Musculoskeletal Pain and Chiropractic Care

This study evaluated chiropractic treatment and its cost effectiveness in caring for manual labor workers who complained of musculoskeletal problems. Of the 34 patients involved in the study, 13 complained of neck/arm pain and 19 of back/leg pain. 57% of the patients complained of symptoms lasting over 3 months. The subjects averaged 3.23 chiropractic treatments a month if they suffered from neck/arm symptoms, and 5.32 treatments a month if they reported back/leg symptoms. The course of treatment lasted six months. The researchers assessed the patient’s pain, functional outcomes, quality of life, perceived improvement, and employee satisfaction over 6 months. As well, they monitored the cost to the employer prior, during, and after the study period.

Throughout the study and its evaluations, back/leg patients displayed larger treatment benefits.

The Functional Outcome category, which is the patients’ ability to perform normal daily tasks, included the areas of mobility, body care, ambulation, house management, and work. Chiropractic modestly improved the subjects’ lives in body care, house management, and ambulation. The category Quality of Life, on the other hand, included social functioning, emotional disposition, general health, vitality, and body pain. The patient’s level of body pain, vitality, and emotional well being also improved with the treatments.

Patient satisfaction reports were very high. In both groups, those who did not feel “cured” at one month definitely did by six months. 84% of the back/leg patients found the treatment beneficial, and 77% of the neck/arm patients were pleased with their treatment outcomes.

In appraising the overall costs of treatments and sickness, the researchers reported that the employer’s overall costs fell by 30% in the first year of the arrangement and by a further 20% the following year. The extensive treatment costs, however, absorbed 40% and 82% of these savings.

Jay TC, Jones SL, Coe N, Breen AC. A chiropractic service arrangement for musculoskeletal complaints in industry: a pilot study. Occupational Medicine 1998;48:389-395.

Chiropractic Patients Have Lower Medical Costs

Let’s face it: cost is an important factor when we’re considering our health-care options. We want quality care that works without racking up unnecessary medical bills.

A growing body of research shows that chiropractic is both effective and less expensive than more invasive medical treatments.

 

 

In a recent study, researchers analyzed the medical spending of over 12,000 adults with spine conditions. They discovered that people who use alternative therapies have lower annual health-care costs compared to patients receiving traditional treatments.

Chiropractic care contributed significantly to reduced costs since chiropractic accounted for 75% of alternative therapy use.

Earlier research has found that chiropractic prevented recurring disability in patients with back pain which could help to minimize medical spending.

Studies have also suggested that chiropractic cuts costs for patients by helping them avoid unnecessary procedures, tests, surgeries, and expensive drugs.

Instead, chiropractors work to harness the body’s innate healing capabilities with a combination of  natural, effective modalities.

Call our office today to learn more.

References1. Martins B, et al. The association of complementary and alternative medicine use and health care expenditures for back and neck problems. Medical Care 2012; 50 (12): 1029-1036. doi: 10.1097/MLR.0b013e318269e0b2.2. Cifuentes M, Willetts J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine 2011; 53(4): 396-404.

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.

Chiropractic and Back Pain

Numerous studies have shown that chiropractic can be an effective treatment for patients with low back pain. Now a new report1 has looked further into the effectiveness of chiropractic by comparing it to physical therapy treatment, and, more significantly, studying the long-term benefits of chiropractic as measured by the annual number of office visits.

Most studies that look at long-term effects of treatment simply look at self-reported outcomes: level of pain and disability. This study took a different approach. By examining how much care patients sought after the initial study period, they could determine the effect each treatment method had on future health care consumption:

“Care seeking behavior by patients with low back pain is most commonly associated with increased pain and disability, meaning more care is sought when worse symptoms are experienced. The amount of health care utilized may therefore be used as a measure of patient health status, and thus may be compared between groups of patients to determine effectiveness of certain therapies.”

“Proctor et al.2 determined that about 25% of patients with chronic, disabling, work-related musculoskeletal disorders pursue new health care services after completing a course of treatment, and among those who sought additional health care from a new provider, a subgroup of <15% accounted for a disproportionate share of lost worker productivity, more surgical procedures, and ongoing financial disputes. They further stated that in patients with chronic, disabling, work-related musculoskeletal disorders, post-treatment utilization of health care from a new provider is an important dimension of outcome…”

The authors started with 191 patients with low back pain. 107 patients received chiropractic care (flexion/distraction treatment, or FD) and 84 patients received active exercise therapy (EP) from physical therapists. All patients received treatment 2 to 4 times per week for four weeks. The study subjects were then followed for one year to assess outcomes. The authors found:

  • 38% of the FD patients and 54% of the EP patients sought care for their back pain during the one-year follow-up.
  • FD patients had an average of 2.2 visits to a health care provider after the treatment period, while EP patients had an average of 6 visits.

“We hypothesized that there would be no group difference in the average number of visits to any health care provider. The results demonstrated that actually there were significant group differences during the year after trial participation, with a higher number of visits to any health care provider and to a general practitioner in the EP group.”

The authors conclude:

“Based on one-year follow-up data imputed for complete analysis, participants who received physical therapy (exercise program) during a clinical trial attended a higher number of visits to any health care provider and to general practitioners during the year after care when compared to participants who received chiropractic care (flexion distraction) within the trial.”

  1. Cambron JA, Gudavalli MR, McGregor M, et al. Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain. Chiropractic and Osteopathy 2006:14:19.
  2. Proctor TJ, Mayer TG, Gatchel RJ, McGreary DD: Unremitting health care utilization outcomes of tertiary rehabilitation of patients with chronic musculoskeletal disorders. Journal of Bone and Joint Surgery 2004, 86A:62-69.

Chiropractic, Exercise Back Pain

Previous studies have shown that chiropractic can be an effective treatment for some patients with low back pain. This new study looked at patients with chronic back pain, with the aim of determining which subgroups of patients find chiropractic beneficial.

For the study, the authors recruited patients from a Chicago suburb; a total of 225 patients met the study requirements. The patients were then randomly assigned to the flexion/distraction (FD) group (123 patients), or the active trunk exercise protocol (ATEP) group (112 patients).

To be included in the study, the subjects had to have pain between L1 and S1 that had lasted at least 3 months.

The authors describe the treatment the subjects received during the study:

The FD technique was performed on a specially constructed table with a moveable headpiece, a stationary thoraco-lumbar piece, and a moveable lower extremity piece. With the subject lying prone, the clinician placed one hand over the lumbar region at the level of interest and used the other hand to flex, laterally flex, and/or rotate the lower extremity section of the table. FD consisted of two biomechanical components. The first component was a series of traction procedures using the flexion range of motion directed at a specified joint level. The motion from the traction procedure resulted in opening of the posterior joint space and a consequent reduction in intradiscal pressure. The second component was a series of mobilization procedures using a possible combination of ranges of motion targeted again at a specific joint level. Most patients moved from the traction component to the mobilization component within 4 weeks of care.”

ATEP was administered by licensed physical therapists and consisted of flexion or extension exercises, weight training, flexibility exercises, and cardiovascular exercises dependent on patient symptoms. The aim of the program was to strengthen the muscles surrounding the spine and increase flexibility. Methods used to develop stabilizing exercises were consistent with those of O’Sullivan and colleagues. The therapists in the study met as a group to choose the specific exercise regime for study purposes and met monthly to reinforce treatment consistency. Biomechanically, the ATEP did not concentrate on a specific joint level but sought to impact the lumbar spine as a whole.”

After the course of treatment, the authors examined the data to see how each group fared. They found the following:

  • Both sets of patients experienced improvement of their pain and symptoms.
  • Subjects in the chiropractic group “had significantly greater relief of pain than those allocated to the exercise program.”
  • Patients who had chronic pain categorized “with moderate to severe symptoms, improved most with the flexion-distraction protocol.”
  • Patients with recurrent pain and moderate to severe symptoms fared best with ATEP.
  • The chiropractic treatment was more effective for patients with radiculopathy.
  • “Overall, flexion-distraction provided more pain relief than active exercise…”
  • Chiropractic patients were more likely to finish the treatment protocol: 13 patients dropped out from the chiropractic group, while 25 dropped out from the ATEP group.

This study shows that low back pain patients cannot be simply lumped into one group and all treated in the same manner:

“The differences in treatment results according to subgroup analyses make biological sense. The FD intervention was intended to provide motion and forces directed at specific intervertebral level. The ATEP on the other hand was intended to concentrate more on strengthening the muscles surrounding the spine and increasing flexibility. As such, a greater decrease in VAS among patients with radiculopathy should be expected for the FD group where changes in disc pressure may be most important.”

These findings can be helpful to clinicians who are trying to determine the best treatment choice for patients.

Gudavalli MR, Cambron JA, McGregor M, et al. A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. European Spine Journal.

Chiropractic May Boost the Body’s Immune Response

Chiropractic treatment has long been shown to be effective for specific symptoms like back pain and neck pain. New research is beginning to investigate the more subtle ways that chiropractic can improve health. A recent study found that spinal manipulation may boost the functioning of the immune system, even in patients with no specific pain issue.

Researchers from the Canadian Memorial Chiropractic College investigated the effect of spinal manipulation on interleukin-2, a signaling protein that controls immune responses. They selected 74 test subjects with no current symptoms or recent history of manipulation. The patients were randomly assigned to three treatment groups to receive either a control venipuncture treatment or two types of spinal manipulation. All treatments were administered on a single day, and blood samples were collected before each treatment, 20 minutes after the treatment and two hours after treatment.

The blood samples were compared to see if there was any increase in the levels of certain antibodies: induced immunoglobin G (IgG) and immunoglobin M (IgM). These two antibodies generally appear in the bloodstream in response to an infection, and they are powerful tools of the immune system.

The researchers found that subjects treated with spinal manipulation with cavitation had significantly increased levels of IgG and IgM within 20 minutes after the session. After two hours, these patients had significantly elevated IgM levels compared to baseline and the control group. These findings suggest that spinal manipulation can have what they call a “priming” effect on the body’s immune response, possibly resulting in faster responses to new infections. Although more study is needed to better explain this response, this research provides fascinating evidence that spinal manipulation may affect the functioning of the body’s immune system and assist in maintaining overall health.

Teodorczyk-Injeyan JA, McGregor M, Ruegg R, Injeyan HS. Interleukin 2-regulated in vitro antibody production following a single spinal manipulative treatment in normal subjects. Chiropractic & Osteopathy 2010, 18:26