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%.

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.

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.

According to experience, chiropractic treatment can often be divided into two phases: Initial treatment of the problem to attempt to bring it back into its pre-clinical or maximum improvement status, and “maintenance care”, during which it is attempted to maintain this status. The first definition of maintenance care that we could find in the literature was provided by Breen in 1977: “…treatment, either scheduled or elective, which occurred after optimum recorded benefit was reached…” and the second definition that we could locate was provided by Mitchell in 1980: “A regimen designed to provide for the patient’s continued well-being or for maintaining the optimum state of health while minimizing recurrences of the clinical status”. In “Advances in Chiropractic” from 1996, the word “maintenance care” is defined as follows: “Appropriate treatment directed toward maintaining optimal body function. This is treatment of the symptomatic patient who has reached pre-clinical status or maximum medical improvement, where condition is resolved or stable”. In other words, maintenance care can be described as both an attempt at secondary prevention (preventing further events from occurring) and tertiary prevention (maintaining an incurable condition at an acceptable level).

According to the literature, spinal manipulative therapy is an important aspect of the maintenance care approach, but also other aspects could be included, such as advice, information, and counselling even in relation to general health promotion. However, the indications for maintenance care and clear descriptions of preventive treatment for specific types of conditions are not found in the literature. Also, general concepts of how to proceed over time with this type of patient are lacking, and the therapeutic value of maintenance care has not been tested, with the exception of a promising pilot study.

Despite this lack of scientific support, it was shown that American chiropractors share a common understanding about the purpose and composition of maintenance care and that they recommend it to the majority of their patients. However, it is not known if there is a general or uniform management culture among chiropractors. In relation to the decision to treat a patient with spinal manipulative therapy, there are various schools of thought within the chiropractic profession. Some chiropractors are guided by both their own clinical findings and the patients’ symptoms whereas others largely disregard the patients’ symptoms, as described in a guideline on the vertebral subluxation in chiropractic practice: “Because the duration of care is being considered relative to the correction of vertebral subluxation, it is independent of clinical manifestations of specific dysfunctions, diseases, or syndromes.”. Maintenance care would therefore probably be undertaken differently for these two groups; the former group using “symptom-guided maintenance care” whereas the approach of the second group would be “clinical findings-guided maintenance care”.

We were interested in finding out whether there is agreement among chiropractors regarding their management for various types of patient groups. In particular, we wanted to find out when chiropractors would recommend maintenance care.

Many patients who visit chiropractors suffer from low back pain (low back pain). It was therefore logical to start this work on chiropractic patients with low back pain. The results from this study may create a base from which further research into maintenance care can be conducted with the ultimate aim to investigate its clinical usefulness. Several such projects are presently underway.

Among the Swedish chiropractors who participated in this survey, a distinct pattern was found, in relation to the management strategies that they would choose for different types of low back pain-scenarios. This pattern corresponded to that which the research team, arbitrarily, considered to be logical and responsible.

However, also other patterns were apparent, sometimes favouring a prolonged management program, either symptom-guided or clinical-findings guided, indicating that some chiropractors have high expectations of “a happy ending” to many clinical conditions. The “quickfix” alternative was not often selected but, then, only cases 1, 2 and 4 were described as completely improved, and therefore the only ones obviously suitable to be considered for closure.

Nevertheless, it is reassuring to see that for the potentially serious cases 8 and 9, the most common strategy would have been referral for “second opinion” and that, for these, none of the participants would have considered any type of maintenance care.

Another interesting finding is that some chiropractors seem to fail to grasp the concept of clinically significant improvement. For example, in case 5, an acute event of low back pain of one week’s duration that is only 20% better after one month and six visits does not appear to be the suitable recipient for clinical findings-guided maintenance care. Nonetheless, this approach was the second most commonly selected strategy for this case, and if both types of maintenance care were considered together, this approach was, in fact, the most preferred choice. It has been shown that patients need to experience more substantial reduction of pain before it can be considered clinically significant. In fact, mere diurnal fluctuations and measurement errors could probably account for an improvement of 20%. In our opinion, maintenance care should only be considered in patients who have responded well to the initial treatment and only in patients who are likely to experience frequent or long-lasting problems in the future. Admittedly though, this is only our humble opinion, and the true indications for maintenance care remain to be studied.

According to a previous study of osteopaths, chiropractors and physiotherapists a subgroup of clinicians will provide prolonged treatment also for patients with low back pain, who do not recover. The reasons for this seemed to be linked with a scope of care, which encompasses more than the immediate symptomatic relief. Obviously, the different aspects of clinical reasoning need to be studied in order to understand various choices of management strategies.

Among those chiropractors who participated in this survey, a clinical management strategy pattern emerged for different cases of low back pain. However, there were also subgroups of chiropractors with different practice cultures, sometimes favouring a maintenance care program. The rationale for their clinical decisions needs to be further elucidated, and the results of this study need to be verified in other study populations with a variety of study designs.

Supplement:

A Questionnaire mailed to 99 Swedish chiropractors asking them to match nine case scenarios with six specific management strategies.

Our next research area will be about maintenance care. First, we need to find out what we really mean by “maintenance care”, because no clear definition and description exists in the chiropractic literature. For this reason we very much need your help. We want to find out what we, the professional chiropractors in Sweden, mean by maintenance care and how it is used in everyday practice.

We are therefore asking you to fill out this questionnaire. When we have received your response, the code will be removed from the questionnaire, and all analyses and final reporting will be on an anonymous basis.

First, please answer the following questions by encircling your response:

Do you use maintenance care in your practice? Yes No

If yes, in your last full working day, how many maintenance care patients did you have

of your total that day? —– maintenance care out of ——-total.

_________________________________________________________________________________

Please, read the following cases and, for each case, give the answer that you consider fits best with the decision you would make in a clinical setting.

We have selected an imaginary patient, as described in the box below. Then, different scenarios for this patient are outlined, and you are asked to select ONE of several clinical solutions (A, B, C etc.) as listed in bold letters below.

You can choose between the following possibilities for each of the cases presented below:

A. I would refer the patient to another health care practitioner for a second opinion.
B. I would advise the patient to seek additional treatment whilst following the patient.
C. I would tell the patient that the treatment is completed but that he is welcome to make a new appointment if the problem returns.
D. I would not consider the treatment to be fully completed and would try a few more treatments and perhaps change my treatment strategy, until I am sure that I cannot do any more.
E. I would follow this patient for a while, attempting to prolong the time period between visits until either the patient is asymptomatic or until we have found a suitable time lapse between check-ups to keep the patient symptomfree.
F. I would recommend that the patient continues with regular visits, as long as clinical findings indicate treatment (eg spinal dysfunction/subluxation) even if the patient is symptomfree.
G. Neither of the above. (Please explain at the back of the page in legible handwriting)

These are the basic facts for our hypothetical patient:

A 40-year old man who consults you for Low Back Pain with no additional spinal or musculoskeletal problems, and with no other health problems.

His X-rays are normal for his age.

There are no “red flags”.

The case above could proceed in the following 9 ways described on the next page.

Please encircle the letter that corresponds best to your clinical judgement in each of the cases.

An acute attack of low back pain of 2 days´ duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient seems to be an uncomplicated person and capable to look after himself and his back. What would you recommend? A B C D E F (G ) ”

An acute attack of low back pain of 2 days´duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient is very worried that the pain will come back again. The patient asks if he could come back regularly to make sure this will not happen. What would you recommend? A B C D E F (G ) ”

An acute attack of low back pain of 2 days´ duration and no previous history of low back pain. The pain is about 20% better after 6 visits. What would you recommend? A B C D E F (G ) ”

An acute attack of low back pain of 1 week´s duration. The patient has had several similar attacks over the past 12 months. The pain is completely gone after 2 weeks of treatment. What would you recommend? A B C D E F (G) g ) ”

An acute attack of low back pain of 1 week´s duration. The patient has had several similar attacks over the past 12 months, but the pain pattern has varied over the treatment period and now, after six visits, the pain is 20% better. What would you recommend? A B C D E F (G ) Choose: A B C D E F G ”

The patient has had low back pain intermittently over the past year. After the 2nd visit, the pain was 50% better but today, after six visits there has been no further change. What would you recommend? A B C D E F (G ) ”

The patient has had low back pain intermittently over the past year. After 6 visits, the pain was 80% better, but after a further two treatments the last month, the problem has gradually got a bit worse. What would you recommend? A B C D E F (G)”

The patient has had low back pain intermittently over the past year. After the 2nd visit the pain was 20% better, but today, after 6 visits and over the past month, the patient has got gradually worse. What would you recommend? A B C D E F (G ) ”

The patient has had low back pain intermittently over the past year. After 6 visits the pain is 20% better. The symptoms come and go for no apparent reason. The patient appears tired and moody. What would you recommend? A B C D E F (G) ”

A description of nine scenarios (cases 1 – 9), together with the clinical reasoning of the research team, and a description of their preferred management strategy for each scenario (not included in the questionnaire).

Case 1. An acute attack of low back pain of 2 days’ duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient seems to be an uncomplicated person and capable to look after himself and his back.

According to the research team, this case indicates a person without a background of persistent or recurrent low back pain, with a quick recovery and a psychological profile that indicates a good prognosis. The team would have selected strategy B (“I would tell the patient that the treatment is completed but that he is welcome to make a new appointment if the problem returns”).

Case 2. An acute attack of low back pain of 2 days’ duration and no previous history of low back pain. The pain is completely gone after 2 visits. The patient is very worried that the pain will come back again. The patient asks if he could come back regularly to make sure this will not happen.

The thoughts of the research team were that, ideally, this patient should be dismissed, similarly to the case above (strategy B). However, the psychological profile of this patient needs to be taken into account and he should be provided with a sense of security whilst guided by the chiropractor and gradually weaned off to prevent dependency upon chiropractic treatment. The team therefore selected strategy E, with the intent of using a couple of more visits to improve the patient’s self-confidence.

Case 3. An acute attack of low back pain of 2 days’ duration and no previous history of low back pain. The pain is about 20% better after 6 visits.

This patient is not improving at a level and rate that should be expected. Because the basic case states that there are no red flags, the team decided that this case should be reconsidered and a few more attempts made. The strategy that best suited for this scenario was C.

Case 4. An acute attack of low back pain of 1 week’s duration. The patient has had several similar attacks over the past 12 months. The pain is completely gone after 2 weeks of treatment.

This is a recurrent problem according to the past history. If the patient considers that the chiropractic treatment shortened the duration of the typical attack, he should simply return as soon as a new problem is felt to commence. Unfortunately, many patients will fail to do so, thinking that the treatment did not help when it starts up again. It might therefore be advantageous to keep an eye on the patient for a while with the intent of finding out if each event of low back pain can be quickly and efficiently treated at a “cost-effect “ time interval (strategy E) or if it is possible to prevent further events (strategy F).

Case 5. An acute attack of low back pain of 1 week’s duration. The patient has had several similar attacks over the past 12 months, but the pain pattern has varied over the treatment period and now, after six visits, the pain is 20% better.

This patient is not improving at a level that should be expected despite the large number of visits, indicating that he may be resistant to the type of treatment that has been provided so far. A change of strategy would be required (strategy C) or if the patient is referred out, it would be relevant to keep in touch to be able to be of support in the continued process (strategy D).

Case 6. The patient has had low back pain intermittently over the past year. After the 2nd visit, the pain was 50% better but today, after six visits there has been no further change.

This patient may have reached his optimal stage with the present type of treatment and the therapy should, at this stage, either be reconsidered “in-house” or by someone else, indicating strategy C or D.

Case 7. The patient has had low back pain intermittently over the past year. After 6 visits, the pain was 80% better, but after a further two treatments the last month, the problem has gradually got a bit worse.

The team used the following reasoning: The improvement seen, to date, may have been independent of the treatment and merely an expression of the typical intermittent pain pattern, or the treatment did have an effect but there is something that re-aggravated the condition. The team would, therefore, have reconsidered the case (strategy C) or sent the patient out for an adjunctive approach, such as training, whilst keeping in touch (strategy D).

Case 8. The patient has had low back pain intermittently over the past year. After the 2nd visit the pain was 20% better, but today, after 6 visits and over the past month, the patient has gradually got worse.

This patient has not really exhibited a positive response to the treatment and is, in fact, getting worse. That the patient is gradually worsening is not a normal pattern. Despite the fact that there are no (obvious) red flags the team would refer the patient for a second opinion (strategy A), because some underlying explanatory condition could have been missed.

Case 9. The patient has had low back pain intermittently over the past year. After 6 visits the pain is 20% better. The symptoms come and go for no apparent reason. The patient appears tired and moody.

This patient has not improved at all and there is no obvious (biomechanical) explanation for the intermittent pattern. There are no red flags but there is a need to consider if there might not be an underlying depression or some other disease, after all. The team would not hesitate to refer out for a second opinion (strategy A).

A description of the six specific management strategies for patients with low back pain receiving chiropractic care, from which the participants in the survey could select one for each of nine scenarios. A brief description for each strategy is included in brackets, used in the report.

A. I would refer the patient to another health care practitioner for a second opinion. (“second opinion”)
B. I would tell the patient that the treatment is completed but that he is welcome to make a new appointment if the problem returns. (“quick-fix”)
C. I would not consider the treatment to be fully completed and would try a few more treatments and perhaps change my treatment strategy, until I am sure that I cannot do any more. (“try again”)
D. I would advise the patient to seek additional treatment whilst following the patient. (“external help – keep in touch”)
E. I would follow this patient for a while, attempting to prolong the time period between visits until either the patient is asymptomatic or until we have found a suitable time lapse between check-ups to keep the patient symptoms free. (“symptom-guided maintenance care”)
F. I would recommend that the patient continues with regular visits regardless of symptoms, as long as clinical findings indicate treatment (e.g. spinal dysfunction/subluxation). (“clinical findings-guided maintenance care”)

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.

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.

Spinal manipulative therapy (SMT) is one of the most commonly used treatment modalities for spinal pain in both younger and older persons. Authors of recent systematic reviews conclude that the effect of SMT is similar to that of other commonly used forms of treatment for many types of low back pain and neck pain. To our knowledge, no randomized clinical trials comparing the effect of SMT with other forms of treatment for low back pain and neck pain in older persons have been conducted.

Exercise is a commonly prescribed treatment for low back pain and neck pain. An active lifestyle involving regular strenuous physical activity has been found to protect against the incidence of low back pain among older persons. Additionally, a systematic review of 61 randomized clinical trials by Hayden et al found exercise to be effective in reducing pain and improving function in persons with chronic low back pain. They also noted that individualized exercise was more effective if supervised. However, there is a paucity of clinical trials involving elderly patients and it is unknown if these findings also apply to this age group.

Minimal intervention in the form of home exercises and self-care is also commonly used in low back pain and neck pain management, and has been shown in some controlled trials to be as effective as more aggressive and more costly alternatives. As such, self-care is an attractive control group in randomized clinical trials, where it represents a credible alternative to placebo or wait-list, thereby enhancing patient compliance. It is also an attractive treatment option in clinical practice, representing an easy and cost-effective way of managing a common and costly problem. A trial by Haas et al compared a self-care program, designed to address chronic pain conditions to a wait-list, among seniors with low back pain. The authors found no advantage to self-care over the wait-list in terms of self-efficacy, pain, or general health. These findings may be due to the non-specificity of the self-care program; further studies of seniors are needed to assess self-care that specifically addresses low back pain and neck pain among this group.

In summary, on-going low back pain and neck pain have substantial impact on the functional capacity and well-being of older people, in the absence of effective prevention and treatment strategies. We, therefore, designed two parallel multi-methods clinical studies focusing on elderly patients with non-acute low back pain and neck pain. Each study includes a randomized clinical trial (RCT), a cost-effectiveness study alongside the RCT, and a qualitative study. The primary aims of the RCT are to determine the relative clinical effectiveness of 1) chiropractic manual therapy plus home exercise, 2) supervised rehabilitative exercises and home exercise, and 3) home exercise alone for low back pain and neck pain patients 65 and older in both the short-term (12 weeks) and long-term (one year) using pain as the primary outcome measure. Secondary aims are to assess the short- and long-term relative effectiveness of the three interventions, using 1) patient-rated outcomes regarding back and neck disability, general health status, patient satisfaction, improvement, and medication use; 2) objective functional performance outcomes of spinal motion, trunk strength and endurance, and functional ability; and 3) cost-effectiveness and cost utility measures. Finally, the qualitative studies will describe low back pain and neck pain patients’ perceptions of treatment and the issues they consider when determining their satisfaction with care.

Participants in the home exercise program (HEP) attend four, 45–60 minute sessions with an exercise therapist. At the first two sessions, participants are given simple information about how to manage their neck or back pain. This includes postural instructions and practical demonstrations of proper body mechanics for lifting, pushing, pulling, and rising from a lying position, all performed with patient participation. They are also given information on self-care for pain management, including the use of ice, heat, and medication. Importantly, patients are reassured that movement and exercise are good for their back and neck, even if they experience some discomfort or have an arthritic condition. To reinforce the message to stay active, patients are given instructions to perform specific exercises designed to improve balance and coordination, as well as enhance trunk strength and endurance without excessive loading.

Exercises in both programs are tailored to the individual patient’s level of ability and are executed on a graded progression over 12 weeks. The low back pain program includes the following exercises:

• Stretching: seated or standing lumbar flexion, full spine flexion/extension motion cycles, quadriceps stretch, hamstring stretch, hip stretch, head retraction, and chest expansion.

• Muscle Strength and Endurance: chair squats, abdominal curls, seated back extension (isometric or using resistance tubing), seated upright rows (using resistance tubing), and push ups.

• Balance: standing knee lifts, standing straight-leg hip flexion and extension.

The neck pain program consists of the following:

• Stretching: head retraction, chest expansion, full spine flexion/extension motion cycles, hamstring stretch, quadriceps stretch, and hip stretch.

• Endurance: cervical flexion and extension (isometric or using resistance tubing), push ups, chest press (using resistance tubing), seated upright rows (using resistance tubing), chair squats, and abdominal curls.

• Balance: standing knee lifts, standing straight-leg hip flexion and extension.

Participants are encouraged to perform the stretching exercises daily, and the strength and balance exercises 3–4 days per week in their home. They are also given a binder with handouts of written and illustrated descriptions of each exercise, and a simple diary to record their exercise progress. The last two sessions give study participants the opportunity to ask questions and perform the exercises with the therapist who can suggest progressions and ensure correct form.

Chiropractic manual treatment plus home exercise
Participants allocated to this group receive chiropractic manual treatment in addition to the home exercise program (described above).

Manual treatment is delivered by a chiropractor, who uses pain provocation and static/motion palpation findings to determine areas of treatment. Care may include spinal manipulation, mobilization and flexion-distraction therapy, with light soft tissue massage as indicated to facilitate the manual therapy. The type of manual treatment technique and the force applied to the spinal structures are modified to accommodate the age and physical condition of the study participant. The number and frequency of treatments is determined by the individual chiropractor, with a maximum of 20 visits.

Supervised rehabilitative exercise plus home exercise
Participants assigned to this group participate in a supervised rehabilitative program in addition to the home exercise program (described above).

Rehabilitative exercise consists of 20, 1-hour sessions supervised by an exercise therapist. Emphasis is placed on performing high repetitions of low load exercises with the aim of increasing endurance, strength, and balance. Each session begins with a light aerobic warm up, consisting of 10–15 minutes on a stationary bicycle, treadmill, or elliptical trainer. Exercises focus on stretching, strength, endurance and balance, similar to the HEP. The low back pain program also includes neck flexion, quadruped, lunges, side bridging, and trunk extension exercises on an adjustable angle roman chair. The neck pain program additionally includes neck flexion, shoulder shrugs, and trunk extension exercises on an adjustable angle roman chair. Both the low back pain and neck pain supervised exercise programs take place under the individualized guidance of exercise therapists who closely monitor form, modify exercises, prescribe progressions, and provide encouragement.

Low back pain and neck pain are important health problems for both younger and geriatric individuals. Of particular concern is that conditions associated with low back pain and neck pain, such as impaired strength and flexibility, can have very serious consequences for an older individual’s independence and overall health. The best treatments for low back and neck conditions will not only aim to treat the pain specifically, but will also address associated strength and motion in a manner that enhances general function and improves quality of life. Chiropractic manual treatment and exercise are treatment approaches that aim to meet these needs and have demonstrated potential in younger individuals.

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.

Chiropractors all over the world are consulted for spinal pain and dysfunction. Because many spinal pain complaints are chronic or recurrent in nature, it is understandable that, once improvement has been achieved, chiropractors attempt to prevent new events or maintain patients at their optimal level. This is usually done by scheduling additional visits over a prolonged period of time but at longer time intervals than during the acute event. Among chiropractors, this approach is named “maintenance care”, whereas in public health terms it is described as secondary or tertiary prevention. Secondary prevention is aimed at preventing new events, whereas tertiary prevention means that improved patients with incurable conditions are maintained at the best possible level.

Although it appears perfectly logical to use maintenance care in chronic and recurrent conditions, when informally discussing this phenomenon with chiropractors, we have often detected either a disinclination to discuss, or an ardour of arguments, often resulting in an embarrassing change of subject. In other words, maintenance care appears to be, for some, a politically incorrect topic.

This might be because the indications for treatment in asymptomatic patients depend solely on tests and observations, such as palpation findings, none of which has been shown to be clearly valid. When treating an acute problem, however, this lack of valid examination tests is of little or no concern, as the patient’s reaction to the treatment will provide feedback on the construct validity of the various treatment procedures. Therefore, there appears to be disagreement among chiropractors as to whether chiropractic treatment is mainly effective in the acute phase or whether it is possible also to prevent the underlying disorder, regardless of whether the patient is symptomatic at the time of examination and treatment.

Jamison has discussed the preventive aspect of maintenance care, when encompassing other than the musculoskeletal conditions. She points out that some chiropractors believe “that subluxations can cause, and spinal adjustments correct, diverse problems ranging from pain to more subtle endocrine, visceral and autonomic dysfunctions” and warns that this scientifically untested theory has considerable ill effects in the scientific and medical communities. In general, if chiropractors believe that “spinal health” equals good health, it is understandable that they would try to convince patients to have regular preventive chiropractic treatments. Jamison discusses this in a second paper, where she also mentions the negative repercussions of such practice. It could also be that the overzealous use of maintenance care has resulted in problems with various reimbursement systems, as Mitchell warned already in 1980. Some individuals’ short-term financial gains could be seen as having negative long-term repercussions for the whole profession.

The concept of maintenance care, therefore, seems to be associated with the very core of disagreement between chiropractors and their styles of practice; those who treat mainly musculoskeletal conditions and those who attempt to treat also other conditions. In addition, it may divide those who believe that their examination method is objective and valid and those who depend (also) on patients’ signs and symptoms for their diagnosis and treatment.

Nevertheless, maintenance care seems to be commonly employed, and if it is a useful model of preventive treatment, it should be recognized as such; but if it is ineffective, it should not be part of the chiropractic patient management strategy. Maintenance care therefore, merits being taken seriously and to be subjected to scientific scrutiny.

In 1993, the Mercy Guidelines attempted to perform a literature review on this subject but ended up making its recommendations largely on clinical experience “of nearly 100 years”. The report suggested that the use of chiropractic adjustments in a regiment of preventive/maintenance care has merit. There are no statements in the guideline in relation to indications, type of treatment, duration and frequency of treatment, nor on effectiveness. It is merely written that maintenance care is “discretionary and elective on the part of the patient” and that when recommended, “it is necessary for the practitioner to clearly identify the type and nature of this care and to give proper patient disclosure”.

Aker and Martel, three years later, performed a narrative review and concluded on the basis of the sparse literature that “there is no scientific evidence to support the claim that maintenance care improves health status” and went on to recommend a series of research actions to be taken. Our continued monitoring of the literature revealed several additional studies since the time of their publication.

This is an interesting article which also seeks definitions of maintenance care. Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary. Their definition is “Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.”

It is interesting to note the term “supportive”. Supportive care (Mercy 1993): Treatment/care for patients having reached MMI, in whom periodic trials of withdrawal from care fail to sustain previous therapeutic gains that would otherwise progressively deteriorate. Supportive care follows appropriate application of active and passive care including lifestyle modifications, it is appropriate when rehabilitative and/or functional restorative and alternative care options including home-based self-care and lifestyle modifications have been considered and attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when the risk of supportive care outweighs its benefits, i.e., physician dependence, somatization, illness behavior, and secondary gain.

Furthermore, a study published in the Journal of Manipulative and Physiological Therapeutics, Volume 27, Issue 8, Pages 509-514 (October 2004) - Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain and Related Disabilities: A Preliminary Study indicates “This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels”.

It seems plausible that supportive care, when documented, is reasonable and necessary. Additionally, the terms supportive and maintenance should not be used interchangeably and seem to be intentionally confused by some. Furthermore, the reference to financial gain sounds like an attack on practice management groups instead of reasonable efforts by sound practitioners.

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.

We have provided a generic description of manual therapies and we have reviewed our recent systematic reviews on manual therapies for acute and chronic neck pain without whiplash. We then provided brief, original reviews of, first, the literature on the treatment of whiplash injury by manual therapies and, then, 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, it was our hope, in the present review, to present a broad overview of the topic with a distinctive approach emphasizing the analysis of change scores in the clinical trials.

The evidence reviewed here provides support for the contention that the manual therapies which induce joint mobility—manipulation and mobilization—are effective in the treatment of neck pain, especially chronic neck pain and neck pain due to whiplash injury, in those subjects who have been randomized to receive these therapies. This is demonstrated by relatively large intragroup effect sizes as well as other indicators of change. These indicators of clinical change or improvement appear to, in general, agree with the levels of clinically important change endorsed in the literature and to exceed those of the natural history of subjects with neck pain enrolled in clinical trials. The evidence reviewed here does not yet support the contention that massage therapy is similarly effective in those subjects randomized to receive it.

While integroup changes were not the focus of this review, the evidence reviewed here does not, in general, contradict the current consensus thatmanual therapies, particularly manipulation or mobilization have been shown to be superior to each other or to other treatments to which they have been compared. A small number of trials have demonstrated a superior effect of manipulation or mobilization versus the comparison treatment in chronic neck pain as well as in whiplash, but, of course, the majority of studies have manual therapies in a multimodal therapeutic approach is still valid and sensible.

Despite the variability in reported outcomes, a number of current clinical guidelines have positively endorsed manual therapies in the treatment of neck pain, although a minority of the published guidelines have not. At present, there is no overall consensus on the status of manual therapies for neck pain. Future research is still warranted to clarify these outstanding issues and to provide guidance to practitioners of these therapies for the optimal management of their neck pain patients.

From: Spine. 2002 Sep 1;27(17):1835-43

A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months. To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache (neck related headache) when used alone and in combination, as compared with a control group.

Headaches related to the neck and arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache.

In patients with cervicogenic headache, manipulative therapy and a low load exercise regimen each reduced headache frequency and intensity more than no physical therapy. A combination of manipulative therapy and exercise was not better than each individual therapy for these outcomes.

200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture. The therapeutic exercise used low load endurance exercises to train muscle control of the neck and scapular region.

There were no differences in headache-related and demographic characteristics between the groups at baseline. The loss to follow-up evaluation was 3.5%. At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained. The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant.

Commentary by Michael Yelland, MBBS, FRACGP

The study by Jull et al is the most rigorous attempt to date to assess the effects of physical therapies on the common clinical problem of cervicogenic headache. Its multicentre design, as well as some flexibility in the number and content of treatment sessions, increase the generalisability of the results to clinical practice. 12 month follow up adequately tested the durability of responses. Blinding was possible only for outcome assessment, but the success of this blinding was not reported.

The results indicate a superior effect of manipulative and exercise therapies used alone and in combination compared with a control condition. On balance, it seems that combined therapy offers slightly more than either therapy alone. The results are
consistent with a review, which showed that multimodal manual therapy, including exercise, is superior to certain physical medicine modalities, rest, and control treatments for cervicogenic headache.

It is impossible to determine the contribution of the non-specific effect of repeated contact with therapists. A course of 8–12 treatment sessions over a 6 week period was given to active treatment groups, but not to the control group. None the less, active treatments worked, and 2 active treatments worked a little better than one. No explanation for the limits on the number of treatment sessions was provided. Only 12–21% of patients in the active treatment groups sought additional treatment in the follow up period, suggesting that ≤ 12 treatments is sufficient. However, is < 8 treatments effective? A small trial of manipulation for cervicogenic headache showed significant improvements from baseline with 6 treatments, but these were not better than the active comparator of laser and deep friction massage; there was no non-intervention group.

Practising clinicians should take note of the trial’s selection criteria of unilateral or predominantly unilateral headache with neck pain and upper cervical tenderness to guide their selection of patients who may benefit from these treatments. Should there be
angst about the potential (small) risk of complications of cervical manipulation, exercise therapy alone would still be effective, or the manual therapy component could be limited to low velocity mobilisation.

From: Journal of Manipulative and Physiological Therapeutics. 2008 Feb;31(2):115-26

Investigating changes in the intrinsic inhibitory and facilitatory interactions within the sensorimotor cortex subsequent to a single session of neck manipulation of the cervical spine using single and paired pulse transcranial magnetic stimulation protocols.

Twelve subjects with a history of reoccurring neck pain participated in this study. Short interval intracortical inhibition, short interval intracortical facilitation, motor evoked potentials, and cortical silent periods were recorded from the abductor pollicis brevis and the extensor indices proprios muscles of the dominant limb after single and paired pulse transcranial magnetic stimulation of the contralateral motor cortex. The experimental measures were recorded before and after spinal manipulation of dysfunctional cervical joints, and on a different day after passive head movement. To assess spinal excitability, F wave persistence and amplitudes were recorded after median nerve stimulation at the wrist.

After neck manipulations, there was an increase in short interval intracortical facilitation, a decrease in short interval intracortical inhibition, and a shortening of the cortical silent periods in abductor pollicis brevis. The opposite effect was observed in extensor indices proprios, with a decrease in short interval intracortical facilitation and a lengthening of the cortical silent periods. No motor evoked potentials or F wave response alterations were observed, and no changes were observed after the control condition.

Spinal manipulation of dysfunctional cervical joints in the neck may alter specific central corticomotor facilitatory and inhibitory neural processing and cortical motor control of 2 upper limb muscles in a muscle specific manner. This suggests that spinal manipulation may alter sensorimotor integration. These findings may help elucidate mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation.

From: Chiropractic & Osteopathy 2005, 13:15

Recommendations from the available literature at the present time suggest that conservative management of cervical discogenic pain and disc protrusion, including chiropractic manipulation and ancillary therapies, can be successful in the absence of progressive neurological deficit. The current case highlights the initial successful management of a football athlete, and the later unsuccessful management. This case highlights the issues involvement in the management of a collision sport athlete with a serious neck injury.

This case outlines a series of cervical traumas producing neck, arm and head pain. The series of injuries involved forced flexion, compression and lateral deviation away from the painful side. This mechanism is in contrast to the mechanism of extension with lateral deviation towards the painful side as described in the majority of studies of neck injuries in American football and rugby. The clinical signs suggest a disc herniation following repeated trauma resulting in compression of the C7 nerve root.

There are several studies reporting chronic recurrent cervical nerve root neuropraxia (sometimes called “chronic burner syndrome”), in American football and in rugby players. This can commonly occur during blocking, tackling or engaging in a scrum. Chronic burner syndrome can be defined as:

1) a chronic recurrent neuropraxia or axonotmesis, or both, of a nerve root associated with prolonged weakness,

2) time loss from practice and games, and

3) recurrence

Nerve root compression in the intervertebral foramina secondary to disc herniation or degenerative changes, or both, is the most common cause in football players seen with recurrent or chronic burners. In such cases, degenerative changes frequently present with concurrent cervical canal stenosis and can predispose injury.

A correlation seems to exist between chronic recurrent cervical nerve root neurapraxia and cervical canal stenosis in tackled football players and risk of more serious cervical spine injury increases with increasing stenosis. A spinal canal-vertebral body ratio (Pavlov’s ratio) on lateral radiographs of 0.80 or less (normal ratio 1:1) at one or more levels has been found in a tackle football population who have experienced an episode of cervical cord neuropraxia manifested by sensory and/or motor symptoms. Despite a series of minor neurological insults, no correlation between the prodromal episodes of cord neuropraxia and occurrence of permanent quadriplegia has been found. Also, the presence of uncomplicated developmental narrowing of the stable cervical spine does not predispose permanent neurological injury.

Absolute contraindications to continued participation in contact sports has been recommended to apply to those individuals who have had a documented episode of cervical cord neurapraxia associated with the following:

• ligamentous instability,

• intervertebral disc disease with cord compression,

• significant degenerative changes,

• MRI evidence of cord defects or swelling,

• positive neurological findings lasting more than 36 hours,

• more than one recurrence

The extremely low predictive value of Pavlov’s ratio (as an indicator of clinically relevant spinal stenosis) precludes its use as a screening mechanism for determining participation in contact activities. To accurately assess spinal canal stenosis, cross-sectional imaging technology such as MRI, contrast positive CT, and myelography should be employed. Plain radiographic identification of a narrow spinal canal in a player sustaining cervical cord neuropraxia warrants MRI investigation to rule out soft tissue based stenosis.

Most of the literature on cervical spine injuries in football, such as burner syndrome, emphasises an extension type mechanism of injury. In our case, the mechanism of injury involved both hyperflexion and a compressive force. As hyperflexion involves more compressive load to the cervical spine than extension, this combination has a greater potential for injury, particularly if a stenosis situation concurrently exists.

With cervical hyperflexion, the spinolaminar line of the superior vertebra and the posterior superior aspect of the vertebral body below approximate, resulting in a rapid decrease of the spinal canal with compression of the spinal cord. The brief, sudden deformation of the cord is thought to produce disturbed sensory and motor function below the involved level. In most instances of acute spinal injury, disruption of cord function is the result of local cord anoxia and increased concentration of intracellular calcium. Playing with improper technique, such as spear tackling, has been associated with catastrophic injuries. In the case presented in this report, the technique of running at a tackler with neck hyperflexion before impact contributed to the repetitive history of injury and should have been corrected.

Hyperflexion injuries in Whiplash Associated Disorders do not involve the exact same mechanism of injury (i.e. absence of axial compression) but the soft tissue damage can be very similar. For example, Grade III Whiplash Associated Disorder features include: cervical herniated disc, cervicalgia with headaches and limited range of motion combined with neurologic symptoms and signs are present.

With compression, a force exerted through the crown of the head can be transmitted through the skull to the cervical vertebrae resulting in the crushing of the vertebrae and extrusion of the vertebral body and disc material posteriorly into the cervical vertebral canal. When the cervical spine is in hyperflexion with rotation, vertebral dislocation without fracture is possible, which is more likely if the head is locked on the ground adding a compressive force. The most damaging mechanisms of injury to the spine are torsional and combined motions (i.e. forward flexion and lateral rotation) with a combined axial load.

The practitioner should be mindful of the potential for iatrogenic joint instability to occur. Damage to the supporting structures resulting in hypermobile joints can be aggravated by and result from repeated manipulations. The recommended management protocol for Grade III Whiplash Associated Disorders, which is a similar injury, and could be viewed as a guideline for management of footballers with cervical stenosis.

This case report has outlined the progression of cervical injury to a disc protrusion resulting in a C7 radiculopathy in a professional rugby league player, due to numerous blows to the cervical spine after a series of hyperflexion injuries. The patient ultimately suffered a severe forced flexion combined with left lateral flexion injury to the cervical spine and experienced sensory and motor changes in the right C7 nerve root distribution. When it became apparent that there was intervertebral foramen encroachment secondary to a disc protrusion the treatment protocol changed toward a more conservative approach.