Chiropractic and exercise for seniors with low back pain or neck pain
Chiropractic and exercise for seniors with low back pain or neck pain: the design of two randomized clinical trials
From: BMC Musculoskeletal Disorders 2007, 8:94
Low back pain and neck pain are major public health problems throughout the western world. These conditions can begin early in life and persist through adulthood and into old age. This places low back pain and neck pain among the most common health complaints experienced over a lifetime. Most research pertaining to low back pain and neck pain has been aimed at the working and middle aged segments of the population. However, it is estimated that, by the year 2025, approximately one third of individuals in developed countries will be over 60 years of age. Anticipating the impact of population projections, interest in low back pain and neck pain among seniors has increased.
Low back pain and neck pain, either alone or in conjunction, affect over 30% of the population 70 years of age and older on a monthly basis. These conditions have important impact, since approximately 15% of this population indicate that they have subsequently altered or diminished their physical activity during the past year due to low back pain or neck pain. Roughly the same proportion have sought some kind of treatment. Furthermore, low back pain has been rated as the third most important condition affecting the physical health status of older Americans, after heart and lung disease. Neck pain has also been found to substantially impact function and well-being in this age group. Thus, while low back pain and neck pain are not life threatening conditions, they may lead to reduced functional ability and decreased independence, resulting in serious socio-economic consequences for elderly individuals, their families, and society. Therefore, research aimed at identifying effective prevention and treatment strategies is a high priority.
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.
