In this upcoming interview, Alice Kongsted, DC, PhD will discuss how the bio-medical/structural approach to back pain has failed and we need to implement a behavioural approach to back pain much more in practice. She will discuss the recommendation of active, non-pharmacological treatments that support self-management. Dr. Kongsted was part of the Lancet Low Back Pain Series Working Group that published three papers in March 2018 to call for worldwide recognition of the disability associated with back pain and the need for prioritizing this globally growing problem. Please comment below if you have any questions for us during the interview. I might choose some of them for our conversation.
Musculoskeletal pain in pregnant women is common and is frequently viewed as short-lived and temporary. Most women report either low back pain (LBP) or pelvic pain (PP) during pregnancy and up to 40% of patients report pain during the 18 months after delivery. Pelvic pain in pregnant women is a health care challenge in which moderate and severe pain develops rather early and has important implications for society. These pain syndromes increase sick leave and impair general level of function during pregnancy.
Previous research has evaluated different treatments to reduce morbidity in women with LBP and/or PP during pregnancy including prescription exercise, manual manipulation, education, acupuncture, and pelvic belts amongst others.
The authors of this study conducted a prospective, randomized, masked clinical trial (including 169 women) to test the hypothesis that a multimodal approach (MOM) involving a chiropractor including manual therapy, exercise, and education for LBP/PP in pregnant women is superior to standard obstetric care (STOB) for reducing pain, impairment, and disability in the antepartum period.
Patients from this study were recruited from 3 university affiliated practices (Washington University, St. Louis, MO). Patients were between 15-45 years old with a single fetus from 24-28 weeks’ gestation. Patients were evaluated by their obstetric provider for LBP, PP or both. Exclusion criteria included acute inflammatory disease, acute infectious disease, chronic back pain for greater than 8 weeks before pregnancy, a mental health disorder, back pain from visceral disease, ongoing treatment for previous back pain, peripheral vascular disease, substance abuse, or litigation pending from back pain.
A single, masked chiropractic specialist conducted the baseline evaluation (BE) with eligible volunteers before randomization. Randomization of subjects across to the STOB group or the STOB plus multimodal musculoskeletal and obstetric treatment (MOM) group was achieved across all 3 sites.
Subjective and objective measures were collected at baseline evaluation (24-28 weeks’ gestation) with follow-up at 33 weeks’ gestation. Three questionnaires including the numerical rating scale, Quebec task force disability questionnaire (QDQ) and personal pain history (PPH) were obtained. Physical assessments included the straight leg raise (SLR), posterior PP provocation test, active SLR, and long dorsal ligament test.
Patients in the both the STOB and MOM groups selected their own obstetric provider. In addition to obstetric care, the MOM group had weekly visits with a chiropractor until 33 weeks’ gestation who provided education, manual therapy, and lower back and pelvic stabilization exercises. Patients were reassured the pain experienced was not likely pathologic and that activation of joints and muscle through exercise would likely improve symptoms and signs without posing risk to the patient or her fetus. Joint mobilization involved gently moving hypomobile joints in their restricted directions to help restore proper range of motion. The gluteus maximus, gluteus medius, quadratus lumborum, abdominal wall, and intrinsic spine muscles were targeted in the quadruped, supine, or side-lying positions.
Key findings of this study were:
- the MOM group (involving chiropractor) had a significant reduction in pain on 7 indices (NRS, QDQ, SLR(left), active SLR, long dorsal ligament test, PPH – leg and shoulders)
- the STOB group had a significant increase in pain on 5 indices and only 1 improvement (PPH -leg)
- The MOM group reported significantly less trouble sleeping at 33 weeks’ gestation than the STOB group
- No adverse events were reported in either group
In summary, including chiropractic interventions with standard obstetric care for low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care alone. The benefits derived are both subjective and objective. Patients perceived less pain and disability and an overall global improvement in daily activities. Their physical examinations revealed improved range of motion, stability, and less irritation at the lumbar and pelvic joints.
George JW, Skaggs CD, Thompson PA, Nelson DM, Gavard JA, Gross GA. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. Am J Obstet Gynecol. 2013 Apr;208(4):295.e1-7.
Dr. Peter McCarthy and I discuss his varied research in the profession from spine function to dysfunction and multidisciplinary teamwork. Professor Peter McCarthy PhD (Full Professor of clinical technology, University of South Wales, UK) has been involved in the education of chiropractors for 30 years. He obtained his PhD in neurophysiology from the University of St Andrews (1986) and worked in various institutes around the world. He first joined the AECC in 1989, moving in 1998 to the University of Glamorgan to help Susan King create and consolidate the first University based chiropractic course in the UK: later becoming the Welsh Institute of Chiropractic. Holding a couple of patents, Peter has been awarded honorary fellowships, from the BCA, RCC and EAC, and research awards from the National Back Pain Association and British Association for Sport and Exercise Medicine, amongst others; even being part of a team that won a National design award. He has successfully supervised PhD students from a wide range of professions across medicine, including 4 chiropractors. Although his research publication profile appears eclectic, it is tied together by his overarching interest in sensory neurophysiology. He has studied the innervation of spinal structures, factors that affect cervical spine function and also performed RCTs of therapies on chronic back pain. More recently, he has been looking at measuring the sensory factors that can help predict relative discomfort when sitting or lying as well as developing a multidisciplinary team interested in studying neck function changes in sport and developing ways of reducing the impact these changes can have.
How to cite this episode:
Smith DL. Chiropractic Science: From Spine Function to Dysfunction and Multidisciplinary Teamwork With Dr. Peter McCarthy [internet]. Eaton, Ohio; Aug 1, 2018. Podcast: 59:14. Available from: https://chiropracticscience.com/podcast/drpetermccarthy/
Below is a list of some of the articles we discuss in this interview.
|1.||A pilot study assessing patient-centred care in patients with chronic health conditions attending chiropractic practice.|
|Stuber KJ, Langweiler M, Mior S, McCarthy PW.|
|Complement Ther Med. 2018 Aug;39:1-7. doi: 10.1016/j.ctim.2018.05.006. Epub 2018 May 18.|
|PMID: 30012379 [PubMed – in process]|
|2.||Modelling the effect of electrode displacement on transcranial direct current stimulation (tDCS).|
|Ramaraju S, Roula MA, McCarthy PW.|
|J Neural Eng. 2018 Feb;15(1):016019. doi: 10.1088/1741-2552/aa8d8a.|
|PMID: 28925375 [PubMed – in process]|
|3.||Effect of Anodal-tDCS on Event-Related Potentials: A Controlled Study.|
|Izzidien A, Ramaraju S, Roula MA, McCarthy PW.|
|Biomed Res Int. 2016;2016:1584947. Epub 2016 Nov 10.|
|PMID: 27957487 [PubMed – indexed for MEDLINE] Free PMC Article|
|4.||The factors and motivations behind United Kingdom chiropractic professional association membership: a survey of the Welsh Institute of Chiropractic Alumni.|
|Wotherspoon SE, McCarthy PW.|
|Chiropr Man Therap. 2016 Sep 12;24(1):35. doi: 10.1186/s12998-016-0115-x. eCollection 2016.|
|PMID: 27621800 [PubMed] Free PMC Article|
|5.||Assessing patient-centered care in patients with chronic health conditions attending chiropractic practice: protocol for a mixed-methods study.|
|Stuber KJ, Langweiler M, Mior S, McCarthy PW.|
|Chiropr Man Therap. 2016 May 9;24:15. doi: 10.1186/s12998-016-0095-x. eCollection 2016.|
|PMID: 27162609 [PubMed] Free PMC Article|
|6.||Wearing American Football helmets increases cervicocephalic kinaesthetic awareness in “elite” American Football players but not controls.|
|McCarthy PW, Hume PJ, Heusch AI, Lark SD.|
|Chiropr Man Therap. 2015 Nov 16;23:32. doi: 10.1186/s12998-015-0077-4. eCollection 2015.|
|PMID: 26576266 [PubMed] Free PMC Article|
|7.||Survey based investigation into general practitioner referral patterns for spinal manipulative therapy.|
|Kier A, George M, McCarthy PW.|
|Chiropr Man Therap. 2013 May 29;21:16. doi: 10.1186/2045-709X-21-16. eCollection 2013.|
|PMID: 23718217 [PubMed] Free PMC Article|
Join Dr. Kongsted and I as we discuss her unique role as an author of the recent groundbreaking Lancet series of articles on Low Back Pain as well as many other topics. Alice Kongsted, DC, PhD graduated from the University of Southern Denmark in 1999 and completed her PhD at the Faculty of Health Sciences at the University of Southern Denmark in 2005. Up till 2009 she had clinical work as a chiropractor alongside her academic work, mainly in an outpatient hospital department. Currently she holds a position as senior researcher at the Nordic Institute of Chiropractic and Clinical Biomechanics (NIKKB) and a position as Associate Professor at the Department of Sports Science and Clinical Biomechanics at University of Southern Denmark. At NIKKB she has set up a network of chiropractic primary care research clinics that regularly participates in data collection for research purposes, the data being made available to researchers both inside and outside NIKKB. Her research interests concern spinal pain with a focus on primary care. This includes investigating the prognosis of spinal pain and why people have different outcomes.
Lately, she has been much occupied with a large project exploring ways to implement evidence-based care in practice. She has an interest in methodology and has taught PhD courses on prognostic research at University of Southern Denmark and at Curtin University in Perth, Australia. Alice Kongsted is an Associate Editor of BMC Musculoskeletal Disorders and she is a member of the editorial board for Chiropractic & Manual Therapies. She has been involved in The Danish Health Authority’s development of three national clinical guidelines for treatment of lumbar radiculopathy, cervical radiculopathy and of non-specific neck pain. She was part of the Lancet Low Back Pain Series Working Group that published three papers in March 2018 to call for worldwide recognition of the disability associated with back pain and the need for prioritizing this globally growing problem. This Lancet series will be a focus of our conversation today.
Visit Dr. Kongsted’s research profile at researchgate.net.
Here is a list of articles Dr. Kongsted mentions during the interview:
|1.||Prevention and treatment of low back pain: evidence, challenges, and promising directions.|
|Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG; Lancet Low Back Pain Series Working Group.|
|Lancet. 2018 Mar 20. pii: S0140-6736(18)30489-6. doi: 10.1016/S0140-6736(18)30489-6. [Epub ahead of print] Review.|
|PMID: 29573872 [PubMed – as supplied by publisher]|
|2.||Low back pain: a call for action.|
|Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P; Lancet Low Back Pain Series Working Group.|
|Lancet. 2018 Mar 20. pii: S0140-6736(18)30488-4. doi: 10.1016/S0140-6736(18)30488-4. [Epub ahead of print]|
|PMID: 29573871 [PubMed – as supplied by publisher]|
|3.||What low back pain is and why we need to pay attention.|
|Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group.|
|Lancet. 2018 Mar 20. pii: S0140-6736(18)30480-X. doi: 10.1016/S0140-6736(18)30480-X. [Epub ahead of print] Review.|
|PMID: 29573870 [PubMed – as supplied by publisher]|
|4.||Identifying subgroups of patients using latent class analysis: should we use a single-stage or a two-stage approach? A methodological study using a cohort of patients with low back pain.|
|Nielsen AM, Kent P, Hestbaek L, Vach W, Kongsted A.|
|BMC Musculoskelet Disord. 2017 Feb 1;18(1):57. doi: 10.1186/s12891-017-1411-x.|
|PMID: 28143458 [PubMed – indexed for MEDLINE] Free PMC Article|
|5.||What have we learned from ten years of trajectory research in low back pain?|
|Kongsted A, Kent P, Axen I, Downie AS, Dunn KM.|
|BMC Musculoskelet Disord. 2016 May 21;17:220. doi: 10.1186/s12891-016-1071-2.|
|PMID: 27209166 [PubMed – indexed for MEDLINE] Free PMC Article|
In this episode Dr. Hestbæk discusses her research involving the life course of back pain and her focus on pediatric chiropractic. Lise Hestbæk, DC, PhD, received her chiropractic degree in 1990 from Palmer College of Chiropractic. She was a practising chiropractor from 1991-2007 and from 1997 to 2007 was involved in part-time research, mostly at the Back Research Center in Ringe, Denmark. She received her Ph.D. in 2003 on a thesis about high-risk groups and risk factors for low back pain in children and adolescents. Since 2008 she has been an associate professor at University of Southern Denmark and senior researcher at the Nordic Institute of Chiropractic and Clinical Biomechanics. Her research focuses on two specific areas: 1. Musculoskeletal health in children and adolescence and; 2. Lifetime epidemiology of back pain.
See Lise’s publications here.
Here is the link to one of Lise’s free full text publications on musculoskeletal pain in children and adolescents as mentioned in the podcast.
“Results: Rates of self-reported MSK pain in adolescents are similar to those in adult populations and they are typically higher in teenage girls than boys. Epidemiological research has identified conditions such as back and neck pain as major causes of disability in adolescents, and in up to a quarter of cases there are impacts on school or physical activities. A range of physical, psychological and social factors have been shown to be associated with MSK pain report, but the strength and direction of these relationships are unclear. There are few validated instruments available to quantify the nature and severity of MSK pain in children, but some show promise. Several national surveys have shown that adolescents with MSK pain commonly seek care and use medications for their condition. Some studies have revealed a link between MSK pain in adolescents and chronic pain in adults.
• The prevalence of MSK pain approaches adult levels by the end of adolescence.
• Persistent adolescent MSK pain is a risk factor for chronic pain in adulthood.
• MSK pain has substantial impacts in up to 1/4 of cases.
• The relationship of other adverse health risk factors and MSK pain is unclear.
• There is little research to inform clinical management of childhood MSK pain”
Musculoskeletal pain conditions are often recurrent in nature, occurring throughout the life-course. Attempts to understand these conditions at a time close to their initial onset may offer a better chance of developing effective prevention and treatment strategies.”
Click here to find a list of Dr. Hestbæk’s publications on researchgate.
Here is a list of the publications we discuss during this interview:
|1.||Validity of Commonly Used Clinical Tests to Diagnose and Screen for Spinal Pain in Adolescents: A School-Based Cohort Study in 1300 Danes Aged 11-15 Years.|
|Aartun E, Hartvigsen J, Hestbaek L.|
|J Manipulative Physiol Ther. 2016 Feb;39(2):76-87. doi: 10.1016/j.jmpt.2016.01.007.|
|PMID: 26896035 [PubMed – indexed for MEDLINE]|
|2.||Clinical examination findings as prognostic factors in low back pain: a systematic review of the literature.|
|Hartvigsen L, Kongsted A, Hestbaek L.|
|Chiropr Man Therap. 2015 Mar 23;23:13. doi: 10.1186/s12998-015-0054-y.|
|PMID: 25802737 [PubMed] Free PMC Article|
|3.||Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery nor constant pain. A latent class analysis of longitudinal data.|
|Kongsted A, Kent P, Hestbaek L, Vach W.|
|Spine J. 2015 May 1;15(5):885-94. doi: 10.1016/j.spinee.2015.02.012.|
|PMID: 25681230 [PubMed – indexed for MEDLINE] Free Article|
|4.||Low back pain across the life course.|
|Dunn KM, Hestbaek L, Cassidy JD.|
|Best Pract Res Clin Rheumatol. 2013 Oct;27(5):591-600. doi: 10.1016/j.berh.2013.09.007. Review.|
|PMID: 24315141 [PubMed – indexed for MEDLINE]|
|5.||Musculoskeletal pain in children and adolescents.|
|Kamper SJ, Henschke N, Hestbaek L, Dunn KM, Williams CM.|
|Braz J Phys Ther. 2016 Feb 16;20(3):275-84. doi: 10.1590/bjpt-rbf.2014.0149.|
|PMID: 27437719 [PubMed – in process] Free PMC Article|
|6.||The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor’s new suit?|
|Hestbaek L, Stochkendahl MJ.|
|Chiropr Osteopat. 2010 Jun 2;18:15. doi: 10.1186/1746-1340-18-15.|
|PMID: 20525199 [PubMed] Free PMC Article|
Learn about Dr. Michael Schneider’s chiropractic research on this episode of Chiropractic Science. Dr. Schneider is a 1982 graduate of Palmer College of Chiropractic and obtained a PhD in Rehabilitation Science from the University of Pittsburgh in 2008. Dr. Schneider has published over 40 peer-reviewed articles on various musculoskeletal topics, and has received over $3 million in US research grant funding from the National Institutes of Health (NIH) and Patient Centered Outcomes Research Institute (PCORI). Dr. Schneider is currently implementing a large randomized clinical trial comparing various types of non-surgical treatment options, including chiropractic care, for patients with lumbar spinal stenosis. We will discuss the clinical significance of his past and present chiropractic research efforts.
Topics for this episode include:
- A paper published in the journal Spine comparing spinal manipulation and usual medical care for acute and subacute low back pain: a randomized clinical trial
- Evidence and the chiropractic identity
- An article regarding US chiropractors’ attitudes, skills and use of evidence-based practice: A cross-sectional national survey
- A paper in Chiropractic and Manual Therapies describing on ongoing study consisting of 180 older adults (>60 years) who have both an anatomic diagnosis of stenosis confirmed by diagnostic imaging, and signs/symptoms consistent with a clinical diagnosis of lumbar spinal stenosis confirmed by clinical examination. Treatment is randomized into 3 groups: 1) usual medical care; 2) individualized manual therapy and rehabilitative exercise; or 3) community-based group exercise.
- Three consensus documents for the chiropractic profession including: 1) chiropractic care in health promotion, disease prevention, and wellness; 2) chiropractic care of older adults and; 3) chiropractic care for infants, children, and adolescents.
- An observational intervention study dealing with a hospital-based standardized spine care pathway. The study looked at implementing a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. In the study, chiropractors were the main providers.
Here’s the link to the Foundations of Evidence Informed Practice modules that Dr. Schneider mentions in this podcast. The course is hosted at the the University of Minnesota Center for Spirituality & Healing – Advancing the health and wellbeing of individuals, organizations and communities.
- 044- Dr. Sidney Rubinstein Discusses Chronic Low Back Pain, Spinal Manipulation and Systematic Reviews February 24, 2019
- 043- Dr. Geoff Outerbridge Discusses World Spine Care and the Global Spine Care Initiative January 22, 2019
- 042- J. David Cassidy, DC, PhD, DrMedSc Discusses Stroke, Concussion, Neck Pain, Whiplash and Epidemiology December 4, 2018
- 041- Spinal Pain in the Elderly and Chiropractic with Dr. Katie de Luca November 15, 2018
- 040- Dr. Anthony Lisi Discusses Chiropractic Practice and Research in the VA October 18, 2018
- 039- Inflammation of Peripheral Nerves, Chiropractic Principles, Manual Therapies and More with Dr. Geoffrey Bove October 4, 2018
- 038- Chiropractic, Opioids, Adverse Drug Events, and Medicare with Dr. James Whedon August 23, 2018
- 037- Interdisciplinary Care and Strategies to Incorporate Evidence Into Practice With Dr. Robert Vining August 7, 2018
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