The clinical aspects of the acute facet syndrome: results from a structured discussion among European chiropractors
From: Chiropr Osteopat. 2009 Feb 5;17(1):2. [Epub ahead of print]
The term ‘facet joint’ became common in the 1970s, when surgeons developed an interest in the small joints of the lumbar spine as a source of low back pain. The formal name for these joints is the zygapophyseal joints, as endorsed by The International Anatomical Nomenclature Committee. They were suggested as a source of pain as early as 1911 and the term ‘facet syndrome’ was introduced by Ghormley in 1936. However, due to the discovery of the lumbar disc as a source of low back pain, the facet joints did not receive much further attention until the 1970s. In 1976, Mooney and Robertson demonstrated that the facet joints could be a source of pain and that certain patients could be relieved from pain by anesthetizing these joints. These findings were later reproduced and thus confirmed the basis for the concept of ‘facet syndrome’, ‘facet joint pain’ or ‘zygapophyseal joint pain’. The term ‘facet syndrome’ is really a contradiction in terms. A syndrome is characterized by a set of detectable characteristics, usually used when the pathophysiology has not yet been discovered. In the case of ‘facet syndrome’, the source of pain is identified but the clinical presentation is poorly defined. Nevertheless, the term is widely used.
During the past three decades, there have been numerous studies of the frequency of facet joint pain in chronic low back pain patients. In these studies, various types of facet joint injections were used to determine whether the facet joints were the source of pain. These included injection of local anaesthetic into the joint itself or the nerves that innervate them, resulting in relief from pain if the pain originated from these joints (diagnostic blocks). Prevalence rates of facet joint pain among those patients with chronic low back pain vary widely in the literature, ranging from 5% to 90% but there is a problem with a high false positive rate in many studies. Therefore, when confirmatory blocks are used, the prevalence rates are somewhat lower, ranging from 9% to 45%. As these studies investigated chronic low back pain, these prevalence rates indicate that the facet joints might be important contributors to the burden of chronic low back pain. However, there does not appear to be any studies describing the prevalence of facet joint pain in acute low back pain.
The etiology of pain from the facet joints has been investigated from several perspectives. Osteoarthrosis has been considered as a source of facet joint pain. Facet joint osteoarthrosis is very common in the general population; the frequency increases with age and the highest prevalence is at the L4-5 spinal level. However, the presence of osteoarthrosis in the facet joints, as seen on plain radiography, does not seem to be associated with low back pain. In contrast, facet joint oedema visualised by MRI correlated with back pain intensity in at least two studies. A common explanation in chiropractic textbooks is that small meniscoids formed of synovial folds and continuous with the periarticular tissues become entrapped or extrapped and through a cascade of events lead to acute locked low back. This is described as being amenable to manipulative therapy. Garges, White and Koestler offer an alternative or supplementary explanation of pain from the facet joints. They describe how inflammatory adhesions of the facet joints and their capsules may cause a painful reduction in motion.
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The Nordic back pain subpopulation program: predicting outcome among chiropractic patients in Finland
From: Chiropr Osteopat. 2008 Nov 7;16(1):13 [Epub ahead of print]
The causes of non specific low back pain are largely unknown. Obviously, this is a hindrance to a rational approach to both prevention and treatment. In general, both etiologic studies and randomized controlled clinical trials are based on the concept that non specific low back pain is one single entity. However, most clinicians with an interest in back pain probably consider it to consist of several specific conditions, which have not been properly recognized, understood and described.
Chiropractors in the Nordic countries use predominantly spinal manipulative therapy in their treatment of back problems, frequently in combination with soft tissue therapy, advice on exercise, ergonomic precautions, and lifestyle changes. Randomized controlled clinical trials have shown that spinal manipulative therapy has a positive effect on low back pain. However, overall, the magnitude of the effect seems to be relatively small. Those, who believe that back pain consists of several specific but (as yet) undefined subgroups, obviously think that the recognition of these would improve the quality of care and that the selection of homogeneous study populations in etiological studies and clinical trials would improve the quality of research.
Until recently it has not been documented which patients with low back pain are most likely to benefit from the chiropractic approach. However, the predictive value of a set of clinical observations has been previously studied in patients with low back pain receiving chiropractic care. This research, conducted in Norway and Sweden under the Nordic Back Pain Subpopulation Program, has been running over the past years, in which specific subgroups of patients with low back pain are systematically studied. For instance, it was shown that it is possible to predict which chiropractic patients with persistent low back pain will not report definite improvement early in the course of treatment, making it possible to exclude from treatment those who are unlikely to become low back pain free. Furthermore, early recovery at the 4th visit was noted to be a predictor for outcome 3 and 12 months later and the status already by the second visit predicted status at the fourth visit.
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Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association
From: J Orthop Sports Phys Ther 2008;38(9):A1-A34
Although the natural history of neck pain appears to be favorable, rates of recurrence and chronicity are high. One study reported that 30% of patients with neck pain will develop chronic symptoms, with neck pain of greater than 6 months duration affecting 14% of all individuals who experience an episode of neck pain. Additionally, a recent survey demonstrated that 37% of individuals who experience neck pain will report persistent problems for at least 12 months. Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern. In a survey of workers with injuries to the neck and upper extremity, it was reported that 42% missed more than 1 week of work and 26% experienced recurrence within 1 year. The economic burden due to disorders of the neck is high, and includes costs of treatment, lost wages, and compensation expenditures. Neck pain is second only to low back pain in annual workers’ compensation costs in the United States. In Sweden, neck and shoulder problems account for 18% of all disability payments. It is reported that patients with neck pain make up approximately 25% of patients receiving outpatient physical therapy. Additionally, patients with neck pain frequently are treated without surgery by primary care and physical therapy providers.
A variety of causes of neck pain have been described and include osteoarthritis, discogenic disorders, trauma, tumors, infection, myofascial pain syndrome, torticollis, and whiplash. Unfortunately, clearly defined diagnostic criteria have not been established for many of these entities. Similar to low back pain, a pathoanatomical cause is not identifiable in the majority of patients who present with complaints of neck pain and neck related symptoms of the upper quarter. Therefore, once serious medical pathology (such as cervical fracture or myelopathy) has been ruled out, patients with neck pain are often classified as having either a nerve root compromise or a “mechanical neck disorder”.
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Satisfaction with low back pain care
From: Spine J. 2008 May-Jun;8(3):510-21. Epub 2007 May 25
By using a unique, prospective study of occupational back pain claims, they examined health care satisfaction by provider type and its effect on return to work. They estimated satisfaction differentials by provider type, decomposing overall satisfaction into two components: bedside manner and effectiveness of care. They also examined how health care satisfaction affects the duration of jobless claims. The Arizona State University Healthy Back Study is a prospective study of work related back pain; 1,831 workers completed a baseline interview, with follow-up interviews at 1 month, 6 months, and 1 year. The Arizona State University Healthy Back Study merged demographic and claim characteristics from the workers’ compensation claim files with self-reported severity measures, measures of satisfaction, and postonset employment from worker interviews.
Overall and detailed satisfaction with treatment and workers’ compensation claim duration. They performed a nonparametric descriptive analysis of satisfaction by provider type and used multivariate regressions to decompose overall satisfaction into component parts. The duration analysis links differentials in health care satisfaction to differences in claim durations. Workers treated by surgeons, chiropractors (DCs), or physical therapists are more satisfied with their health care than those treated by MDs. Workers are more concerned with the effectiveness of care than with the bedside manner of their provider. A one standard deviation improvement in satisfaction with the health care provider reduces claim duration by about 25%.
A comparison between chiropractic management and pain clinic management for chronic low back pain in a national health service outpatient clinic
From: J Altern Complement Med. 2008 Jun;14(5):465-73
To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low back pain when managed in a hospital by either a regional pain clinic or a chiropractor. Design: The study was a pragmatic, randomized, controlled trial. The trial was performed at a National Health Service hospital outpatient clinic (pain clinic) in the United Kingdom. Subjects and interventions: Patients with chronic low back pain (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an National Health Service hospital setting. Outcome measures: The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student’s t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated.
Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023).
This study suggests that chiropractic management administered in an National Health Service setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with chronic low back pain.
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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Predictors of a favorable outcome in patients treated by chiropractors for neck pain
From: Spine. 2008 Jun 1;33(13):1451-1458
Study to examine which clinical and sociodemographic baseline variables can predict a favorable outcome in subjects with neck pain treated by chiropractors. Relatively little is known on predictors of neck pain, particularly for those subjects undergoing chiropractic care. No previous study has examined predictors of outcome for subjects with neck pain by modeling the trajectories of subjects in a longitudinal design.
All new, consecutive patients, between 18 and 65 years of age with neck pain of any duration, who had not undergone chiropractic or manual therapy in the prior 3 months, were recruited. Questionnaires were administered at the first 3 visits, and at 3 and 12 months. In all, 29 putative prognostic baseline variables were evaluated. Multivariate multilevel longitudinal regression analyses were conducted using neck pain, neck disability, and perceived recovery as outcomes.
In total, 529 patients fulfilled the inclusion criteria. The response rate at 12-months was 92%. In the multivariate analyses, 14 (48%) of the prognostic variables examined were retained in at least one of the models. Shorter duration of neck pain at the first visit was the only variable retained in all 3 final regression models. The following were predictive of a favorable outcome for any 2 of the 3 outcome measures examined: intermittent neck pain, those not on sick-leave or receiving workers compensation at baseline, a higher level of education, less tiredness, higher expectations that the treatment would be beneficial, lack of morning pain, and worse perceived general health.
On the basis of the patient’s history, the clinician can identify a number of determinants, which are predictive of a favorable outcome. Shorter duration of neck pain at the first visit was the only variable consistently found to be predictive of a favorable outcome for all 3 outcome measures examined.
Chiropractic and exercise for seniors with low back pain or neck pain: the design of two randomized clinical trials
From: BMC Musculoskeletal Disorders 2007, 8:94
Low back pain and neck pain are major public health problems throughout the western world. These conditions can begin early in life and persist through adulthood and into old age. This places low back pain and neck pain among the most common health complaints experienced over a lifetime. Most research pertaining to low back pain and neck pain has been aimed at the working and middle aged segments of the population. However, it is estimated that, by the year 2025, approximately one third of individuals in developed countries will be over 60 years of age. Anticipating the impact of population projections, interest in low back pain and neck pain among seniors has increased.
Low back pain and neck pain, either alone or in conjunction, affect over 30% of the population 70 years of age and older on a monthly basis. These conditions have important impact, since approximately 15% of this population indicate that they have subsequently altered or diminished their physical activity during the past year due to low back pain or neck pain. Roughly the same proportion have sought some kind of treatment. Furthermore, low back pain has been rated as the third most important condition affecting the physical health status of older Americans, after heart and lung disease. Neck pain has also been found to substantially impact function and well-being in this age group. Thus, while low back pain and neck pain are not life threatening conditions, they may lead to reduced functional ability and decreased independence, resulting in serious socio-economic consequences for elderly individuals, their families, and society. Therefore, research aimed at identifying effective prevention and treatment strategies is a high priority.
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Maintenance care in chiropractic – what do we know?
From: Chiropractic & Osteopathy. 2008 May 8;16(1):3 [Epub ahead of print]
Back problems are often recurring or chronic. It is therefore not surprising that chiropractors wish to prevent their return or reduce their impact. This is often attempted with a long-term treatment strategy, commonly called maintenance care. However, some aspects of maintenance care are considered controversial. It is therefore relevant to investigate the scientific evidence forming the basis for its use.
A review of the literature was performed in order to obtain answers to the following questions: What is the exact definition of maintenance care, what are its indications for use, and how is it practised? How common is it that chiropractors support the concept of maintenance care, and how well accepted is it by patients? How frequently is maintenance care used, and what factors are associated with its use? Is maintenance care a clinically valid method of approach, and is it cost-effective for the patient?
Thirteen original studies were found, in which maintenance care was investigated. The relative paucity of studies, the obvious bias in many of these, the lack of exhaustive information, and the diversity of findings made it impossible to answer any of the questions.
There is no evidence-based definition of maintenance care and the indications for and nature of its use remain to be clearly stated. It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. Therefore, our conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial.
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Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews
From: Europa Medicophysica. 2007 Mar;43(1):91-118
Manual therapy for neck pain enjoys a long history, with increasing popularity in recent times. The evidence base for manual therapies for neck pain consists of a reasonably large body of clinical trials, an even greater number of systematic reviews and, more recently, a number of practice guidelines. We have conducted several systematic reviews pertaining to the evidence base for both acute and chronic neck pain as well as for the outcome of control groups of chronic neck pain subjects in clinical trials of conservative therapies. In this review, we first provide background material on the definition and characterization of manual therapies as well as on the epidemiology of neck pain. We then review our recent systematic reviews on manual therapies for acute and chronic neck pain without whiplash. Finally, we provide brief, original reviews of, first, the literature on the treatment of whiplash injury by manual therapies followed by the current practice guidelines pertaining to manual therapies for neck pain. While there are several publications, especially those registered with the Cochrane Collaboration, that are currently the authoritative evaluations of the use of manual therapies for neck pain, the present review is designed to present a broad overview of the topic with a distinctive approach emphasizing the analysis of change scores in the clinical trials. It is hoped that this will benefit researchers and clinicians alike in their management of neck pain patients.
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