Case management of chiropractic patients with low back pain: The Nordic Maintenance Care program - A survey of Swedish chiropractors
From: Chiropractic & Osteopathy journal. 2008 Jun 18;16(1):6 [Epub ahead of print]
Chiropractic treatment for low back pain can often be divided into two phases: Initial treatment of the problem to attempt to remove pain and bring it back into its pre-clinical or maximum improvement status, and “maintenance care”, during which it is attempted to maintain this status. Although the use of chiropractic maintenance care has been described and discussed in the literature, there is no information as to its precise indications. The objective of this study is to investigate if there is agreement among Swedish chiropractors on the overall patient management for various types of low back pain-scenarios, with a special emphasis on maintenance care.
The design was a mailed questionnaire survey. Members of the Swedish Chiropractors’ Association, who were participants in previous practice-based research, were sent a closed-end questionnaire consisting of nine case scenarios and six clinical management alternatives and the possibility to create one’s own alternative, resulting in a “nine-by-seven” table. The research team defined its own pre hoc choice of “clinically logical” answers based on the team’s clinical experience. The frequency of findings was compared to the suggestions of the research team.
A pattern of self-reported clinical management strategies emerged, largely corresponding to the “clinically logical” answers suggested by the research team. In general, patients of concern would be referred out for a second opinion, cases with early recovery and without a history of previous low back pain would be quickly closed, and cases with quick recovery and a history of recurring events would be considered for maintenance care. However, also other management patterns were noted, in particular in the direction of maintenance care.
To a reasonable extent, Swedish chiropractors participating in this survey appear to agree on the clinical management for different cases of low back pain.
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Mechanical or inflammatory low back pain. What are the potential signs and symptoms?
From: Manual Therapy Journal. In Press - published online 16 June 2008
Non specific low back pain is commonly conceptualised and managed as being inflammatory and/or mechanical in nature. This study was designed to identify common symptoms or signs that may allow discrimination between inflammatory low back pain and mechanical low back pain. Experienced health professionals from five professions were surveyed using a questionnaire listing 27 signs/symptoms.
Morning pain on waking demonstrated high levels of agreement as an indicator of inflammatory low back pain. Pain when lifting demonstrated high levels of agreement as an indicator of mechanical low back pain. Constant pain, pain that wakes, and stiffness after resting were generally considered as moderate indicators of inflammatory low back pain, while intermittent pain during the day, pain that develops later in the day, pain on standing for a while, with lifting, bending forward a little, on trunk flexion or extension, doing a sit up, when driving long distances, getting out of a chair, and pain on repetitive bending, running, coughing or sneezing were all generally considered as moderate indicators of mechanical low back pain.
This study identified two groups of factors that were generally considered as indicators of inflammatory low back pain or mechanical low back pain. However, none of these factors were thought to strongly discriminate between inflammatory low back pain and mechanical low back pain.
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Whiplash headache is transitory worsening of a pre-existing primary headache
From: Cephalalgia. 2008 Jul;28 Suppl 1:28-31
Acute and chronic whiplash headache are new diagnostic entities in the ICHD-2 (5.3, 5.4). In a prospective cohort study, 210 rear-end collision victims were identified consecutively from police records and asked about head and neck pain in questionnaires after 2 weeks, 3 months and 1 year. The results were compared with those of matched controls who were also followed for 1 year. Of 210 accident victims, 75 developed headache within 7 days. Of these, 37 had also neck pain and complied with the criteria for acute whiplash headache. These 37 had the same headache diagnoses, headache features, accompanying symptoms and long-term prognosis as the 38 without initial neck pain who therefore did not comply with the acute whiplash headache diagnosis. Previous headache was a major risk factor for headache both in the acute and chronic stage. Compared with the non-traumatized controls, headache in the whiplash group had the same prevalence, the same diagnoses and characteristic features, and the same prognosis. Both acute and chronic whiplash headache lack specificity compared with the headache in a control group, and have the same long-term prognosis, indicating that such headaches are primary headaches, probably elicited by the stress of the situation.
Rasch analysis of three versions of the Oswestry Disability Questionnaire for Low Back Pain
From: Manual Therapy. Volume 13, Issue 3, Pages 222-231 (June 2008)
The Oswestry Disability Questionnaire is one of the oldest self-report questionnaires for measuring functional outcomes in patients with low back pain and remains widely used. The Oswestry Low Back Pain Disability Questionnaire was developed as a clinical assessment tool that would provide an estimate of disability expressed as a percentage score. Ten sections or items assess pain, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life and travelling. The developers provided little detail on how the items were selected, saying only that the activities chosen were those most relevant to people with low back pain.
Each item of the Oswestry Low Back Pain Disability Questionnaire has 6 response choices arranged in order of difficulty and the respondent is asked to select the response that most closely describes you today. For example, the Sitting section responses are I can sit in any chair as long as I like, I can only sit in my favourite chair as long as I like, Pain prevents me sitting more than 1hr, Pain prevents me from sitting more than 30min, Pain prevents me from sitting more than 10min and Pain prevents me from sitting at all. A score of 0 is awarded if the first response option is selected, through to 5 for the last option. A total score is calculated by summing the individual items scores, dividing by the total possible score (adjusted if any items are missed) and multiplied by 100. The possible score range is 0–100 and a higher score indicates greater disability. The Oswestry Low Back Pain Disability Questionnaire is therefore an atypical questionnaire because there is no consistent rating scale used across all items: instead, each step of each item has its own definition.
The Oswestry Low Back Pain Disability Questionnaire was modified by Baker et al. who removed references to medication from the Pain and Sleeping items, thereby improving the relevance of these items to people not taking medication. Davidson and Keating further modified this version by replacing miles with kilometres in the Walking section. A modified version sometimes called the Chiropractic version replaced Sex Life with a new item called Changing Degree of Pain. This version has been criticised for including a transitional rating, which is conceptually different from the other items that ask about pain intensity and activity limitations. More recently, Fritz and Irrgang reported a version that replaced Sex Life with a new item called Employment/ Homemaking. This modification added an aspect of activity/participation that is otherwise absent from the Oswestry Low Back Pain Disability Questionnaire. The developers recommend Version 2.0 of the Oswestry, which instructs patients to answer the questions in relation to how their back problem is affecting them today, rather than the original instructions, which do not specify a time-frame. Selection of any particular version of the Oswestry Low Back Pain Disability Questionnaire is at present based solely on preference for content and no studies have directly compared different versions.
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Association between sitting and occupational Lower Back Pain
From: European Spine Journal. 2007 February; 16(2): 283–298.
Lower back pain has been identified as one of the most costly disorders among the worldwide working population. Sitting has been associated with risk of developing lower back pain. The purpose of this literature review is to assemble and describe evidence of research on the association between sitting and the presence of lower back pain. The systematic literature review was restricted to those occupations that require sitting for more than half of working time and where workers have physical co-exposure factors such as whole body vibration and/or awkward postures. Twenty-five studies were carefully selected and critically reviewed, and a model was developed to describe the relationships between these factors. Sitting alone was not associated with the risk of developing lower back pain. However, when the co-exposure factors of whole body vibration and awkward postures were added to the analysis, the risk of lower back pain increased fourfold. The occupational group that showed the strongest association with lower back pain was Helicopter Pilots.
For all studied occupations, the odds ratio increased when whole body vibration and/or awkward postures were analyzed as co-exposure factors. whole body vibration while sitting was also independently associated with non-specific lower back pain and sciatica. Vibration dose, as well as vibration magnitude and duration of exposure, were associated with lower back pain in all occupations. Exposure duration was associated with lower back pain to a greater extent than vibration magnitude. However, for the presence of sciatica, this difference was not found. Awkward posture was also independently associated with the presence of lower back pain and/or sciatica. The risk effect of prolonged sitting increased significantly when the factors of whole body vibration and awkward postures were combined. Sitting by itself does not increase the risk of lower back pain. However, sitting for more than half a workday, in combination with whole body vibration and/or awkward postures, does increase the likelihood of having lower back pain and/or sciatica, and it is the combination of those risk factors, which leads to the greatest increase in lower back pain.
Lower back pain is an important public health problem in all industrialized countries. It remains the leading cause of disability in persons younger than 45 years old and comprises approximately 40% of all compensation claims in the United States. More than one-quarter of the working population is affected by lower back pain each year, with a lifetime prevalence of 60–80% and a large percentage of lower back pain claims for long durations (more than 90 workdays lost.
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Are cervical multifidus muscles active during whiplash and startle? An initial experimental study.
From: BMC Musculoskeletal Disorders 2008, 9:80
The data from this study indicates that the multifidus muscles of some individuals are active early enough during whiplash to potentially increase the collision induced loading of the facet capsular ligaments.
The cervical multifidus muscles insert onto the lower cervical facet capsular ligaments and the cervical facet joints are the source of pain in some chronic whiplash patients. Reflex activation of the multifidus muscle during a whiplash exposure could potentially contribute to injuring the facet capsular ligament. Our goal was to determine the onset latency and activation amplitude of the cervical multifidus muscles to a simulated rear-end collision and a loud acoustic stimuli.
The cervical facet joints are a source of neck pain in about half of chronic whiplash patients. In addition to guiding better diagnostic and treatment techniques, this finding provides an anatomical focus to biomechanical studies aimed at understanding the aetiology of whiplash injuries. Pinching of the posterior synovial fold of the cervical facet capsular ligament is one possible injury mechanism, but more attention has been devoted toward excess strain of the capsular ligament itself. Injurious levels of strain have been observed in some capsular ligaments when loads simulating a rear-end collision were applied in-vitro. More recently, allodynia (measured as paw withdrawals in a rat model) has been correlated to levels of capsular ligament strain relevant to whiplash injury, and Group III and IV afferents from the facet joint capsule have demonstrated a graded response to mechanical loading in an in-vivo goat model.
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A Distinct Pattern of Myofascial Findings in Patients After Whiplash Injury
From: Archives of Physical Medicine and Rehabilitation. 2008 Jun 3; [Epub ahead of print]
To identify objective clinical examinations for the diagnosis of whiplash syndrome, whereby we focused on trigger points in a cross-sectional study with 1 measurement point. A quiet treatment room in a rehabilitation center, patients (n=124) and healthy subjects (n=24) participated in this study. Among the patient group were patients with whiplash associated disorders (n=47), fibromyalgia (n=21), nontraumatic chronic cervical syndrome (n=17), and endogenous depression (n=15). Each patient and control subject had a manual examination for trigger points of the semispinalis capitis, trapezius pars descendens, levator scapulae, scalenus medius, sternocleidomastoideus, and masseter muscles bilaterally.
Forty (85.1%) of the patients with whiplash had positive trigger points in the semispinalis capitis muscle. The patients with whiplash had a significantly higher prevalence of positive trigger points in the semispinalis capitis muscle than any of the control groups (P<.05). For the other examined muscles, the prevalence of trigger points in the patients with whiplash did not differ significantly from the patients with fibromyalgia or nontraumatic chronic cervical syndrome. It did differ from the patients with endogenous depression and the healthy controls. Patients with whiplash showed a distinct pattern of trigger point distribution that differed significantly from other patient groups and healthy subjects. The semispinalis capitis muscle was more frequently affected by trigger points in patients with whiplash, whereas other neck and shoulder muscles and the masseter muscle did not differentiate between patients with whiplash and patients with nontraumatic chronic cervical syndrome or fibromyalgia.
