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.

The trapped meniscoid and inflammatory adhesion explanations have given rise to the theory that the ‘facet syndrome’ is a lesion which responds well to manipulative therapy. Cassidy and Kirkaldy-Willis write: “An adjustment (manipulation) that separates the articular surfaces may release entrapped synovial folds and stretch the segmental muscles initiating spindle mediated reflexes that relieve the state of hypertonicity [of paraspinal muscles splinting the posterior joints]”, and Murphy et al postulate that the facet joints are the target of all successful spinal manipulation. Likewise, Cox describes the facet syndrome as “probably the most common factor seen in chiropractic practices with low back pain patients….”.

It is therefore not surprising that the facet syndrome has a prominent place in chiropractic education and practice. Unfortunately, this is not reflected in research, which creates a gap between practice and scientific evidence. When practising evidence-based medicine, one has to draw on empirical evidence in the areas where scientific evidence is lacking. In the case of the acute facet syndrome, the amount of scientific evidence relating to diagnosis and treatment is almost non-existent. Despite this uncertainty, ‘acute facet syndrome’ appears to be a commonly used diagnosis in primary care among general practitioners, chiropractors and physiotherapists, at least in Denmark. Since the term ‘acute facet syndrome’ is widely used and accepted among chiropractors, research into the degree of consensus on the subject amongst a large group of practitioners was seen to be a useful contribution. Therefore, this study aims to describe chiropractors’ views of the clinical presentation of, and course of treatment for, acute facet syndrome in the lumbar spine.

Generally, the participating chiropractors’ views of the acute facet syndrome and the description of chronic facet joint pain found in the existing literature were surprisingly similar. The chiropractors attending the ECU workshop described the characteristics of an acute, uncomplicated facet syndrome as follows: local, ipsilateral pain, occasionally extending into the thigh with pain and decreased range of motion in extension and rotation both standing and sitting. They thought that the pain could be relieved by walking, lying with knees bent, using ice packs and taking NSAIDs, and aggravated by prolonged standing or resting. They also stated that there would be no signs of neurologic involvement and no sign of aggravation of pain from sitting, flexion or coughing/sneezing. Finally, they did not link the acute facet syndrome with an antalgic posture.

When interpreting results, it must be remembered that the groups were asked to agree on a maximum of three words. Thus, even if a term is only mentioned by one group, this does not necessarily mean that the other groups disagree. For example, to the question of relieving factors, one group chose to answer “avoid aggravating factors”. Although this was only mentioned by one group, it is likely that the other groups would agree. The authors decided they could only focus on obvious sources of disagreement in cases where the groups clearly contradicted each other and this did not happen in the study.

Since the early 1980s, several investigators have attempted to define clinical criteria to distinguish pain from the facet joints from other types of low back pain, but some results have been contradictory. Several authors agree that absence of positive signs of neurological compromise, such as positive straight leg raising, pain on coughing and dermatomal radicular pain, increases the likelihood of the pain originating in the facet joints. Likewise, there is some agreement that the frequency of facet joint involvement in chronic low back pain increases with age, but Manchikanti did not find an association with age in two earlier studies. Other studies failed to find any associations between response to facet joint blocks and patient history or physical examination, including straight leg raising and pain on movement. With the exception of Fairbank et al’s study from 1981, all of these studies included only patients with chronic low back pain. The essence is that so far only diagnostic blocks (including confirmatory blocks), not clinical signs and symptoms, can accurately diagnose back pain arising from the facet joints, regardless of whether it is acute or chronic.

Regarding the distribution of facet joint pain, some investigators have found it to be paraspinal, three studies have found pain extending into the groin or thigh and two found pain extending into the calf to be a negative indicator for facet joint pain. If the pain does extend into the leg it seems to be in the sclerodermal structures, referred from the nociceptors of the facet joint capsules.

The chiropractors in the current study agreed with the existing literature on chronic low back pain: local, paraspinal pain in the back, occasionally referring to groin and thigh, rarely below the knee. There was no information to be extracted from the workshop with regard to the intensity of pain, and interestingly, literature on this subject has not been found either. One finding that was a surprise was the chiropractors’ belief that the pain is located to the side of involvement. Mention of such laterality in the literature has not been found, nevertheless, all groups agreed on the pain only being present on the side of involvement.

As for aggravating and relieving types of movement, there is more disagreement in the existing literature. Fairbank reported pain on flexion, whereas absence of pain aggravation on forward flexion was reported in three other studies. Revel also reported absence of pain aggravation with extension and rotation while increased pain on extension was found in four other studies and increased pain on rotation in two. Furthermore, pain relief from lying supine/recumbent, from walking and from sitting has been reported. Finally, absence of pain when rising from sitting or flexion has been shown to distinguish facet joint pain from pain from other structures.

Also for aggravating and relieving types of movement, the participants in this study agreed to a large extent with the literature pertaining to chronic facet syndrome: primarily pain on extension and rotation and relief from walking and lying down. In addition, the chiropractors also considered sudden movements, prolonged standing and prolonged rest as aggravating factors. The authors have not found any evidence for or against this in the literature. The same was true for supported flexion, icepacks and NSAIDs as relieving factors. This might be because the retrieved literature related to the distinction between pain originating from the facet joints and pain from other structures. Supported flexion, icepacks and NSAIDs might be relevant for all types of acute low back pain. The only clear discrepancy between the responses in this study and the existing literature is that one of the study groups considered getting up from flexion an aggravating factor whereas both Revel and Laslett found that absence of aggravation of pain on rising from flexion was characteristic of pain originating from the facet joints.

The results of the open discussion with all participants on how to distinguish the acute pain of facet joints from that of discal structures was also in concordance with the existing literature relating to chronic pain. It was believed that pain on sitting, flexion and prolonged walking would indicate disc rather than facet joint involvement and the same symptoms would indicate a typical radicular pattern, especially if accompanied by coughing and sneezing. One thing raised in the discussion, which is not mentioned in the facet joint literature, was antalgic posture as a sign of discogenic pain but not a sign of facet joint pain. This might be because the literature primarily considered chronic pain, in which antalgia is less common.

The participants in this study generally considered the syndrome to have an uncomplicated course, typically requiring 2-4 treatments over a period of two weeks. There did not appear to be any existing literature with regard to chiropractic management of the acute facet syndrome.

The high agreement among chiropractors and between chiropractors and the literature may indicate that chiropractors have a common educational background, and that their beliefs about facet joint pain to a large degree reflect what they were taught. Since chiropractors have a profound belief that facet joint pain responds well to manipulation therapy, it is likely that this description is actually of the typical patient responding well to manipulation rather than a patient with acute pain originating in the facet joints. Nevertheless, it is possible that these results do indeed capture the clinical picture of a patient with facet joint pain.

Based on the opinion of the chiropractors in this study, two hypotheses can be generated: (1) acute facet joint pain can be clinically defined, and (2) acute facet joint pain responds well to spinal manipulative therapy. Both of these hypotheses can be tested by verifying diagnoses using diagnostic blocks. The results would have implications for clinical decisions with regard to diagnosis and treatment for patients with low back pain. Since the clinical presentation thought to represent this condition is rather common and, to date poorly investigated, it is hoped that the above hypotheses will be tested in the near future.

The chiropractors attending the workshop seemed to have a common understanding of pain originating from the facet joints. They described the characteristics of an acute, uncomplicated lumbar facet syndrome in much the same way as chronic pain from the facet joints has been described in the literature. Furthermore, the acute, uncomplicated facet syndrome was considered to have an uncomplicated clinical course, responding quickly to manipulative therapy – a concept that appears never to have been scientifically tested.

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.

Specifically, in a Swedish study of patients with low back pain, it was shown that patients with low back pain for altogether at least 30 days in the past year, who had leg pain, and who did not report some improvement by the second treatment, were not good candidates for definite improvement by the 4th visit. Although the final model was excellent in predicting non-response at the 4th visit (96%), it could only predict 19% of patients who would be “definitely better”.

The results of the present study confirm that it is possible to predict short-term outcome in patients with low back pain who receive chiropractic care. This is a clinically relevant finding, as it has been previously shown that short-term outcome (i.e. recovery by the fourth visit) is a predictor for the outcome at both 3 and 12 months, at least in patients with relatively long-lasting or recurrent low back pain.

When the previously achieved best Swedish model was applied to patients from Finland, the associations between outcome and the three relevant variables (leg pain, duration of pain in the past year and leg pain) were again positive, although duration failed to reach significance and leg pain was only weakly associated, and in the final analysis, only improvement at the second visit remained significant.

Improvement at the second visit meant that patients reported that at least one of the five “disabilities” was better than at base-line, namely sleeping, turning in bed, putting on socks/shoes, getting up from a chair, or walking.

Even when adding the three new factors (BMI, other spinal pain and general health), improvement at the second visit was the only strongly associated variable that emerged from the multivariate analysis.

In the final analysis, taking into account also leg pain and BMI did not really improve the estimates in a clinically meaningful way. However, when the number of these predictor variables present in each person was tested against outcome, a doseresponse was revealed. In the whole study sample, the proportion of patients in the study who were “definitely better” at the fourth visit was 66%. In patients with none of these three predictors, 84% were better, whereas only 34% of those who had all three belonged to this category.

There are three important messages in this report. First, already at the first visit one should be vigilant with overweight/obese patients who have pain radiating into the leg. Second, at the return visit, for these patients if there is lack of improvement, the short-term prognosis is poor. Third, that any patient, who fails to improve at the 2nd visit has a poor short-term prognosis. Therefore, when treating patients with low back pain, the treatment strategy should be different for overweight/obese patients with leg pain as it should be for all patients who fail to improve by the 2nd and 4th visits.

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”.

In some conditions, particularly those that are degenerative in nature or involve abnormalities of the vertebral motion segment, abnormal findings are not always associated with symptoms. Fourteen to 18% of people without neck pain demonstrate a wide range of abnormalities with imaging studies, including disc protrusion or extrusion and impingement of the thecal sac on the nerve root and spinal cord. However, degenerative changes are still suggested to be a possible cause of mechanical neck pain in some cases, despite the fact that these changes are present in asymptomatic individuals, are non-specific, and are highly prevalent in the elderly. Disorders such as cervical radiculopathy and cervical compressive myelopathy are reported to be caused by space-occupying lesions (osteophytosis or herniated cervical disc). These may be secondary to degenerative processes and can give rise to neck and/or upper quarter pain as well as neurologic signs and symptoms. While cervical disc herniation and spondylosis are most commonly linked to cervical radiculopathy and myelopathy, the bony and ligamentous tissues affected by these conditions are themselves pain generators and are capable of giving rise to some of the referred symptoms observed in patients with these disorders

Because most patients with neck pain usually lack an identifiable pathoanatomic cause for their problem, the majority are classified as having mechanical neck disorders.

Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain.

Investigatios into the clinical course and predictors of recovery for patients with neck and shoulder pain indicated four hundred forty three patients who consulted their primary care physician with neck or shoulder symptoms were followed for 12 months. At 12 months, 32% of patients reported that they had recovered. Predictors of poor pain-related outcome at 12 months included less intense pain at baseline, a history of neck and shoulder symptoms, more worrying, worse perceived health, and a moderate or bad quality of life. The predictors for a poor disability-related response at 12 months included older age, less disability at baseline, longer duration of symptoms, loss of strength in hands, having multiple symptoms, more worrying, moderate or bad quality of life, and less vitality.

Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, bicycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain.

Approximately 44% of patients experiencing neck pain will go on to develop chronic symptoms, and many will continue to exhibit moderate disability at long-term follow-up A recent systematic review examined the outcomes of nontreatment control groups in clinical trials for the conservative management of chronic mechanical neck pain – not due to whiplash. The outcomes of patients receiving a control or placebo intervention were analyzed and effect sizes were calculated. The changes in pain scores over the varying trial periods in these untreated subjects with chronic mechanical neck pain were consistently small and not significant.

Conversely, there is substantial evidence that favorable outcomes are attained following treatment of patients with cervical radiculopathy. For example, nearly 90% of patients with cervical radiculopathy presented with only mild symptoms at a median follow-up of 4.9 years. It was found that 70% of patients with cervical radiculopathy excellent outcomes after a 2-year follow-up. Outcomes for the patients in the aforementioned studies appeared favorable and suggest that 70-90% of this population can experience improvement without surgical intervention. In contrast, the clinical prognosis of patients with whiplash associated disorder is less favorable. A survey of 108 patients with a history of whiplash requiring care at an emergency department found that 55% had residual pain and disability referable to the original accident at a mean follow-up of 17 years later. Neck pain, radiating pain, and headache were the most common symptoms. Thirty-three percent of the respondents with residual symptoms suffered from work disability, compared to 6% in the group of patients without residual disorders.

Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain. (Recommendation based on theoretical/foundational evidence.)

Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, cycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain. (Recommendation based on moderate evidence.)

Neck pain, without symptoms or signs of serious medical or psychological conditions, associated with (1) motion limitations in the cervical and upper thoracic regions, (2) headaches, and (3) referred or radiating pain into an upper extremity are useful clinical findings for classifying a patient with neck pain into one of the following International Statistical Classification of Diseases and Related Health Problems (ICD) categories: cervicalgia, pain in thoracic spine, headaches, cervicocranial syndrome, sprain and strain of cervical spine, spondylosis with radiculopathy, and cervical disc disorder with radiculopathy; and the associated International Classification of Functioning, Disability, and Health (ICF) impairmentbased category of neck pain with the following impairments of body function:

• Neck pain with mobility deficits (Mobility of several joints)
• Neck pain with headaches (Pain in head and neck)
• Neck pain with movement coordination impairments (Control of complex voluntary movements)
• Neck pain with radiating pain (Radiating pain in a segment or region)

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with mobility deficits and the associated ICD categories of cervicalgia or pain in thoracic spine. (Recommendation based on moderate evidence.)

• Cervical active range of motion
• Cervical and thoracic segmental mobility

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with headaches and the associated ICD categories of headaches or cervicocranial syndrome. (Recommendation based on moderate evidence.)

• Cervical active range of motion
• Cervical segmental mobility
• Cranial cervical flexion test

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with movement coordination impairments and the associated ICD category of sprain and strain of cervical spine. (Recommendation based on moderate evidence.)

• Cranial cervical flexion test
• Deep neck flexor endurance test

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with radiating pain and the associated ICD categories of spondylosis with radiculopathy or cervical disc disorder with radiculopathy. (Recommendation based on moderate evidence.)

• Upper limb tension test
• Spurling’s test
• Distraction test

Clinicians should consider diagnostic classifications associated with serious pathological conditions or psychosocial factors when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline, or, when the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function. (Recommendation based on moderate evidence.)

Clinicians should use validated self-report questionnaires, such as the Neck Disability Index and the Patient-Specific Functional Scale for patients with neck pain. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring a change in a patient’s status throughout the course of treatment. (Recommendation based on strong evidence.)

Clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with their patient’s neck pain to assess the changes in the patient’s level of function over the episode of care. (Recommendation based on expert opinion.)

Clinicians should consider utilizing cervical manipulation and mobilization procedures, thrust and non-thrust, to reduce neck pain and headache. Combining cervical manipulation and mobilization with exercise is more effective for reducing neck pain, headache, and disability than manipulation and mobilization alone. (Recommendation based on strong evidence.)

Thoracic spine thrust manipulation can be used for patients with primary complaints of neck pain. Thoracic spine thrust manipulation can also be used for reducing pain and disability in patients with neck and neck-related arm pain. (Recommendation based on weak evidence.)

Flexibility exercises can be used for patients with neck symptoms. Examination and targeted flexibility exercises for the following muscles are suggested: anterior/medial/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major. (Recommendation based on weak evidence.)

Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache. (Recommendation based on strong evidence.)

Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions. (Recommendation based on weak evidence.)

Clinicians should consider the use of upper quarter and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain. (Recommendation based on moderate evidence.)

Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain. (Recommendation based on moderate evidence.)

To improve recovery in patients with whiplash associated disorder, clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs. (Recommendation based on strong evidence.) Pain and impairment of the neck is common. It is estimated that 22% to 70% of the population will have neck pain some time in their lives. In addition, it has been suggested that the incidence of neck pain is increasing At any given time, 10% to 20% of the population reports neck problems, with 54% of individuals having experienced neck pain within the last 6 months. Prevalence of neck pain increases with age and is most common in women around the fifth decade of life.

Complete neck pain clinical guidelines

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.