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Low Recurrence Rate of Low Back Pain After Chiropractic Care

There was a low recurrence rate (using a stringent definition of recurrence) in a large population of patients with low back pain (LBP) up to 1 year after chiropractic care. However, the vast majority of patients were not pain free after 1 year. This is the conclusion of a recent observational study published in the Journal of Manipulative and Physiological Therapeutics.

Patients in the study were located in Switzerland.  Seven hundred and twenty-two patients with LBP (375 male) completed the Numeric Rating Scale for pain (NRS) and the Oswestry Disability Index (ODI) before chiropractic treatment and 1, 3, 6, and 12 months later (ODI up to 3 months). Patients were then categorized based on pain rating scores into “fast recovery,” “slow recovery,” “recurrent,” “chronic,” and “others.”

Based on these pain ratings, 13.4% of the patients were categorized as recurrent. The recurrent pattern significantly differed from fast recovery in duration of complaint. The duration of complaint before treatment was the main predictor for recurrence. Specifically, a subacute duration, defined in the present study as longer than 14 days, significantly increased the odds for an unfavorable course of LBP, which is of clinical relevance.

Reference: Knecht C, Humphreys BK, Wirth B. An Observational Study on Recurrences of Low
Back Pain During the First 12 Months After Chiropractic Treatment. J Manipulative
Physiol Ther. 2017 Jul – Aug;40(6):427-433.

 

 

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Update on the Magnitude and Time Course of Low Back Pain

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The high prevalence of low-back pain (LBP) has been highlighted for many years, but until recently, awareness of its influence on the population was inadequate. The results of the Global Burden of Disease (GBD) Projects 2010 have informed us that the leading cause of disability (as measured by years lived with disability) worldwide is low back pain.  Additionally, musculoskeletal conditions as a whole are the second greatest cause of disability globally according to a report by international experts, published in The Lancet on December 15th, 2012.  In the first comprehensive study of the worldwide impact of all diseases and risk factors, musculoskeletal (MSK) conditions such as arthritis and back pain affect over 1.7 billion people worldwide, and have the fourth greatest impact on the overall health of the world population, considering both death and disability.  This burden has increased by 45% over the last 20 years and will continue to do so unless action is taken.  This landmark study of the global burden of all diseases provides indisputable evidence that musculoskeletal conditions are an enormous and emerging problem in all parts of the world and need to be given the same priority for policy and resources as other major conditions like cancer, mental health and cardiovascular disease.

With the knowledge that LBP is the number one cause of disability in the world, it is unfortunate that little is known about the detailed course, and trajectory, of LBP.  Until recently LBP was believed to be a self-limiting condition, similar to the common cold. However, research in the past two decades has shown that LBP is actually a recurrent condition that could be likened to a more chronic condition such as asthma.  In this regard, we are starting to look at LBP as not seen as a single entity, but rather to the LBP condition which can be regarded as a chain of LBP episodes.  So, we need to view LBP (and maybe all types of spine pain) as having a lifelong course – perhaps with different etiology and modifying factors as life progresses, but always existing as an underlying ‘trait’.

When researchers have looked at the non-benign, and non self-limiting nature of the condition, three large groups of LBP patients emerge: 1): those without LBP; 2) those who experience it on and off and; 3) those who have it most of the time. It is pretty clear that definite recovery with no recurrences does not appear to be common, although to date, we do not know how these patterns develop over the course of a lifetime. People with LBP will not necessarily seek care, but a person who consults a chiropractor for an episode of LBP is likely to feel better fairly quickly. In light of these findings, clinicians should observe and convey information about episodes within the context of a longer-term pain trajectory, to provide patients with a realistic view of the problem. The authors of the recent trajectories of low back pain article referenced herein suggest that effective short-term treatment strategies, pain management and activity maintenance as well as secondary and tertiary prevention should be high on the clinical agenda. ‘Management rather than cure’ might be a helpful catch phrase, similar to the well-known recommendation of ‘don’t worry – keep active’ (Axén and Leboeuf-Yde, 2013).

Given the shift in attention of LBP to view it as a chronic condition, researchers and clinicians are putting more emphasis on investigating LBP throughout the life course.  What is emerging from this life course investigation is that similar factors (e.g., genetics, parental factors, psychological factors, injury, physical activity, comorbidity) are associated with the pain at different times. There appears to be strong evidence for the links between back pain, pain at other locations (e.g., shoulder) and other health problems. This evidence leads to the potential conclusion that vulnerability for long-term back pain develops at an early age, likely in childhood, and influences the occurrence of, and recovery from, episodes of back pain (Dunn et al, 2013).

Furthermore, results of a recent meta-analysis of LBP in children and adolescents indicates higher prevalence rates of LBP in the most recent studies suggesting that this a problem that is increasing in this young population (Calvo-Muñoz et al, 2013). As a consequence, more attention should be devoted to develop and apply prevention programs and early detection programs for young children in order to reverse this tendency.

Key Points

  • The leading cause of disability worldwide is low back pain
  • Evidence is mounting that classifying low back pain as acute, subacute and chronic is no longer helpful
  • Many individuals experience multiple episodes of back pain with the first episode occurring early in life
  • LBP is now being thought of as a potentially chronic health condition in its own right

References:

1. Vos T et al.Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2163-96.

2.Axén I, Leboeuf-Yde C. Trajectories of low back pain. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):601-12.

3. Dunn KM, Hestbaek L, Cassidy JD. Low back pain across the life course. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):591-600.

4. Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013 Jan 26;13:14.

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Back Pain During Pregnancy and Chiropractic Care

adobestock_69723890Low back pain is one of the most common and often disabling problems in pregnancy. The prevalence of pregnancy related low back pain (PLBP) or pelvic girdle pain (PGP) is 20% to 90% with most studies reporting more than 50% prevalence. —PGP is almost 2x more common than lumbar pain. —25% of all postpartum women suffer from PGP and/or PLBP.

A 2014 prospective, cohort, outcomes study involving 115 pregnant women with low back or pelvic pain participated in the study.  Baseline numerical rating scale (NRS) of pain intensity and Oswestry Low Back Pain Disability Index questionnaire data were collected.  In addition, The patient’s global impression of change (PGIC) (primary outcome), NRS, and Oswestry data (secondary outcomes) were collected at 1 week, 1 and 3 months after the first treatment.  Then, at 6 months and 1 year the PGIC and NRS scores were collected again. PGIC responses of ‘better’ or ‘much better’ were categorized as ‘improved’. Chiropractic treatment was pragmatic and left to the discretion of the treating clinician.

Results:

  • 52% of 115 recruited patients ‘improved’ at 1 week, 70% at 1 month, 85% at 3 months, 90% at 6 months and 88% at 1 year.
  • There were significant reductions in NRS and Oswestry scores
  • Patients with more prior LBP episodes had higher 1 year NRS scores

Most pregnant patients with low back or pelvic pain undergoing chiropractic treatment reported clinically relevant improvement at all time points.

Reference: Peterson CK, Mühlemann D, Humphreys BK. Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1 year follow up. Chiropr Man Therap. 2014 Apr 1;22(1):15.

 

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Spinal Manipulation Versus Usual Medical Care for Acute and Subacute Low Back Pain

1005989_highIn a recent study, manual manipulation by a chiropractor led to greater short term reductions in self-reported pain and disability than manual assisted manipulation (Activator) or usual medical care by a physical medicine and rehabilitation specialist.

Low back pain (LBP) is an extremely common presenting complaint that occurs in greater than 80% of people. Chiropractors care for patients who have no symptoms and those who have symptoms.  Chiropractic has been used as a treatment for those with lower back pain but evidence is mixed with some reviews finding no advantage of chiropractic spinal manipulation therapy (SMT) compared to other treatments while some guidelines find moderate effectiveness of chiropractic care for back pain.  Research has demonstrated that chiropractic care in addition to standard medical care improves pain and disability scores, and in another study a subgroup of patients with acute nonspecific LBP – spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo (Spine 2013; 38:540-548).  The study reviewed here sought to compare the effectiveness of manual thrust manipulation (MTM) and manual assisted manipulation (MAM), to usual medical care (UMC) for the treatment of acute and subacute LBP.

Methods:

This study was a prospective, randomized controlled trial evaluating the comparative effectiveness of manual and mechanical spinal manipulation to usual medical care for the treatment of acute and subacute LBP.  Participants were at least 18 years old and had a new LBP episode within the previous 3 months.  They also were required to have a minimum level of self-rated pain of 3 out of 10 and minimum disability rating of 20 out of 100. Exclusions included: chronic LBP (greater than 3 months duration), previous treatment for the current episode, radicular signs/symptoms, contraindications to SMT, current use of prescription pain medicine.

Participants and treating clinicians were not blinded to treatment allocation but the principal investigator was blinded to treatment assignment and had no interaction with participants.

The study interventions consisted of:

  1. Manual thrust manipulation (MTM) – high velocity low amplitude thrust delivered by a chiropractor to the lower thoracic, lumbar and SI joints in the side posture position as deemed necessary
  1. Mechanical-assisted manipulation (MAM) – certified Activator Methods chiropractor delivered MAM in the prone position to the lower thoracic, lumbar and SI joints as deemed necessary
  1. Usual medical care (UMC) – participants were seen by a board certified physical medicine and rehabilitation medical doctor and prescribed over the counter analgesic and NSAID medications, given advice to stay active and avoid bed rest

All groups had a 4 week course of care.  All groups received an educational booklet describing proper posture and movements during activities of daily living. Both manipulation groups had 8 visits (2 per week x 4 wks).  The UMC group had 3 visits (initial, at 2 weeks and at 4 weeks).  Following the 4 week assessment, participants were free to pursue rehabilitation or manipulation.

The primary outcome was the Oswestry LBP Disability Index (OSW) and this index provides a valid and reliable way to assess functional impairment.  Pain intensity ratings were also collected using the mean of current pain, worst pain in 24 hours and average pain during last week.  Outcomes were assessed at baseline, 4 weeks, 3 months and 6 months. Other outcomes were physical examination, fear avoidance questionnaire, and treatment credibility-expectation questionnaire.

Participants with at least 30% or 50% reductions in an outcome measure were considered to be ‘responders’ and had moderate or substantial improvement respectively.

Results:

  • No adverse events were reported

Longitudinal Analysis:

  • For disability, no statistically significant differences were found between groups
  • For pain, MTM yielded lower pain scores compared to MAM and UMC
  • For pain, there were no significant differences between MAM and UMC

Responder Analysis:

  • 76% of MTM group achieved at least 30% reduction in disability compared with about 50% of MAM and 50% of the UMC groups (MAM not significantly different from UMC)
  • 50% of MTM group achieved at least a 50% reduction compared with 16% of the MAM and 39% of the UMC groups (MAM was significantly worse than UMC in this outcome)
  • 94% of MTM achieved greater than 30% reduction in pain compared with 69% of MAM and 56% of UMC
  • 76% of MTM achieved greater than 50% reduction in pain compared to 47% of MAM and 41% of UMC (MAM not significantly different from UMC)

Key Points:

  • Manual thrust manipulation by a chiropractor led to greater short term reductions in self-reported pain and disability than manual assisted manipulation (Activator) or usual medical care by a physical medicine and rehabilitation specialist
  • The benefits seen at the end of 4 weeks of care was no longer statistically significant at 3 or 6 months
  • MTM should be considered as an effective short term treatment option for patients with acute and subacute LBP
  • Significantly more patients in the MTM group achieved moderate or substantial reductions in disability and pain scores
  • These results contradict assumptions of therapeutic similarity between manual thrust and mechanical-assisted manipulation

Reference: Schneider M, Haas M, Glick R, Stevans J, Landsittel D. Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976). 2015 Feb 15;40(4):209-17.

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Lower Medicare Costs for Chiropractic Users with Chronic Low Back Pain and Multiple Comorbidities

BackacheManaging and controlling health care expenditures is a top priority.  Multiple comorbidities in the aging population has become more prevalent likely because of the extended lifespan experienced in the U.S. over the last few decades.  It is estimated that more than sixty percent of Americans over age 65 have multiple chronic conditions, and twenty-three percent of Medicare beneficiaries have 5 or more chronic conditions.

Patients with chronic low back pain (cLBP) have been thought to present to our offices with high prevalence of psychological, somatoform, and musculoskeletal comorbidity. The persistence of LBP may contribute to the development of these disorders and comorbidities have also been associated with poor outcome of LBP. Additionally, patients with comorbidities present with worse physical and psychosocial functioning, poorer response to treatment, and higher rates of health care utilization than other patients suffering from LBP.

The care of individuals with chronic conditions is estimated to account for 78% of US healthcare spending, and Medicare beneficiaries with more than 1 chronic condition account for 95% of all Medicare spending.  Not surprisingly, those with more than 5 chronic conditions account for 66% of Medicare spending. The probability that patients will use expensive health care such as hospital care increases substantially when there are comorbidities.

The rising prevalence of low back pain (LBP) among Medicare beneficiaries, the growing costs of its treatment, and the high use and costs of prescription drugs suggest an essential need to identify suitable, cost-effective, non-drug, non-surgical treatments for older patients with LBP.

Most LBP in older adults can be managed non-surgically.  Randomized controlled clinical trials have shown that chiropractic manipulative treatment (CMT) is an effective, conservative treatment option for LBP. With this in mind, the authors wanted to explore whether older Medicare fee-for service beneficiaries with an episode of LBP and multiple comorbidities who obtained CMT during their episode had lower costs than those who did not.

Methods:

This study was an observational, retrospective study that used Medicare fee-for-service data from 2006 to 2012 to identify older (aged 66 to 99) patients who had a discrete episode of cLBP.  The episode was defined as lasting at least 90 days and was preceded and followed by 180 days in which no LBP diagnosis was noted.  Additionally, each patient also had an additional musculoskeletal disorder diagnosis and a mental health disorder. If a patient had multiple episodes during the study period, only the first episode was included in the analysis.

The study included 4 groups of patients who used: 1) only CMT; 2) conventional medical care followed by CMT; 3) CMT followed by conventional medical care; and 4) only conventional medical care.

For these 4 treatment groups, the authors used un-weighted and propensity-score weighted inflation- and price-adjusted Medicare Part A, B, and D reimbursements during the episode.  Propensity scoring is a powerful tool to strengthen causal inferences drawn from observational studies. Propensity scoring helps in selecting similar patient groups for comparison. Medicare Part A covers hospital, skilled nursing facility, home health and hospice care expenditures. Medicare Part B covers doctors’ services and other outpatient expenditures; and Medicare Part D covers prescription medications. Particular attention was given to Part B reimbursements for chiropractic care, psychiatric care, physical therapy care, and spinal manipulation therapy (SMT) provided by doctors of osteopathy (DOs) as well as to Part D reimbursements for pain medications.

The study also looked at rate of spine surgery within 1 year of the end of the episode as well as compound rates of growth for price and inflation-adjusted Medicare expenditures. In addition, the study examined expenditures for psychiatric visits and pain medications.

Results:

  • Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone
  • CMT only patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode
  • Costs were greatest for patients receiving medical care alone
  • Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories
  • Patients who used only CMT had the lowest Part A and Part B expenditures per episode day, although there was no indication of lower psychiatric or pain medication expenditures associated with CMT

Key Points:

  • Among older, multiply-comorbid Medicare beneficiaries with a chronic low back pain episode, chiropractic manipulative treatment was associated with lower overall episode costs and lower episode costs per day
  • Use of CMT was associated with lower total Part A and Part D Medicare cost growth for multiply-comorbid patients with chronic low back pain episodes over the course of the study period
  • The authors found overall Medicare cost-savings associated with use of chiropractic care
  • There was no evidence of lower psychiatric or pain medication expenditures associated with CMT

Source: Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities. J Manipulative Physiol Ther. 2016 Feb 19. pii: S0161-4754(16)00007-5. doi: 10.1016/j.jmpt.2016.01.006.

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Chiropractic Reduces Cost and Medication Use

back pain chiropractic

Up to 84% of the general population has been found to report low back pain (LBP) symptoms at some point during their lifetime.  Another staggering fact is that low back pain is the leading cause of disability worldwide affecting nearly one in ten people. Not surprisingly then, back pain is the second most common symptom-related reason for clinician visits in the United States.

The costs for spinal conditions continue to rise. Consider that back pain has substantial recurrence rates that may affect 40% to 50% of patients within 6 months and 70% within 12 months.  Current evidence suggests that the natural history of LBP is alike chronic conditions such as asthma, marked by chronic mild symptoms and periodic exacerbations. These developments have highlighted that LBP is a priority for employers focusing on workforce health and productivity (H&P).  Employers are seeking to maximize the ratio of outcomes achieved relative to costs incurred (ie, value) for the investments that they are making in their employees.  Furthermore, employers are in the unique position of being able to determine what treatments actually cost and how effective they are in their workforce.

The authors of this article point out that previous research has found that patients receiving chiropractic care have lower associations of probability of disability recurrence than patients of physicians and physical therapists.  They also state that early use of magnetic resonance imaging (MRI) has been linked to prolonged disability, higher costs, and greater use of surgery without evidence of benefit on health and function.

The goals of this study were to assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain.

—The study involved a retrospective time series analysis of tracked episodes of three types of ICD-9 code–identified back problems (n = 14,787) during 2001 to 2009 from a Fortune 500 company.

—The sample consisted of back pain episodes stratified into 3 groups:
#1: LBP (low back pain) with neurologic findings  (LBP/neuro) (n=1837)
#2: LBP with no neurologic findings (LBP/nonneuro) (n=8569)
#3: Other back (n=4381)

Of all employees, 39.4% of employees had at least one back pain episode and many had multiple episodes of LBP.  Total costs (direct/indirect) per employee were calculated per year.

Results indicated that 5 overall episode treatment patterns emerged (overall sample percentage in parentheses):

  1. Information and Advice (TalkInfo): simple office visits, lab tests, emergency department or hospital visits, talk therapy, or visits involving imaging (59%).
  2. Complex Medical Management (Complex MM): visits for nerve blocks, surgeries, or comparable procedures. Any ties with other categories went to this category (2%).
  3. Chiropractic (Chiro): number of visits to a chiropractor was greater than 1 and comprised the plurality or greater of procedures. This included cases involving manipulation billed as PT if the manipulation occurred on the same day (11%).
  4. Physical therapy (PT): number of visits to a PT was greater than 1 and comprised the plurality or greater of procedures. Physical therapy by itself (no chiropractor) sometimes included devices or other palliative treatments (11%).
  5. Dabble: at most one visit for physician, chiropractic, or PT care, or at most one visit to two or more of these categories (17%).

—The chiropractic group had the lowest prescription medication rates, least costs per episode of low back pain, and least guideline-incongruent use of medications and imaging.  —The chiropractic group also was the least likely to receive complex medical procedures like surgeries. —Complex medical management costs were greater than 4 times more expensive for an episode of low back pain (over 3 years) with neurological findings than chiropractic care ($6983.82 vs $28,231.5).  —Physical therapy costs were more than double per episode of low back pain (over 3 years) with neurological findings compared with chiropractic care ($6983.82 vs $17,193.92). —Similar cost savings in favor of chiropractic were found for an episode of low back pain (over 3 years) without neurological findings (chiropractic care = $6768.43, complex medical management = $29,344.25, physical therapy = $13,448.82).

Of note is that the complex medical management approach recorded the highest rates of prescription fills for opiods, other pain medications, SSRI/SNRI/tricyclics, and anxiolytics/sedatives/hypnotics.  The PT group had the highest rates for NSAIDs, muscle relaxant, and oral steroids.

Reference: Tracking low back problems in a major self-insured workforce: toward improvement in the patient’s journey. Allen H, Wright M, Craig T, Mardekian J, Cheung R, Sanchez R, et al.  J Occup Environ Med. 2014;56(6):604-20.

 

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We’re not ‘just treating’ back and neck pain

WorldSpineChiropracticWe’re not ‘just treating’ back and neck pain!  We are reducing the leading global burden of disease! Low back pain causes more global disability than any other condition.  Neck pain is the 4th leading cause of global disability.

Reference: Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014 Jun;73(6):968-74.

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Chiropractic Manipulation Versus Usual Medical Care for Acute and Subacute Low Back Pain

33609004_sLow back pain (LBP) is an extremely common presenting complaint that occurs in greater than 80% of people. Chiropractors care for patients who have no symptoms and those who have symptoms.   Research has demonstrated that chiropractic care in addition to standard medical care improves pain and disability scores, and in another study a subgroup of patients with acute nonspecific LBP – spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo (Spine 2013; 38:540-548).  The study reviewed here sought to compare the effectiveness of manual thrust manipulation (MTM) and manual assisted manipulation (MAM), to usual medical care (UMC) for the treatment of acute and subacute LBP.

This study was a prospective, randomized controlled trial evaluating the comparative effectiveness of manual and mechanical spinal manipulation to usual medical care for the treatment of acute and subacute LBP.  Participants were at least 18 years old and had a new LBP episode within the previous 3 months.  They also were required to have a minimum level of self-rated pain of 3 out of 10 and minimum disability rating of 20 out of 100. Exclusions included: chronic LBP (greater than 3 months duration), previous treatment for the current episode, radicular signs/symptoms, contraindications to SMT, current use of prescription pain medicine.

Participants and treating clinicians were not blinded to treatment allocation but the principal investigator was blinded to treatment assignment and had no interaction with participants.

The study interventions consisted of:

  1. Manual thrust manipulation (MTM) – high velocity low amplitude thrust delivered by a chiropractor to the lower thoracic, lumbar and SI joints in the side posture position as deemed necessary
  1. Mechanical-assisted manipulation (MAM) – certified Activator Methods chiropractor delivered MAM in the prone position to the lower thoracic, lumbar and SI joints as deemed necessary
  1. Usual medical care (UMC) – participants were seen by a board certified physical medicine and rehabilitation medical doctor and prescribed over the counter analgesic and NSAID medications, given advice to stay active and avoid bed rest

All groups had a 4 week course of care.  All groups received an educational booklet describing proper posture and movements during activities of daily living. Both manipulation groups had 8 visits (2 per week x 4 wks).  The UMC group had 3 visits (initial, at 2 weeks and at 4 weeks).  Following the 4 week assessment, participants were free to pursue rehabilitation or manipulation.

The primary outcome was the Oswestry LBP Disability Index (OSW).  Pain intensity ratings were also collected. Outcomes were assessed at baseline, 4 weeks, 3 months and 6 months.  Participants with at least 30% or 50% reductions in an outcome measure were considered to be ‘responders’ and had moderate or substantial improvement respectively.

Results and Conclusions:

  • Manual thrust manipulation by a chiropractor led to greater short term reductions in self-reported pain and disability than manual assisted manipulation (Activator) or usual medical care by a physical medicine and rehabilitation specialist
  • The benefits seen at the end of 4 weeks of care were no longer statistically significant at 3 or 6 months
  • MTM should be considered as an effective short term treatment option for patients with acute and subacute LBP
  • Significantly more patients in the MTM group achieved moderate or substantial reductions in disability and pain scores
  • These results contradict assumptions of therapeutic similarity between manual thrust and mechanical-assisted manipulation

Reference: Schneider M, Haas M, Glick R, Stevans J, Landsittel D. Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976). 2015 Feb 15;40(4):209-17.

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Episode

065- Dr. Clinton Daniels Discusses Manipulation and Prior Spine Surgery, Medications for Back Pain and More

Dr. Daniels and I discuss some of his publications dealing with prior spine surgery, medications for low back pain, suicide prevention, and health promotion. Dr. Clint Daniels is chiropractic section chief at VA Puget Sound Health Care System in Tacoma, Washington where he supervises a team of 9 chiropractors and is a resident director. He serves on the VA chiropractic Field Advisory Committee as the Research Coordinator, is a scientific commission board member for Clinical Compass, and is appointed to the Washington State Health Technology Clinical Committee. He is a 2010 chiropractic graduate from Logan University, where he also received his Master of Science in Sports Science and Rehabilitation. He worked in private practice for 4 years, and then joined VA and was the first graduate of the St. Louis VA chiropractic integrated clinical practice residency program. He has authored and contributed to numerous scientific publications on the topics of chiropractic integration into veteran and military facilities, postsurgical spine pain, suicide prevention, chiropractic best practices, and numerous case reports on a variety clinical presentations.

Please find Dr. Daniel’s researchgate.net profile here.

Here are the articles we discuss in this episode.

1.Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review.Daniels CJ, Cupler ZA, Gliedt JA, Walters S, Schielke AL, Hinkeldey NA, Golley DJ, Hawk C.Complement Ther Clin Pract. 2021 Feb;42:101261. doi: 10.1016/j.ctcp.2020.101261. Epub 2020 Nov 17.PMID: 33276229
2.Systematic review of guideline-recommended medications prescribed for treatment of low back pain.Price MR, Cupler ZA, Hawk C, Bednarz EM, Walters SA, Daniels CJ.Chiropr Man Therap. 2022 May 13;30(1):26. doi: 10.1186/s12998-022-00435-3.PMID: 35562756 Free PMC article. Review.
3.The chiropractor’s role in primary, secondary, and tertiary prevention of suicide: a clinical guide.Cupler ZA, Daniels CJ, Anderson DR, Anderson MT, Napuli JG, Tritt ME.J Can Chiropr Assoc. 2021 Aug;65(2):137-155.PMID: 34658386 Free PMC article.
4.The Role of Chiropractic Care in Providing Health Promotion and Clinical Preventive Services for Adult Patients with Musculoskeletal Pain: A Clinical Practice Guideline.Hawk C, Amorin-Woods L, Evans MW , Jr, Whedon JM, Daniels CJ, Williams RD , Jr, Parkin-Smith G, Taylor DN, Anderson D, Farabaugh R, Walters SA, Schielke A, Minkalis AL, Crivelli LS, Alpers C, Hinkeldey N, Hoang J, Caraway D, Whalen W, Cook J, Redwood D.J Altern Complement Med. 2021 Oct;27(10):850-867. doi: 10.1089/acm.2021.0184. Epub 2021 Jul 26.PMID: 34314609
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064- Dr. Matt Fernandez Discusses Physical Activity, Exercise and Chiropractic

Dr. Matt Fernandez is a registered chiropractor in Australia and is currently a senior lecturer at Central Queensland University (CQU), where he teaches and supervises students in the Master of Chiropractic program. Prior to his CQU appointment, he was a lecturer at the Department of Chiropractic, Macquarie University. Matt is very passionate about research and following the completion of his PhD at the University of Sydney, he now leads various research projects and supervises research students. He also regularly presents his research at conferences in targeted areas that advances the knowledge and understanding of chiropractic through physical activity, exercise and patient education interventions. Matt is also a member of the inaugural CARL fellows.

In this episode, we discuss physical activity, exercise, practice guidelines, and the chiropractic profession.

Please find Dr. Fernandez’s researchgate.net profile here.

Here are the articles we discuss in this episode.

1.Physical activity promotion in chiropractic: a systematic review of clinician-based surveys.Fernandez M, Young A, Milton K, Pinhiero M, de Luca K, Ferreira P, Hebert J.Chiropr Man Therap. 2022 Dec 13;30(1):55. doi: 10.1186/s12998-022-00467-9.PMID: 36514061 Free PMC article. Review.
2.GLA:D® Back Australia: a mixed methods feasibility study for implementation.Fernandez M, Young A, Kongsted A, Hartvigsen J, Barton C, Wallis J, Kent P, Kawchuk G, Jenkins H, Hancock M, French SD.Chiropr Man Therap. 2022 Apr 7;30(1):17. doi: 10.1186/s12998-022-00427-3.PMID: 35392935 Free PMC article.
3.The prevalence and determinants of physical activity promotion by Australian chiropractors: A cross sectional study.Fernandez M, Moore C, Eklund A, Swain M, de Luca K, Sibbritt D, Adams J, Peng W.Complement Ther Med. 2019 Aug;45:172-178. doi: 10.1016/j.ctim.2019.06.012. Epub 2019 Jun 18.PMID: 31331556
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057- Low Back Pain, The Brain and Movement with Dr. Michael Meier

In this episode, Dr. Meier discusses how people move differently in the presence of (or in anticipation of) pain. Changes in motor control may play an important role in musculoskeletal pain. His lab uses a cross-disciplinary approach that combines neuroscience and movement biomechanics to provide new insights into the role of potential interactions between movement behavior, psychological factors and supraspinal mechanisms in the development and maintenance of persistent low back pain. We’ll touch also on fear avoidance and pain related movement avoidance.  Dr. Michael L. Meier is a senior pain researcher and group leader at the Department of Chiropractic Medicine at the University of Zurich. He received his master’s degree in neuropsychology and his doctorate in cognitive neuroscience from the University of Zurich, focusing on the processing of pain and nociception in the brain. In 2019, he received a grant from the Swiss National Science Foundation (SNF) to study the role of movement behavior and cortical processes in the development and persistence of low back pain. A hallmark of his work is linking research from different disciplines such as biomechanics, neuroscience, and psychology, shedding light on novel interacting pathomechanisms underlying persistent low back pain whose pathoanatomical cause is often unclear.

Please see Dr. Michael Meier’s research profile at researchgate.net.  Further information and links to his research can be found at the Balgrist University Hospital website.

Below are the articles Dr. Michael Meier and I discuss in this episode:

1.
Fear-avoidance beliefs are associated with reduced lumbar spine flexion during object lifting in pain-free adults.
Knechtle D, Schmid S, Suter M, Riner F, Moschini G, Senteler M, Schweinhardt P, Meier ML.
Pain. 2021 Jun 1;162(6):1621-1631. doi: 10.1097/j.pain.0000000000002170.
PMID: 33323888 Free PMC article.
2.
Neural responses of posterior to anterior movement on lumbar vertebrae: a functional magnetic resonance imaging study.
Meier ML, Hotz-Boendermaker S, Boendermaker B, Luechinger R, Humphreys BK.
J Manipulative Physiol Ther. 2014 Jan;37(1):32-41. doi: 10.1016/j.jmpt.2013.09.004. Epub 2013 Nov 12.
PMID: 24229849
3. Identifying Motor Control Strategies and Their Role in Low Back Pain: A Cross-Disciplinary Approach Bridging Neurosciences With Movement Biomechanics.
Schmid Stefan, Bangerter Christian, Schweinhardt Petra, Meier Michael L.
Frontiers in Pain Research. 2021 Aug;(2):42. doi: 10.3389/fpain.2021.715219
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038- Chiropractic, Opioids, Adverse Drug Events, and Medicare with Dr. James Whedon

Dr. James Whedon

In this episode, Dr. James Whedon and I discuss his research on chiropractic, opioids, adverse events, risk of injury, medicare, and much more.  For instance, his research found the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with nonrecipients.  Dr. Jim Whedon is Director of Health Services Research at Southern California University of Health Sciences and adjunct instructor at The Dartmouth Institute for Health Policy and Clinical Practice. He holds a DC degree from Logan College and an MS from Dartmouth College. He has authored 33 peer reviewed publications. He is advisor to the Project for Integrative Health and the Triple Aim, co-chair of the research working group of The Academic Consortium for Integrative Health, charter member of the Academy of Integrative Health & Medicine, and recipient of the Jerome F. McAndrews DC Memorial Research Fund Award from NCMIC Foundation.

Dr. Jim Whedon is a national award-winning, NIH-funded clinical and health services investigator with interests in trauma, integrative medicine, spinal disorders and Medicare health policy. Experience in clinical database development and medical editing. IRB and editorial advisory board member. Licensed chiropractic physician with 25 years clinical experience. Faculty appointment with Geisel School of Medicine at Dartmouth.

Much of his research has focused upon geographic variations in access to chiropractic services under Medicare. He conducts observational research using claims and registry data.

Dr. Whedon’s long-term research goals are to improve access to health services that people need and want, and to improve quality through systematic care of acute problems and conservative upstream care of chronic problems. He has a particular interest in helping to improve access to care for vulnerable populations.

He is also a member of the Advisory Team, Project for Integrative Health and the Triple Aim, and of the Research Working Group, Academic Consortium for Complementary and Alternative Health Care (ACCAHC).

See Dr. Whedon’s list of publications on researchgate.net.

How to cite this episode:
Smith DL. Chiropractic Science: Chiropractic, Opioids, Adverse Drug Events, and Medicare with Dr. James Whedon [internet]. Eaton, Ohio; Aug 23, 2018. Podcast: 1:05:21. Available from: https://chiropracticscience.com/podcast/drjameswhedon/

Below is a list of the articles Dr. Whedon discusses in this episode:

1. Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Risk of Adverse Drug Events.
Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
J Manipulative Physiol Ther. 2018 Jun;41(5):383-388. doi: 10.1016/j.jmpt.2018.01.004. Epub 2018 May 26.
PMID: 29843912 [PubMed – in process]
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2. Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids.
Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
J Altern Complement Med. 2018 Jun;24(6):552-556. doi: 10.1089/acm.2017.0131. Epub 2018 Feb 22.
PMID: 29470104 [PubMed – indexed for MEDLINE]
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3. Relevance of Quality Measurement to Integrative Healthcare in the United States.
Whedon JM, Punzo M, Dehen R, Menard MB, Fogel D, Olejownik J.
J Altern Complement Med. 2016 Nov;22(11):853-858. Epub 2016 Sep 23.
PMID: 27660896 [PubMed – indexed for MEDLINE]
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4. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities.
Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM.
J Manipulative Physiol Ther. 2016 Feb;39(2):63-75.e1-2. doi: 10.1016/j.jmpt.2016.01.006. Epub 2016 Feb 19.
PMID: 26907615 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
5. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66 to 99 years.
Whedon JM, Mackenzie TA, Phillips RB, Lurie JD.
Spine (Phila Pa 1976). 2015 Feb 15;40(4):264-70. doi: 10.1097/BRS.0000000000000725.
PMID: 25494315 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
6. Risk of stroke after chiropractic spinal manipulation in medicare B beneficiaries aged 66 to 99 years with neck pain.
Whedon JM, Song Y, Mackenzie TA, Phillips RB, Lukovits TG, Lurie JD.
J Manipulative Physiol Ther. 2015 Feb;38(2):93-101. doi: 10.1016/j.jmpt.2014.12.001. Epub 2015 Jan 14.
PMID: 25596875 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
7. Comparing Propensity Score Methods for Creating Comparable Cohorts of Chiropractic Users and Nonusers in Older, Multiply Comorbid Medicare Patients With Chronic Low Back Pain.
Weeks WB, Tosteson TD, Whedon JM, Leininger B, Lurie JD, Swenson R, Goertz CM, O’Malley AJ.
J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):620-8. doi: 10.1016/j.jmpt.2015.10.005. Epub 2015 Nov 5.
PMID: 26547763 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
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037- Interdisciplinary Care and Strategies to Incorporate Evidence Into Practice With Dr. Robert Vining

Dr. Robert Vining

In this episode, Dr. Robert Vining and I discuss his involvement in chiropractic research at a specialty hospital in New Hampshire, low back pain classification and strategies on how to implement evidence into practice. Dr. Vining is an Associate Professor and Research Clinic Director at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic. Beginning in private practice in Pennsylvania, he eventually transitioned to the role of clinician/educator, teaching courses in clinical biomechanics at Cleveland Chiropractic College (now Cleveland University), and serving as a teaching clinic director at Logan College of Chiropractic. More recently, Dr. Robert Vining has taken on the role of clinician/scientist, serving as a co-investigator on 11 federally funded clinical studies including those conducted within Veterans Affairs and the US Department of Defense health systems. He was also co-principal investigator on a series of privately funded research projects focused on integrating chiropractic care into a rehabilitation specialty hospital. Dr. Vining is a lead or co-author on over 30 peer reviewed scientific journal articles, 2 book chapters, and numerous other publications related to chiropractic care, musculoskeletal diagnosis, and translating research evidence into clinical practice.

You can view Dr. Vining’s research articles at researchgate.

How to cite this episode:
Smith DL. Chiropractic Science: Interdisciplinary Care and Strategies to Incorporate Evidence Into Practice With Dr. Robert Vining [internet]. Eaton, Ohio; Aug 7, 2018. Podcast: 1:21:13. Available from: https://chiropracticscience.com/podcast/drrobertvining/

1. “Be good, communicate, and collaborate”: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team.
Salsbury SA, Vining RD, Gosselin D, Goertz CM.
Chiropr Man Therap. 2018 Jun 22;26:29. doi: 10.1186/s12998-018-0200-4. eCollection 2018.
PMID: 29977521 [PubMed – in process] Free PMC Article
Similar articles
2. Patients receiving chiropractic care in a neurorehabilitation hospital: a descriptive study.
Vining RD, Salsbury SA, Cooley WC, Gosselin D, Corber L, Goertz CM.
J Multidiscip Healthc. 2018 May 3;11:223-231. doi: 10.2147/JMDH.S159618. eCollection 2018.
PMID: 29760552 [PubMed] Free PMC Article
Similar articles
3. Interdisciplinary rehabilitation for a patient with incomplete cervical spinal cord injury and multimorbidity: A case report.
Vining RD, Gosselin DM, Thurmond J, Case K, Bruch FR.
Medicine (Baltimore). 2017 Aug;96(34):e7837. doi: 10.1097/MD.0000000000007837.
PMID: 28834891 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
4. An evidence-based diagnostic classification system for low back pain.
Vining R, Potocki E, Seidman M, Morgenthal AP.
J Can Chiropr Assoc. 2013 Sep;57(3):189-204.
PMID: 23997245 [PubMed] Free PMC Article
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027- Low Back Pain Trajectories and Chiropractic Practice with Iben Axén, DC, PhD

In this interview, Dr. Axén and I discuss the trajectories of low back pain, the characteristics of chiropractic patients with low back pain and practice based research. Iben Axén is a chiropractor in private practice in Stockholm, Sweden, who started to engage in practice-based research in the 1990’s. In 2011, she earned her PhD at Karolinska Institutet (KI) in Stockholm. She previously held a post-doc position shared between KI and the University of Southern Denmark. Currently she is an Associate professor in Musculoskeletal Health at the Karolinska Institutet. Her research centers on chiropractic care for low back pain (LBP). She has published work regarding predictors of treatment outcome, the clinical course and episodes of LBP and of subgrouping patients. Further, she is involved in the Nordic Maintenance Care Program, including the use of, indications for and outcomes of prevention. Iben Axen’s work is mainly based ondata from multicentre longitudinal studies. She is a firm believer in engaging chiropractic clinicians in data collection as part of the implementation process. In several studies, she has used a novel way of frequently measuring outcome using mobile phones and text messages, which allow for detailed studies of conditions that vary over time, for instance LBP.

View Dr. Axen’s research here.

Below are the articles discussed in this episode:

1. “Typical” chiropractic patients- can they be described in terms of recovery patterns?
Axén I, Leboeuf-Yde C.
Chiropr Man Therap. 2017 Aug 9;25:23. doi: 10.1186/s12998-017-0152-0. eCollection 2017.
PMID: 28804617 [PubMed] Free PMC Article
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2. 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 – in process] Free PMC Article
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3. Trajectories of low back pain.
Axén I, Leboeuf-Yde C.
Best Pract Res Clin Rheumatol. 2013 Oct;27(5):601-12. doi: 10.1016/j.berh.2013.10.004. Epub 2013 Oct 10. Review.
PMID: 24315142 [PubMed – indexed for MEDLINE]
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4. Conducting practice-based projects among chiropractors: a manual.
Axén I, Leboeuf-Yde C.
Chiropr Man Therap. 2013 Feb 1;21(1):8. doi: 10.1186/2045-709X-21-8.
PMID: 23369259 [PubMed] Free PMC Article
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5. The Nordic maintenance care program: the clinical use of identified indications for preventive care.
Axén I, Bodin L.
Chiropr Man Therap. 2013 Mar 6;21(1):10. doi: 10.1186/2045-709X-21-10.
PMID: 23497707 [PubMed] Free PMC Article
Similar articles
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