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Integrating Connective Tissue and Nervous System Mechanisms
Medical Hypotheses
Volume 68, Issue 1, January 2007, Pages 74-80

Helene M. Langevin and Karen J. Sherman

The primary author is from the Department of Neurology, University of Vermont, College of Medicine.

FROM ABSTRACT

Although chronic low back pain (cLBP) is increasingly recognized as a complex syndrome with multifactorial etiology, the pathogenic mechanisms leading to the development of chronic pain in this condition remain poorly understood.

This article presents a new, testable pathophysiological model integrating connective tissue plasticity mechanisms with several well-developed areas of research on cLBP (pain psychology, postural control, neuroplasticity).

We hypothesize that pain-related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation, nervous system sensitization and further decreased mobility.

The integration of connective tissue and nervous system plasticity into the model of cLBP will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise).

Non-invasive measures of connective tissue remodeling may eventually become important tools to evaluate and follow patients with cLBP in research and clinical practice.

THESE AUTHORS ALSO NOTE:

“Historically, mechanistic models for cLBP have tended to focus on musculoskeletal tissues, on the nervous system, or on behavior. In this paper, we propose a new, dynamic and integrative pathophysiological model for cLBP bringing together recent research on movement and neuroplasticity along with well-established connective tissue remodeling mechanisms.”

These authors propose that “plasticity in both connective tissue and nervous systems, linked to each other via changes in motor behavior, play a key role in the natural history of cLBP, as well as the response of cLBP to treatments and placebos.”

The “association between symptoms and imaging results (X-ray, CT, MRI) has been consistently weak, and up to 85% of patients with low back pain cannot be given a precise pathoanatomical diagnosis using these methods.”

“The generally poor predictive value of diagnostic imaging in cLBP, and the often disappointing effects of many ‘lesion-specific’ treatments such as intra-articular corticosteroid injections, has spurred research efforts toward ‘non-structural’ psychological and behavioral aspects of cLBP, and away from tissue pathology.”

“Rest may be initially important in the face of acute low back injury (e.g. disc herniation, muscle sprain), it is increasingly recognized that timely resumption of physical activity is critical to successful rehabilitation.”

“In addition to abnormal movement patterns, patients with cLBP have been shown to have generalized augmented pain sensitivity and cortical activation patterns suggesting abnormal central pain processing.”

“Ongoing pain is associated with widespread neuroplastic changes at multiple levels within the nervous system and including primary afferent neurons, spinal cord, brainstem, thalamus, limbic system and cortex.”

Neuroimaging has shown that there are distinct “brain networks” involved in acute vs. chronic pain. Chronic pain is specifically related to regions for cognition and emotions.

Chronic back pain results in neuronal or glial loss in the pre-frontal and thalamic gray matter.

Current models view chronic pain as a multisystem output, the “pain neuromatrix” includes both sensory and motor components.

“We hypothesize that connective tissue remodeling occurs in cLBP as a result of emotional, behavioral and motor dysfunction.”

“We further hypothesize that increased connective tissue stiffness due to fibrosis is an important link in the pathogenic mechanism leading to chronicity of pain, fear-avoidance and further movement impairment.”
[Very Important: The Fibrosis of Repair, Fibrotic Changes]

“Abnormal movement patterns can have important influences on the connective tissues that surround and infiltrate muscles.” [Very Important]

“A hallmark of connective tissue is its plasticity or ‘remodeling’ in response to varying levels of mechanical stress.”

“Both increased stress due to overuse, repetitive movement and/or hypermobility, and decreased stress due to immobilization or hypomobility can cause changes in connective tissue.”

“A chronic, local increase in stress can lead to microinjury and inflammation (overuse injury, cumulative trauma disorder).”

“A consistent absence of stress, on the other hand, leads to connective tissue atrophy, architectural disorganization, fibrosis, adhesions and contractures.”

“Fibrosis can be the direct result of hypomobility or the indirect result of hypermobility via injury and inflammation.” [Very Important]

During the early phase of immobilization, loss of muscle length is primarily due to shortening of muscle-associated connective tissue, which is later followed by actual shortening of muscle fibers.

Muscle connective tissue fibrosis promotes hypomobility. “Connective tissue fibrosis is detrimental, as it leads to increased tissue stiffness and further movement impairment.” [Important]

“Tissue microinjury, inflammation and fibrosis not only can change the biomechanics of soft tissue (e.g. increased stiffness) but also can profoundly alter the sensory input arising from the affected tissues.” [Very Important]

“Connective tissue is richly innervated with mechanosensory and nociceptive neurons.” [Very Important]

Activation of nociceptors can contribute to the development or worsening of fibrosis and inflammation, causing even more tissue stiffness and movement impairment. [Important]

In patients with cLBP, connective tissue fibrosis can occur in the lower back due to one or several of the following factors:

1) Decreased activity

2) Changes in muscle activation patterns causing muscle co-contraction, muscle spasm or tissue microtrauma

3) Neurally-mediated inflammation

Chronic low back pain may be caused by pathological connective tissue fibrosis, which causes adverse changes in movement. This is well documented in ligaments and joint capsules. [Very Important] This pathological connective tissue fibrosis is plastic and can therefore be remodeled. However, the remodeling must take place over time.

“In fibrosed connective tissue and muscle, blood and lymphatic flow may be chronically compromised by the disorganized tissue architecture and thus vulnerable to unusual muscle activity (e.g. beginning a new work activity or sport), or to conditions causing further decrease in perfusion such as prolonged sitting.”

Pain leads to reduced motion, and movement restriction increases fibrosis, “setting the patient up for more painful episodes.” [Very Important]

“In addition to its role in the pathological consequences of immobility and injury, the dynamic and potentially reversible nature of connective tissue plasticity may be key to the beneficial effects of widely used physical therapy techniques as well as ‘alternative’ treatments involving external application of mechanical forces (e.g. massage, chiropractic manipulation, acupuncture), changes in specific movement patterns (e.g. movement therapies, tai chi, yoga) or more general changes in activity levels (e.g. increased recreational exercise).”

“Manual or movement-based treatments have the advantage of not causing drug-induced side effects (e.g. gastritis, sedation),” but excessive motion may lead to inflammation.

A “carefully applied direct tissue stretch may be necessary in cases of long standing hypomobility with pronounced fibrosis and stiffness.”
[Very Important]

“The model presented in this paper predicts that beneficial connective tissue remodeling can result from a variety of therapeutic interventions.”

Connective tissue remodeling may be assessed with “non-invasive ultrasound based techniques such as ultrasound elastography.”

KEY POINTS FROM THIS ARTICLE:

1) In chronic low back pain, there is an integration between connective tissue fibrosis and the nervous system perception of pain.

2) Adverse connective tissue fibrosis can be remodeled by applying mechanical forces to soft tissues, including chiropractic spinal adjusting. [Note, chiropractic was included as the applying of a mechanical force to reverse adverse connective tissue fibrosis and its influence on the nervous system.]

3) The “association between symptoms and imaging results (X-ray, CT, MRI) has been consistently weak, and up to 85% of patients with low back pain cannot be given a precise pathoanatomical diagnosis using these methods.”

4) “Ongoing pain is associated with widespread neuroplastic changes at multiple levels within the nervous system and including primary afferent neurons, spinal cord, brainstem, thalamus, limbic system and cortex.”

5) Neuroimaging has shown that there are distinct “brain networks” involved in acute vs. chronic pain. Chronic pain is specifically related to regions for cognition and emotions.

6) Chronic back pain results in neuronal or glial loss in the pre-frontal and thalamic gray matter. [Brain atrophy]

7) “Increased connective tissue stiffness due to fibrosis is an important link in the pathogenic mechanism leading to chronicity of pain.”

8) “Abnormal movement patterns can have important influences on the connective tissues that surround and infiltrate muscles.” [Very important because the subluxation complex includes abnormal movement patterns.]

9) “A hallmark of connective tissue is its plasticity or ‘remodeling’ in response to varying levels of mechanical stress.” [This is important because it implies that spinal adjusting can initiate remodeling of abnormal connective tissues.]

10) “Both increased stress due to overuse, repetitive movement and/or hypermobility, and decreased stress due to immobilization or hypomobility can cause changes in connective tissue.”
[Both increased and decreased motion are deleterious.]

11) A chronic local increase in stress leads to micro-injury and inflammation.
[Subluxation can cause micro-injury and inflammation.]

12) “A consistent absence of stress leads to connective tissue atrophy, architectural disorganization, fibrosis, adhesions and contractures.” [Fibrosis]

13) “Fibrosis can be the direct result of hypomobility or the indirect result of hypermobility via injury and inflammation.” [Very Important]

14) During the early phase of immobilization, loss of muscle length is primarily due to shortening of muscle-associated connective tissue, which is later followed by actual shortening of muscle fibers.

15) Muscle connective tissue fibrosis promotes hypomobility. “Connective tissue fibrosis is detrimental, as it leads to increased tissue stiffness and further movement impairment.” [Important, Fibrosis]

16) “Tissue microinjury, inflammation and fibrosis not only can change the biomechanics of soft tissue (e.g. increased stiffness) but also can profoundly alter the sensory input arising from the affected tissues.” [Very Important: many contend that the tissue changes associated with the subluxation alter the afferent input into the CNS, which is the nerve interference of the subluxation.]

17) “Connective tissue is richly innervated with mechanosensory and nociceptive neurons.” [Very Important]

18) Activation of nociceptors can contribute to the development or worsening of fibrosis and inflammation, causing even more tissue stiffness and movement impairment. [Important]

19) Chronic low back pain may be caused by pathological connective tissue fibrosis, which causes adverse changes in movement. This is well documented in ligaments and joint capsules. [Very Important] This pathological connective tissue fibrosis is plastic and can therefore be remodeled. However, the remodeling must take place over time.

20) “In fibrosed connective tissue and muscle, blood and lymphatic flow may be chronically compromised by the disorganized tissue architecture and thus vulnerable to unusual muscle activity (e.g. beginning a new work activity or sport), or to conditions causing further decrease in perfusion such as prolonged sitting.”

21) Pain leads to reduced motion, and movement restriction increases fibrosis, “setting the patient up for more painful episodes.” [Very Important, Fibrosis]

22) “In addition to its role in the pathological consequences of immobility and injury, the dynamic and potentially reversible nature of connective tissue plasticity may be key to the beneficial effects of widely used physical therapy techniques as well as ‘alternative’ treatments involving external application of mechanical forces (e.g. massage, chiropractic manipulation, acupuncture), changes in specific movement patterns (e.g. movement therapies, tai chi, yoga) or more general changes in activity levels (e.g. increased recreational exercise).”

23) “Manual or movement-based treatments have the advantage of not causing drug-induced side effects (e.g. gastritis, sedation),” but excessive motion may lead to inflammation.

24) A “carefully applied direct tissue stretch may be necessary in cases of long standing hypomobility with pronounced fibrosis and stiffness.”
[Very Important, as a chiropractic adjustment may be considered to be a “carefully applied direct tissue stretch.”]

A Model Based Upon This Article

 

The Journal of the American Board of Family Practice
17:S13-S22 (Nov/Dec. 2004)

Alan B. Douglass, MD and Edward T. Bope, MD

FROM ABSTRACT

Neck pain is almost universal and is a common patient complaint.

Although the differential diagnosis is extensive, most symptoms are from biomechanical sources, such as axial neck pain, whiplash-associated disorder (WAD), and radiculopathy.

There is relatively little high-quality treatment evidence available, and no consensus on management of axial neck pain or radiculopathy.

The goal of diagnosis is to identify the anatomic pain generator(s).

Patient history and examination are important in distinguishing potential causes and identifying red flags.

Diagnostic imaging should be ordered only when necessary because of the high incidence of asymptomatic radiographic abnormalities.

First-line drug treatments include acetaminophen, cyclo-oxygenase 2–specific inhibitors or nonsteroidal anti-inflammatory drugs. [NOTE: since September 30, 2004, the cox-2 inhibitors Vioxx and Bextra have been pulled from the market because they have been found to increase strokes and heart attacks.]

Short-term use of muscle relaxants may be considered.

Opioids should be used if other treatments are ineffective and continued if improved function outweighs impairment.

Adjuvant antidepressants and anticonvulsants should be considered in chronic or neuropathic pain and coincident depression.

Epidural steroids should be considered only in radiculopathy.

Physical modalities supported by evidence should be used.
[This included manipulation and mobilization]

If symptoms have not resolved in 4 to 6 weeks, re-evaluation and additional workup should be considered.

THESE AUTHORS ALSO NOTE:

The human neck is highly susceptible to irritation.

In any given month, 10% of people will have neck pain.

Neck pain generators include bones, muscles, ligaments, facet joints, and discs.

“Almost any injury or disease process within the neck or adjacent structures will result in reflexive protective muscle spasm and loss of motion.”

“Gradual collapse of the intervertebral discs and degeneration of the facet joints is a universal part of the aging process and, in some people, can lead to nerve or spinal cord impingement.”

Further, neck mobility is so important to normal human functioning that any disruption in its normal function is quickly noticed.

“By far, the most common causes are biomechanical: axial neck pain, whiplash-associated disorder (WAD), and cervical radiculopathy.”

Pain also may be referred to the neck from shoulder disorders, thoracic outlet syndrome, esophagitis, angina, and vascular dissection.

“Neck pain may also present as part of complex generalized pain syndromes such as fibromyalgia.”

This article focuses on the 3 most common sources of neck pain that are encountered by primary care physicians: axial neck pain, WAD, and cervical radiculopathy

“Axial neck pain (also known as uncomplicated neck pain and cervical strain) is the result of the complex interaction of muscular and ligamentous factors related to posture, sleep habits, ergonomics such as computer monitor and bifocal position, stress, chronic muscle fatigue, postural adaptation to other primary pain sources (shoulder, temporomandibular joint, craniocervical), or degenerative changes of the cervical discs or facet joints. The ICD-9 code is 723.1.”

Whiplash-associated disorder (WAD) neck pain results from acceleration/deceleration transfer of energy to the neck. Its pain generators include myofascia, ligamentous, disc, and facet joints. It most commonly occurs in rear-end motor vehicle crashes.

The Quebec Classification of Whiplash-Associated Disorders identifies 4 categories of injury (The ICD-9 code is 847.0.):

Grade I comprises general, nonspecific complaints regarding the neck, such as pain, stiffness, or soreness without objective physical findings.

Grade II comprises neck complaints plus signs limited to musculoskeletal structures.

Grade III comprises neck complaints plus neurologic signs.

Grade IV comprises neck pain plus fracture or dislocation.

“Cervical radiculopathy is motor and/or sensory changes in the neck and arms resulting from extrinsic pressure on a cervical nerve root, usually by osteophytes or disk material.” “Seventy to ninety percent of cases are associated with foraminal encroachment by degenerative bony changes; herniated disk material is present in most of the remainder [IMPORTANT]. An inflammatory response is probably necessary for the initiation of symptoms [IMPORTANT]. The ICD-9 code is 723.4.”

“Myelopathy is the manifestation of long tract signs resulting from a decrease in the space available in the cervical canal for the spinal cord. A number of factors contribute to extrinsic pressure, including the congenital cord diameter, osteophytes, protruding disk material, dynamic changes in canal diameter and the cord itself, and the vascular supply to the cord. The ICD-9 code is 721.1.”

One study found that 66% of adults experienced neck pain at some point in their lifetimes.

54% of adults have had neck pain in the most recent 6 months.

At any point in time, 9% of the adult population had neck pain.

“Neck pain accounts for 1% of all visits to primary care physicians in the US.

Axial neck pain is the most common type, and up to 32% will have moderate or severe long-term residual pain. [IMPORTANT: this indicates that a significant number of those with non-traumatic axial neck pain will have long-term residuals].

There are 1 million cases of WAD annually in the US.

There is little evidence for a link between the mechanism of WAD injury and chronic symptoms.

“In 11 high-quality studies, 19% to 60% (mean, 33%) of patients with WAD reported chronic symptoms.” [Again, IMPORTANT] [Freeman MD, Croft AC, Rossignol AM. Whiplash associated disorders: redefining whiplash and its management, by the Quebec task force. A critical evaluation. Spine 1998; 23: 1043–49]

7% of people who are asymptomatic 3 months after an accident will have symptoms after 2 years.
[This means their symptoms go away and then later return].

85% of people who are symptomatic 3 months after an accident will remain so after 2 years. [This means that if they do not recover within the first 3 months, they are very likely to have chronic symptoms].

Most patients with radiculopathy will have resolution of symptoms without surgery.

“However, a number of studies have documented progressive deterioration without surgery.”

PRESENTING SYMPTOMS

Axial neck pain and WAD often present as pain or soreness in the posterior neck muscles, with radiation to the occiput, shoulder, or intrascapular region.
[IMPORTANT: Just because it radiates does not mean it is radicular in origin.]

Axial neck pain and WAD also often present with stiffness and headache and can be associated with local warmth or tingling.

“Radicular pain is sharp, tingling, or burning in a specific dermatomal distribution in the upper extremity.” [IMPORTANT]

“True radicular pain follows dermatomal patterns.” [IMPORTANT]

Radicular pain is aggravated by arm position and with extension or lateral flexion of the head.

Regarding radicular pathology, one study notes [Henderson CM, Hennessy RG, Shuey HM Jr, Shackelford EG. Posterior-lateral foramenectomy as an exclusive operative technique for cervical radiculopathy: a review of 846 consecutively operated cases. Neurosurgery 1983; 13: 504–12]:

1) 99% of patients had arm pain.

2) 85% had sensory deficits.

3) 79% had neck pain.

4) 71% had reflex deficits.

5) 68% had motor deficits.

6) 52% had scapular pain.

Cervical myelopathy may have complaints of insidious clumsiness, weakness, or stiffness in the upper and lower extremities. [NOTE: lower extremities].

Cervical myelopathy may present with deep, aching pain in the neck, shoulder, or arm.

Cervical myelopathy may also display arm or leg dysfunction and gait and balance difficulties are common. [Note again, leg and gait problems].

Cervical myelopathy may result in urinary complaints, such as urgency or hesitancy, but frank urinary or fecal incontinence is unusual. [IMPORTANT]

TREATMENT

“There is no clear consensus on the management of axial neck pain or radiculopathy.”

“Morning stiffness that improves over the course of the day is sometimes indicative of rheumatic causes.”

“Fever, weight loss, night sweats, and other systemic symptoms are indicative of infection or neoplasm.”

Unremitting night pain may be secondary to a bony tumor.

“Gait disturbance, balance problems, sphincter dysfunction, or loss of coordination suggests myelopathy.”

The physical examination should include:

1) Cervical range of motion.

2) Shoulder range of motion.

3) Neurologic examination of sensory and motor function as well as reflexes is vital.

4) Spurling’s compression maneuver will often provoke radicular pain.

“Placing the affected hand on top of the head (abduction relief sign) takes stretch off of the affected nerve root and may decrease or relieve radicular symptoms.”

“An electric shock sensation down the center of the back after neck flexion (Lhermitte sign) is indicative of cervical spinal cord pathology such as cervical myelopathy.” [This can also occur in multiple sclerosis].

“One study of radiographs of asymptomatic persons between 50 and 65 years of age demonstrated that 79% of subjects had disk space narrowing, endplate sclerosis, or osteophytes.” [Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine 1986; 11: 521–24].

“A study of magnetic resonance images revealed major abnormalities, such as bulging or herniated discs, foraminal stenosis, disk space narrowing, or abnormal cord signal in 14% of asymptomatic subjects younger than 40 years and in 28% older than 40 years.” [Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Weisel S. Abnormal magnetic resonance scans of the cervical spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am 1990; 72: 1178–84].

“Radiographs are recommended in patients with WAD grade III or suspected grade IV (grade IV cannot be diagnosed without an radiograph) and in patients with a history of trauma.” [This is contradictory, because WAD grade I and grade II are a “history of trauma.”]

“Plain radiographs also should be considered in patients with axial neck pain unresponsive to 6 to 8 weeks of conservative treatment.” [IMPORTANT]

“Magnetic resonance imaging should be performed if myelopathy, infection, or neoplasm is suspected; in patients with radicular pain associated with motor or reflex deficits; and in patients with radicular symptoms that have not resolved in 6 to 8 weeks.” [IMPORTANT]

There are relatively few high-quality evidence specific studies for the treatment of neck pain.

These authors warn that acetaminophen [Tylenol] can cause liver toxicity in alcoholism, fasting states, hepatic disease, the presence of anticonvulsant drugs, or in the frail elderly, even at recommended doses.

“Acetaminophen toxicity increases substantially when it is taken in conjunction with a cyclo-oxygenase (COX-2)-specific inhibitor or nonsteroidal anti-inflammatory drug (NSAID).”

NSAIDs can have gastrointestinal side effects.

“Muscle relaxants are not recommended for acute phase WAD because of limited evidence of efficacy.”

Opioid drugs have adverse effects such as constipation, sedation, and physiologic dependence, and there is no evidence that they produce significant or sustained improvement in neck pain.

These authors do not advocate trigger point injections for neck pain.

There exists no rationale for epidural steroid injection in nonradicular pain. “Their use should be reserved for clear radicular pain.”

“Intra-articular injection of steroids has not been shown to provide effective long-term pain relief, and they are not recommended in chronic WAD.”

These authors note that percutaneous radio frequency neurotomy works for facet pain, but note that “this technique is currently available only in research centers.”

Good evidence supports that early return to activity is important in WAD.

Exercise is recommended in WAD. [IMPORTANT]

“Manipulation of the spine directs a high-velocity thrust at one or more joints of the cervical spine. Mobilization includes all manual therapies directed at cervical joint dysfunction that do not involve high-velocity thrusts. Both modalities probably provide at least short-term benefit in patients with neck pain.”

“Both manipulation and mobilization are recommended in grades II and III WAD.” [Key Point]

Pulsed electromagnetic field therapy resulted in significant reductions in pain and increases in cervical range of motion in 4 studies of high methodologic quality.

“The following physical modalities may be helpful in individual patients, but their use is not currently supported by a reasonable quantity of high-quality scientific evidence.” [IMPORTANT “may be helpful in individual patients.”]

Heat therapy does not benefit neck pain.

Cervical collars should not be used, or at most be used for no more than 3 days in WAD grades II and III. Collar use beyond 72 hours probably prolongs disability.

Good-quality studies show no evidence of effect of transcutaneous electrical nerve stimulation on neck pain.

Good-quality evidence shows no benefit to using ultrasound on neck pain

One review found postural advice had a positive effect on acute traumatic neck injuries.

Available high-quality studies do not clearly show the effectiveness of cervical traction, and “no major recommending body has found convincing evidence of positive effect for traction in either acute or chronic neck pain, and none recommends it.”

No reviews show clear demonstration of effectiveness for acupuncture, acupuncture treatment is not currently recommended for any form of neck pain by any major recommending body.

CONCLUSIONS

1) Neck pain is an almost universal human condition and is among the most common complaints presented to family physicians.

2) Most neck symptoms are produced by biomechanical sources, such as axial neck pain, WAD, and cervical radiculopathy

3) There is relatively little high-quality evidence available that is specific to the treatment of neck pain, and there is a dearth of long-term outcomes data.

4) There is a high incidence of cervical radiographic abnormalities in asymptomatic persons.

5) Physical modalities supported by evidence of benefit should be used, including early return to usual activities, supervised exercise, electromagnetic therapy, manipulation, and mobilization.
[This sounds an awful lot like a standard chiropractic practice].

6) If symptoms have not resolved within 4 to 6 weeks, re-evaluation and additional diagnostic workup should be considered.

KEY POINTS FROM THIS ARTICLE

1) Neck pain is almost universal and is a common patient complaint.

2) Most neck pain is biomechanical. [Important for chiropractors]

3) Whiplash injuries are a primary cause of neck pain, and there are 1 million cases of WAD annually in the US.

4) There is no evidence linking the mechanism of WAD injury and chronic symptoms.

5) In 11 high-quality studies, 19% to 60% (mean, 33%) of patients with WAD reported chronic symptoms.

6) There are very few high-quality treatment studies available for neck pain.

7) Many asymptomatic people have radiographic abnormalities.

8) Any injury or disease process within the neck will result in reflexive muscle spasm and loss of motion.

9) Cervical radiculopathy is almost always from extrinsic pressure on a cervical nerve root, usually by osteophytes or disk material, accompanied with inflammation.

10) 7% of people injured in WAD who become symptom free within 3 months will have their symptoms return and remain symptomatic after 2 years.
[This means their symptoms go away and then later return].

11) 85% of people who are symptomatic 3 months after a whiplash injury will still have symptoms 2 years later. [This means that if they do not recover within the first 3 months, they are very likely to have chronic symptoms].

12) Just because pain radiates does not mean it is radicular in origin.

13) Radicular pain is sharp, tingling, or burning in a specific dermatomal distribution in the upper extremity. [IMPORTANT]

14) Cervical myelopathy will often cause complaints in the lower extremities as well as urinary complaints. [IMPORTANT]

15) Acetaminophen [Tylenol] can cause liver toxicity in alcoholism, fasting states, hepatic disease, the presence of anticonvulsant drugs, or in the frail elderly, even at recommended doses.

16) Acetaminophen toxicity increases substantially when it is taken in conjunction with a cyclo-oxygenase (COX-2)-specific inhibitor or nonsteroidal anti-inflammatory drug (NSAID).

17) NSAIDs can damage the gastrointestinal tract.

18) Opioid drugs [Vicodin, Oxycontin, etc.] cause constipation, sedation, and physiologic dependence, and they do not produce significant or sustained improvement in neck pain.

19) Facet steroid injections do not provide long-term pain relief in chronic whiplash pain.

20) Exercise is recommended in whiplash-injured patients.

21) Cervical collar use beyond 72 hours probably prolongs disability.

22) Physical modalities supported by evidence to treat neck pain include early return to usual activities, supervised exercise, electromagnetic therapy, manipulation, and mobilization.

23) Manipulation and mobilization of the spine provides short-term benefit in patients with neck pain and are recommended in WAD grades II and III.
[Key Point]

Journal of Manipulative and Physiological Therapeutics

January 2005, Volume 28, Number 1

Reinhold Muller, PhD, Lynton G.F. Giles, DC, PhD

This study is a follow-up to the study in Spine, July 15, 2003, which showed the short-term superiority of chiropractic adjustment over Celebrex, Vioxx, and acupuncture in treating chronic spine pain.

[Giles LGF, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture and spinal manipulation Spine 2003;28:1490-1503].

Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation

Spine, July 15, 2003; 28(14): 1490-1502

Treatment	Drugs (Celebrex or Vioxx)	Acupuncture	Chiropractic Adjustments
Years Of Chronic Spinal Pain	4.5 or 6.4	4.5 or 6.4	8.3
% Asymptomatic within 9 weeks	5%	9.4%	27.3%
% That suffered an adverse event	6.1%	0%	0%
% Improvement In General Health Status	18%	15%	47%

FROM ABSTRACT:

Objective
To assess the long-term benefits of medication, needle acupuncture, and spinal manipulation as exclusive and standardized treatment regimens in patients with chronic (>13 weeks) spinal pain syndromes.

Study Design
Extended follow-up (>1 year) of a randomized clinical trial was conducted at the multidisciplinary spinal pain unit of Townsville’s General Hospital between February 1999 and October 2001.

Patients and Methods
Of the 115 patients originally randomized, 69 had exclusively been treated with the randomly allocated treatment during the 9-week treatment period (results at 9 weeks were reported earlier).

These patients were followed up and assessed again 1 year after inception into the study reapplying the same instruments (ie, Oswestry Back Pain Index, Neck Disability Index, Short-Form-36, and Visual Analogue Scales).

Questionnaires were obtained from 62 patients reflecting a retention proportion of 90%.

The main analysis was restricted to 40 patients who had received exclusively the randomly allocated treatment for the whole observation period since randomization.

Results
Comparisons of initial and extended follow-up questionnaires to assess absolute efficacy showed that only the application of spinal manipulation revealed broad-based long-term benefit: 5 of the 7 main outcome measures showed significant improvements compared with only 1 item in each of the acupuncture and the medication groups.

Conclusions
In patients with chronic spinal pain syndromes, spinal manipulation, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit. [Important]

THESE AUTHORS ALSO NOTE:

Chronic spinal pain is often triggered by injury or disease.

For mechanical spine pain, a pathological cause cannot be identified, only about 15% of patients are given a definitive diagnosis, and a specific diagnosis is often impossible.

Chronic spinal pain has an immense impact on public health, poses an enormous financial strain on the health systems in developed countries, and affects the economy by lost working time through illness.

The high incidence of back pain, its chronic and recurrent nature in many patients, is a main cause of absence from work.

These authors have shown [In the July 15, 2003 Spine study] that spinal manipulation results in greater short-term (9 weeks) improvement than acupuncture and medicine.

“The present study assesses the extended follow-up (of at least 1 year) efficacy of medication, needle acupuncture, and spinal manipulation, as standardized and exclusive treatment regimens.”

In the 2003 Spine study, these authors randomly allocated medication, needle acupuncture, or spinal manipulation to chronic spine patients. A range of validated subjective questionnaires and objective measurements were taken initially and at the end of the study treatment period to assess the improvements in these patients. In this current study, these authors used the same questionnaires a year later to assess the stability of the acute findings.

Patients were excluded from this study if they had nerve root involvement, spinal anomalies other than sacralization or lumbarization, pathological conditions other than mild to moderate osteoarthrosis, greater than a grade 1 spondylolisthesis of L5 on S1, previous spinal surgery, or leg length inequality of >9 mm with postural scoliosis. [This means the most difficult patients were eliminated]

The medication patients were given Celebrex or Vioxx followed by acetaminophen.

The acupuncture was performed using standard needles placed in local paraspinal intramuscular maximum pain areas, and approximately 5 needles were placed in distal acupuncture point meridians according to the “near and far” technique (upper limb, lower limb, or scalp). Needle agitation was performed by turning or ‘flicking’ the needles at approximately 5-minute intervals. Two 20-minute office visits per week were given until patients became asymptomatic or achieved a status of feeling that they had achieved acceptable pain relief.

High-velocity low-amplitude spinal manipulative thrust to a joint was performed by the treating chiropractor for the spinal level of involvement to mobilize the spinal joints at that level.

Two chiropractic spinal manipulations per week were given until patients became asymptomatic or achieved a status of feeling that they had achieved acceptable pain relief.

“Statistical testing revealed that only in the manipulation group, 5 of the 7 observed improvements were statistically significant which compares with only 1 item in each of the acupuncture and the medication groups, respectively.”

DISCUSSION

The patients in this study had chronic spinal pain (average duration of more than 2 years) and had long histories of having sought pain relief.

“The overall results of this extended follow-up efficacy study appears to favor the application of manipulation” which successfully achieve long-term benefits in chronic spinal pain syndrome patients.

“No such benefit could be observed for medication.”

These results corroborate the findings of the 9-week analysis (Spine, July 15, 2003).

Patients were allowed to change treatment groups if the treatment was not helping. Importantly, “manipulation showed by far the lowest proportion (38.7%) of changeovers compared with acupuncture (53.3%) and medication (81.2%).”

“Spinal manipulation appeared to provide the highest satisfaction.”

Both the 9-week findings and the extended follow-up results are consistent with others who conclude that “those treated by chiropractic derived more short-term and long-term benefit and satisfaction than those treated by hospital therapists.”

“Medication apparently did not achieve an improvement in chronic spinal pain, although the SF-36 indicator of general health status did show an improvement for general health status.”

CONCLUSIONS

These authors also note that chronic mechanical spinal pain syndromes “compromised immune function.”

“Patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes.”

“For patients receiving acupuncture, consistent improvements were also observed, although without reaching statistical significance (with a single exception). For patients receiving medication, the findings were less favorable.”

KEY POINTS FROM THIS ARTICLE

1) The first study (Spine, July 15, 2003) showed that in treating chronic spine pain for 9 weeks, that chiropractic spinal adjusting was better than 5 times more effective than the drugs Celebrex or Vioxx.

2) This study showed that in the one-year follow-up to the different treatments of chronic spine pain, specific chiropractic manipulation resulted in statistically significant improvement in 5 of 7 outcomes, compared with only 1 improvement outcome in both the acupuncture and the drug groups. This indicates that the therapeutic benefit of chiropractic spinal manipulation is largely stable for at least a year, much better than either drugs (Celebrex / Vioxx) or needle acupuncture.

3) For mechanical spine pain, a pathological cause cannot be identified, only about 15% of patients are given a definitive diagnosis, and a specific diagnosis is often impossible.

4) In this study, spinal manipulation provided the highest satisfaction as compared to drugs (Celebrex / Vioxx) or needle acupuncture.

5) In this study and in two prior hospital studies, “those treated by chiropractic derived more short-term and long-term benefit and satisfaction than those treated by hospital therapists.”

6) Drugs did not achieve an improvement in chronic spinal pain.

Spine
July 15, 2003; 28(14):1490-1502

Lynton G. F. Giles, DC, PhD; Reinhold Muller, PhD

FROM THE ABSTRACT:

Study Design.
A randomized controlled clinical trial was conducted.

Objective.
To compare medication, needle acupuncture, and spinal manipulation for managing chronic (>13 weeks duration) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain.

Summary of Background Data.
Between February 1999 and October 2001, 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital’s multidisciplinary spinal pain unit.

Methods.
One of three separate intervention protocols was used: medication, needle acupuncture, or chiropractic spinal manipulation.
[THE MANIPULATION WAS DONE BY CHIROPRACTORS]

Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index (Oswestry), the Neck Disability Index (NDI), the Short-Form-36 Health Survey questionnaire (SF-36), visual analog scales (VAS) of pain intensity and ranges of movement.

These instruments were administered again at 2, 5, and 9 weeks after the beginning of treatment.

Results.
The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).

Manipulation achieved the best overall results, with improvements of 50% on the Oswestry scale, 38% on the NDI, 47% on the SF-36, and 50% on the VAS for back pain, 38% for lumbar standing flexion, 20% for lumbar sitting flexion, 25% for cervical sitting flexion, and 18% for cervical sitting extension.

However, on the VAS for neck pain, acupuncture showed a better result than manipulation (50% vs 42%).

Conclusions.
The consistency of the results provides evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication.

However, the data do not strongly support the use of only manipulation, only acupuncture, or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain.

THESE AUTHORS ALSO NOTE:

“A pathologic cause cannot be identified for most episodes of spinal pain, and clinicians often have great difficulty establishing the underlying cause.”

“Only about 15% of patients receive a definitive diagnosis because it often is impossible to reach specific diagnosis.”

“Numerous studies have shown that patients with low back pain do exhibit abnormal spinal motion.”

“The proportion of primary care patients with uncomplicated spinal pain who have poor outcomes appears to be higher than generally recognized.”

“Adverse reactions to nonsteroidal antiinflammatory (NSAID) medication have been well documented.”

“Gastrointestinal toxicity induced by NSAIDs is one of the most common serious adverse drug events in the industrialized world.”

“The newer COX-2-selective NSAIDs are less than perfect, so it is imperative that contraindications be respected.”

There is “insufficient evidence for the use of NSAIDs to manage chronic low back pain, although they may be somewhat effective for short-term symptomatic relief.”
[IMPORTANT]

The drugs used in this study were Celebrex (200-400 mg/day); the next drug of choice was Vioxx (12.5-25 mg/day), followed by paracetamol (up to 4 g/day).

Acupuncture was performed by one of two experienced acupuncturists. Two acupuncture treatments per week were given.

High-velocity, low-amplitude thrust spinal manipulation to a joint was performed by a chiropractor at the spinal level of involvement to mobilize the spinal joints. Two treatments per week were given.

Patients were assessed at the initial visit and then at weeks 2, 5, and 9 after the initial treatment.

For the subjective measurements used the Oswestry Questionnaire for low back and thoracic spine pain, the Neck Disability Index (NDI) for neck pain, and the Short-Form-36 Health Survey questionnaire (SF-36).

The visual analog scales (VAS) was used to assess subjective pain intensity.

RESULTS

115 patients were eligible to participate in the study.

The average duration of spinal pain symptoms was 8.3 years for the spinal manipulation group, 6.4 years for the medication group, and 4.5 years for the acupuncture group.

[THE CHIROPRACTIC GROUP WAS THE MOST CHRONIC GROUP]

“The highest proportion of asymptomatic patients before or at the week 9 assessment was found in the manipulation group (n = 9, 27.3%) followed by the acupuncture group (n = 3, 9.4%) and the medication group (n = 2, 5%).”

“Manipulation yielded the best results over all the main outcome measures except the NDI, for which acupuncture achieved a better result than manipulation.”

Confounding of variables such as age, gender, body mass index, pain duration, and involvement in litigation were not correlated with the main outcome measures.

DISCUSSION

The authors note “any small possible placebo effect would have been distributed equally across the three treatment regimens in this study, not imparting any advantage to one group.”

“The results of this efficacy study suggest that spinal manipulation, if not contraindicated, may be superior to needle acupuncture or medication for the successful treatment of patients with chronic spinal pain syndrome, except for those with neck pain.”

“The NDI showed that for neck pain acupuncture achieved a better result than manipulation. Considering that the patients in this study had experienced chronic spinal pain syndrome for an average of 4.5 years in the medication group, 6.4 years in the acupuncture group, and 8.3 years in the spinal manipulation group, it is notable that manipulation, during a maximum treatment duration of 9 weeks, achieved asymptomatic status for every fourth patient (27%).” [IMPORTANT]

“This result is superior to the percentages for acupuncture (9.4%) and medication (5%) for short-term outcomes.”

“Medication apparently did not achieve a marked improvement in chronic spinal pain and caused adverse reactions in 6.1% of the patients. The adverse symptoms disappeared once medication was stopped.”

“Interestingly, although “new” medication (i.e., not previously tried by patients) showed no significant improvement for the subjective pain and disability measures or the objective measures, the SF-36 did show an improvement of 18% for general health status, as compared with 15% for acupuncture and 47% for spinal manipulation.”

“Because the patients had chronic spinal pain syndromes, it is unlikely that improvement resulted from “self-limiting” spinal pain, as could be the case with acute spinal pain.”

“In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

These authors will provide data on 12-month follow-up status of these patients in about 1 year.

KEY POINTS FROM THIS ARTICLE

1) It is impossible to reach specific diagnosis for the pathologic cause for 85% of those with an episode of spinal pain.

2) Patients with low back pain do exhibit abnormal spinal motion.

3) There is insufficient evidence for the use of NSAIDs to manage chronic low back pain.

4) The new COX-2 nonsteroidal antiinflammatory (NSAIDs) have problems and significant contraindications.

5) Gastrointestinal toxicity induced by NSAIDs is one of the most common serious adverse drug events in the industrialized world.

6) In this study, in the medication group, more patients experienced adverse events (6.1%) than recovered from their spinal complaints (5%).

7) Even though the chiropractic treatment group was the most chronic (8.3 years), 27.3% recovered with 18 spinal adjustments over a period of 9 weeks, or less.

This means that better than every fourth patient became asymptomatic with 9 weeks or less of chiropractic manipulation, even though they had been chronic for more than 8 years.

8) The chiropractic treatment group showed significantly greater improvement in subjective complaints, functional abilities, objective range of spinal motion, and in general health status than acupuncture and medication.

9) In this study, patient involvement in litigation did not influence the outcome measures.

10) In the treatment of chronic spinal pain, chiropractic manipulation is superior to acupuncture and medication.

Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation

Spine, July 15, 2003; 28(14): 1490-1502

 

Treatment	Drugs (Celebrex or Vioxx)	Acupuncture	Chiropractic Adjustments
Years Of Chronic Spinal Pain	4.5 or 6.4	4.5 or 6.4	8.3
% Asymptomatic within 9 weeks	5%	9.4%	27.3%
% That suffered an adverse event	6.1%	0%	0%
% Improvement In General Health Status	18%	15%	47%

UK BEAM Trial Team (Andrea Manca)
British Medical Journal
329:1381 December 11, 2004

FROM ABSTRACT

Objective
To assess the cost effectiveness of adding spinal manipulation, exercise classes, or manipulation followed by exercise (“combined treatment”) to “best care” in general practice for patients consulting with low back pain.

Design
Stochastic cost utility analysis alongside pragmatic randomised trial with factorial design.

Setting
181 general practices and 63 community settings for physical treatments around 14 centers across the United Kingdom.

Participants: 1287 (96%) of 1334 trial participants.

Main outcome measures
Healthcare costs, quality adjusted life years (QALYs), and cost per QALY over 12 months.

Results
Over one year, mean treatment costs relative to “best care” were £195 ($360) for manipulation, £140 for exercise, and £125 for combined treatment.

All three active treatments increased participants’ average QALYs compared with best care alone.

Each extra QALY that combined treatment yielded relative to best care cost £3800; in economic terms it had an “incremental cost effectiveness ratio” of £3800.

Manipulation alone had a ratio of £8700 relative to combined treatment.

If the NHS was prepared to pay at least £10 000 for each extra QALY (lower than previous recommendations in the United Kingdom), manipulation alone would probably be the best strategy.

If manipulation was not available, exercise would have an incremental cost effectiveness ratio of £8300 relative to best care.

Conclusions
Spinal manipulation is a cost effective addition to “best care” for back pain in general practice.

Manipulation alone probably gives better value for money than manipulation followed by exercise. [Key Point]

THIS STUDY ALSO NOTES:

“Back pain is a major economic problem.”

“A UK trial comparing private chiropractic and NHS outpatient treatment found that reductions in time off work more than offset the net health service cost incurred by chiropractic.” [Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300: 1431-7].

In this study, “best care” in general practice consisted of advising the patient to remain active and providing them with The Back Book for patients.

Exercise program comprised an initial assessment and up to nine classes in community settings over 12 weeks.

Spinal manipulation package—The UK chiropractic, osteopathic, and physiotherapy professions agreed to use a package of techniques developed by a multidisciplinary group, during eight sessions over 12 weeks.

Combined treatment—Participants received six weeks of manipulation followed by six weeks of exercise.

Participants completed questionnaires at baseline, three months, and 12 months.

There was “no difference in clinical outcome between manipulation in private and NHS premises.”

[This is important because chiropractors are in private practice].

This study estimated how many quality adjusted life years (QALYs) participants had experienced over their year in the UK BEAM trial by ranking the cost effectiveness for the different treatments.

These authors “excluded those participants whose costs exceeded £2000 ($3700).

RESULTS

Exercise achieved a small back pain functional benefit at three months but not at one year.

Manipulation achieved a small to moderate back pain benefit at three months and a small benefit at one year.

Combined exercise and manipulation achieved a moderate back pain benefit at three months and a small benefit at one year.

Manipulation and exercise combined dominated exercise alone, which costs more and achieves less over 12 months. [IMPORTANT]

Manipulation alone yielded the highest improvement in QALYs, and did so for the lowest cost. [IMPORTANT]

“Manipulation achieves extended dominance over both exercise and combined treatment” of manipulation plus exercise.

DISCUSSION

“If decision makers value additional quality adjusted life years (QALYs)…manipulation alone is probably the best treatment.” [Key Point]

“We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice.”

“The improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain.”

Patients continued to show benefits of treatment at 12 months, so the cost effectiveness of manipulation “may be better than we have reported.”

“As back pain is a common problem, making manipulation generally available will require many therapists.” [IMPORTANT]

“In the United Kingdom there are 2100 registered chiropractors, 3200 registered osteopaths, and about 5000 manipulative physiotherapists.”

“Whereas physiotherapists can rapidly train to deliver the exercise package, insufficient trained manipulators are available in the United Kingdom to meet potential demand, and it will take several years to produce additional manipulators.”

“Purchasing manipulation from the private sector to provide treatment within the NHS would still represent good value for money if decision makers were willing to pay £10 000 per additional QALY.”

WHAT THIS STUDY ADDS FROM AUTHOR:

“Spinal manipulation, exercise classes, and manipulation followed by exercise all increased participants’ quality of life over 12 months by more than “best care” in general practice.”

“Adding spinal manipulation to best care in general practice is effective and cost effective for patients in the United Kingdom.” [IMPORTANT]

“If the NHS can afford at least £10 000 for each quality adjusted life year yielded by physical treatments, manipulation alone probably gives better value for money than manipulation followed by exercise.” [IMPORTANT]

MEANING OF THIS STUDY FROM AUTHOR:

“Adding spinal manipulation to best care in general practice is effective and cost effective for patients with back pain in the United Kingdom.”

“If the NHS can afford more than £10 000 for an extra QALY, manipulation alone probably gives better value for money than manipulation followed by exercise.”

“These conclusions hold even if the NHS has to buy spinal manipulation from the private sector.” [IMPORTANT]

KEY POINTS FROM THIS ARTICLE

1) Actually, this article is incredible. It basically shows that the most cost effective way to improve the quality of life for back pain sufferers, and to improve their quality of life for years, is to pay for spinal manipulation.

2) If public health authorities in the UK want to take advantage of the cost effective improvement in the quality of life of back pain sufferers, the UK will need many more spinal manipulators.

3) Spinal manipulation is a cost effective addition to “best care” for back pain in general practice.

4) Manipulation alone gives better value for the money than manipulation followed by exercise. [Important]

5) Back pain is a major economic problem.

6) A prior study comparing chiropractic and NHS outpatient treatment found that reduced time off work more than compensated for the additional cost incurred by chiropractic.

7) In this study, manipulation and exercise combined dominated exercise alone, which costs more and achieves less over 12 months.

8) In this study, manipulation alone yielded the highest improvement in quality of life, and did so for the lowest cost.

9) In this study, manipulation dominated over both exercise and combined treatment of manipulation plus exercise.

10) If decision makers value additional quality adjusted life years, manipulation alone is the best treatment.

11) This is the first study for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. [Important]

12) In this study, manipulation and manipulation/exercise resulted in statistically significant improvements in health status, including improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain.

13) In this study, patients continued to show benefits of treatment at 12 months, so the cost effectiveness of manipulation may be better than reported.

An Instructional Course Lecture,
American Academy of Orthopaedic Surgeons

THE JOURNAL OF BONE AND JOINT SURGERY
VOLUME 86-A · NUMBER 8 · AUGUST 2004

BY DARREL S. BRODKE, MD, AND STEPHEN M. RITTER, MD

THESE AUTHORS NOTE:

Low back pain is often a difficult problem to solve.

“There is a paucity of evidence from the health professional literature regarding its cause, management, and prognosis.”

“The difficulty of managing patients with low back pain stems from the fact that there often is very little association between any pathological physical findings and the patient’s pain and disability.”

“The professional must then find ways of clinically treating a syndrome that betrays the principles of basic science.” [IMPORTANT]

This lecture will review some of the available nonoperative modes of low back pain treatment, which can be applied regardless of whether a particular pain mediator has been identified.

EPIDEMIOLOGY AND NATURAL HISTORY

Low back pain is epidemic in the United States, with an annual incidence of 5% per year, and an associated prevalence of 60% to 90%.

“The one-month prevalence of low back pain is estimated to be 43% of the population.”

“Only visits for the common cold have outnumbered presentations of low back pain to primary care physicians.”

“The length of time that a patient is absent from work because of low back pain correlates with a decreasing chance of return to work.”

“A patient who has missed work for more than six months has a 50% chance of returning to work, one who has missed more than a year has a 25% chance of returning, and one who has missed two years or more has a <5% chance of returning.”

Low back pain is the leading cause of disability in persons younger than forty-five years of age.”

Between $33 – $55 billion is spent yearly in direct medical costs for the treatment of low back pain.

The indirect costs such as lost work-days and productivity have been estimated to be $90 billion.

Most studies have suggested that low back pain is usually a self-limited disease, with dramatic improvement in up to 80% of people in the first two weeks.

85% of low back conditions cannot be diagnosed with history, physical examination findings, or diagnostic testing. [IMPORTANT]

“There is an increased incidence of both low back pain and disc herniations in smokers.”

There is a threefold higher risk of lumbar disc herniations and a 3.9-fold higher risk of cervical disc herniations in smokers.”

Nicotine interferes with bone disc metabolism.

In smokers, disc nutrition is impaired with progressive disc degeneration.

Oxygen levels are reduced in smokers, leading to hyalinization and necrosis of the nucleus pulposus.

“Outcomes of treatment, operative or nonoperative, are less successful in patients who smoke than they are in those who do not smoke.”

Smokers have progressive osteoporosis and surgical healing rates are lower.

“Cessation of smoking is an important aspect of the treatment of patients with low back pain.”

CLINICAL PRESENTATION

“Low back pain with radiation to one or both buttocks and posterior aspects of the thighs in combination with exacerbation while coughing or sneezing is suggestive of lumbar disc disease.”

“A positive straight-leg-raise test or a decreased Achilles reflex is a characteristic finding associated with disc herniation.”

“Radicular sensory deficits, unilateral pain, and tension signs with or without reflex alterations all suggest nerve root impingement.”

“Pain with standing that improves with short walks and pain with back flexion and with no substantial muscle tenderness suggest a discogenic etiology.”

“Focal night pain without associated tenderness may be consistent with a tumor.”

Obesity contributes to low back pain.

“Repetitive bending and twisting can increase the risk of low back pain and disc herniation.”

Non-musculoskeletal causes of low back pain include kidney stones or and abdominal aortic aneurysm.

“Tenderness and pain with percussion over the dorsal twelfth rib region, lateral to the midline, suggest kidney involvement.”

Tumors may manifest as back pain, presenting as pain at night without response to activity or rest, unexplained weight loss, and fatigue.

IMAGING

Anteroposterior and lateral plain radiographs of the lumbar spine are useful for the evaluation of osseous anatomy and alignment.

Computed tomography is helpful for the assessment of fractures and spondylolysis.

Magnetic resonance imaging is the “most accurate and sensitive modality for the diagnosis of subtle spinal pathology, making it the test of choice.”

“Bone scanning with SPECT (single photon emission computed tomography) allows physiologic assessment of bone by identifying increased osteoblastic activity. It is a highly sensitive study with a low specificity, making it a good screening test for degenerative changes or metastatic disease.”

“Discography is an invasive, provocative, painful procedure done under fluoroscopic guidance. Contrast medium is injected to pressurize the disc and mimic the pressure of prolonged sitting or standing.” Fissuring and leakage of the contrast medium is seen, but the patient’s pain response is the most important determinant of the result.

Discography is the best study for identifying disc pain.

TREATMENT OPTIONS

“The best strategy for nonoperative management of low back pain combines active intervention with education and rehabilitation.”

Bed rest should be short-term (two days) if used at all.

MEDICATIONS

“Although no analgesic should be promoted as a cure for pain or a replacement for non-pharmacological interventions, medications are frequently used in the nonoperative care of low back pain.”

Nonsteroidal anti-inflammatory drugs limit inflammation by “interfering with prostaglandin synthesis and cyclooxygenase (COX) activity.” “Dyspepsia is common, and complications such as gastric erosion, ulceration, and hemorrhage can develop.”

“Other risks, such as renal toxicity, are associated with COX-1 and COX-2-regulating nonsteroidal anti-inflammatory drugs.”

“Acetaminophen and opioids are commonly used analgesics but they are associated with substantial risks.” Hepatotoxicity is a risk with overdosing of acetaminophen.

“Although opioid use is on the rise and can be effective for symptom control, these drugs do not work over the long term and they can lead to other problems. They often have side effects including drowsiness, dizziness, fatigue, nausea, respiratory depression, and constipation.”

“Tolerance to the analgesic effect of opioids begins to occur when the drugs have been continuously used for longer than several weeks.”

“Opioids produce analgesia by binding to receptors that are normally bound by endogenous compounds in the central nervous system.”

“All narcotics are best avoided if possible.”

“Steroids should play a minimal role in the treatment of low back pain. They are associated with substantial gastrointestinal risks. Long-term use is known to lead to osteopenia and an increased risk of infection. Concerns about osteonecrosis of the proximal part of the femur and humerus should prompt judicious use.”

“Muscle relaxants work for only a limited period of time and should be considered for the acute treatment of back pain rather than for long-term treatment.”

“Muscle relaxants and opioids should be avoided by patients with chronic pain.”

PHYSICAL THERAPY

“Physical therapy can be used as a broad term to refer to stretching and strength training, back school for the education of patients, and other modalities to address low back pain. It has been shown to be better than medical care alone over a six-month period.”

It is unclear whether one form of exercise therapy is more effective than any other.

Massage decreases symptoms and improves function in patients with nonspecific low back pain, especially when the massage was coupled with exercise and education.

Transcutaneous electrical nerve stimulation (TENS) is no better than placebo.

Lumbar traction distracts the lumbar vertebrae, enlarges the intervertebral foramen, creates a vacuum to reduce herniated discs, puts tension on the posterior longitudinal ligament which aids in reduction of herniated discs, and frees adherent nerve roots.

Intradiscal pressure can be decreased by 20% to 30% with traction, but traction does change the natural history of back pain.

CHIROPRACTIC MANIPULATION

“Chiropractic manipulation is the most common ‘alternative’ therapy for managing low back pain.”

“It has been estimated that nearly 15% of the United States population seeks chiropractic help each year.”

“Chiropractic manipulation and physical therapy have equivalent success in the management of acute low back pain, and both are better than medical care alone.”

Vertebral body fracture and spondylolysis with spondylolisthesis as well as the need for postoperative support are all possible indications for prescribing an orthosis.

“There is no evidence in the literature to support long-term use of orthotics for the treatment of low back pain.”

“Orthoses do not appear to change the natural history of low back pain.”

The sacroiliac joint is not the source of the pain in the majority of low back pain patients.

“Facet or zygapophyseal joints can be generators of low back pain with referred buttock and lower-limb pain.”

“The patient’s history, physical examination, and imaging studies have each been shown to be unreliable when used alone for the diagnosis of symptomatic facet joints.”

“Computed tomography scans of the lumbar spines of asymptomatic individuals over the age of forty years frequently show degenerative changes of the facet joints, so such studies alone are not diagnostic.”

“Extension-based back pain, as opposed to worse pain with flexion, along with radiographic evidence of arthropathy suggests the presence of facet-mediated pain.”

Relief of back pain with selective blockade of the medial branch of the posterior rami nerve or facet joint injection is used to diagnose painful facet joints.

Long relief of facet pain may be afforded by radiofrequency dorsal rhizotomy, which denervates the facet joint by the localized insertion of a probe that destroys the afferent fibers with a radiofrequency current.”

“Intradiscal electrothermal therapy has become popular in recent years for the treatment of low back pain thought to be of discogenic origin,” from internal disc derangements. “The procedure involves the posterolateral placement of a probe around the inner circumference of the anulus followed by heating of the probe.” It is performed for patients who are not ideal surgical candidates.

OVERVIEW

“Acute back pain is generally a self-limited process that is likely to get better in the short term no matter what treatment is undertaken.”

“Chronic low back pain is far more difficult to treat or even to define in terms of etiology.”

“A specific treatment program must be customized to the patient’s specific findings, and all patients must be active participants in their return to health and activity.”

KEY POINTS FROM THIS ARTICLE

1) Through today, low back pain is often difficult to solve; the literature on its cause, management, and prognosis is scant; there is little association between pathological physical findings and the patient’s pain and disability.

2) 43% of the US population experience LBP in a give month.

3) Low back pain is second only to the common cold in visits to primary care physicians.

4) The longer a patient is off work with low back pain, the higher the chances that he/she will never return to work. {I believe that one of our primary goals of treating these patients is to get them to return to work as soon as possible.

5) Low back pain is the leading cause of disability in persons younger than 45.

6) Direct costs of treating LBP is $33 – $55 billion per year, and indirect costs are $90 billion.

7) Low back pain is usually a self-limited disease, with dramatic improvement in up to 80% of people in the first two weeks.

8) 85% of low back conditions cannot be diagnosed with history, physical examination findings, or diagnostic testing.

9) Smokers have more incidences of back pain, more disc herniations, progressive disc degeneration, poor treatment outcomes, and poor healing.

10) Low back pain with radiation to one or both buttocks and posterior aspects of the thighs in combination with exacerbation while coughing or sneezing is suggestive of lumbar disc disease.

11) A positive straight-leg-raise test or a decreased Achilles reflex is a characteristic finding associated with disc herniation.

12) Radicular sensory deficits, unilateral pain, and tension signs with or without reflex alterations all suggest nerve root impingement.

13) Pain with standing that improves with short walks and pain with back flexion and with no substantial muscle tenderness suggest a discogenic etiology.

14) Obesity contributes to low back pain.

15) Repetitive bending and twisting can increase the risk of low back pain and disc herniation.

16) Non-musculoskeletal causes of low back pain include kidney stones or and abdominal aortic aneurysm.

17) Tenderness and pain with percussion over the dorsal twelfth rib region, lateral to the midline, suggest kidney involvement.

18) Tumors may manifest as back pain, presenting as pain at night without response to activity or rest, unexplained weight loss, and fatigue.

19) Anteroposterior and lateral plain radiographs of the lumbar spine are useful for the evaluation of osseous anatomy and alignment.

20) Computed tomography is helpful for the assessment of fractures and spondylolysis.

21) Magnetic resonance imaging is the “most accurate and sensitive modality for the diagnosis of subtle spinal pathology, making it the test of choice.”

22) Bone scanning with SPECT (single photon emission computed tomography) allows physiologic assessment of bone by identifying increased osteoblastic activity, making it a good screening test for degenerative changes or metastatic disease.

23) Discography is an invasive and painful, and is the best study for identifying disc pain.

24) Bed rest for more than 2 days is a bad idea in the treatment of low back pain.

25) Nonsteroidal anti-inflammatory drugs cause gastric erosion, ulceration, and hemorrhage, and renal toxicity.

26) Acetaminophen [Tylenol] is associated with hepatotoxicity.

27) Opioid drugs do not work over the long term and they can lead to drowsiness, dizziness, fatigue, nausea, respiratory depression, and constipation. They are addictive and have reduced effectiveness [tolerance] when used for more than several weeks.

28) All narcotics should be avoided in the management of back pain.

29) Steroids are associated with substantial gastrointestinal injury, osteopenia, an increased risk of infection, and osteonecrosis of the proximal part of the femur and humerus.

30) Muscle relaxants work for only for acute of back pain.

31) Muscle relaxants and opioids should be avoided by patients with chronic pain.

32) Stretching and strength training is better than medical care for back pain.

33) Massage decreases symptoms and improves function in patients with back pain, especially when coupled with exercise and education.

34) Transcutaneous electrical nerve stimulation (TENS) is no better than placebo.

35) Lumbar traction distracts the lumbar vertebrae, enlarges the intervertebral foramen, creates a vacuum to reduce herniated discs, puts tension on the posterior longitudinal ligament that aids in reduction of herniated discs, and frees adherent nerve roots.

36) Chiropractic manipulation is the most common ‘alternative’ therapy for low back pain.

37) 15% of the United States population seeks chiropractic help each year.

38) Chiropractic manipulation is better than medical care for back pain.

39) Vertebral body fracture and spondylolysis with spondylolisthesis often require bracing.

40) The sacroiliac joint is not the source of the pain in the majority of low back pain patients.

41) The facet joints can generate of low back pain with referred buttock and lower-limb pain.

42) Patient history, physical examination, and imaging studies are unreliable to diagnosis symptomatic facet joints.

43) Computed tomography of the lumbar spines of asymptomatic individuals over the age of forty often shows degenerative changes of the facet joints.

44) Facet back pain is often worse with extension.

45) Anesthetic blocks of the medial branch of the posterior rami or facet joint injection is used to diagnose painful facet joints.

46) Longer relief of facet pain is obtained by radiofrequency dorsal rhizotomy, which denervates the facet joint by the localized insertion of a probe that destroys the afferent fibers with a radiofrequency current.

47) Intradiscal electrothermal [IDET] therapy can successfully help discogenic low back pain.

Patient Characteristics, Utilization, and Costs

Archives of Internal Medicine
October 11, 2004;164:1985-1992

Antonio P. Legorreta, MD, MPH; R. Douglas Metz, DC; Craig F. Nelson, DC, MS; Saurabh Ray, PhD; Helen Oster Chernicoff, MD, MSHS; Nicholas A. DiNubile, MD

FROM ABSTRACT:

Background: Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations.

This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal specific consumption of health care resources within a large managed-care system.

Methods: A 4-year retrospective claims data analysis comparing more than 700,000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit.

Results: Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year).

Having chiropractic coverage was associated with a 1.6% decrease in total annual health care costs at the health plan level.

Back pain patients with chiropractic coverage, compared with those without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7), low back surgery (3.3 vs 4.8), hospitalizations (9.3 vs 15.6), and magnetic resonance imaging (43.2 vs 68.9).

Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode–related costs ($289 vs $399).

Conclusions: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care.

Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.

THESE AUTHORS ALSO NOTE:

“In the US, back pain is the second leading cause of physician visits and is second only to childbirth for hospitalizations.”

Back pain is “the most prevalent chronic medical problem, the number one cause of long-term disability, and the second most common cause of restricted activity and use of prescription and nonprescription drugs.”

There is likely to be more individuals with back problems as “the average age of the US population continues to increase.”

EFFICACY AND SAFETY OF CHIROPRACTIC CARE FOR BACK PAIN

“A comprehensive review of the literature evaluating the efficacy of chiropractic treatments for low back pain and other conditions reported that randomized control trials ‘show spinal manipulation to be better, and no trial finds it to be significantly worse, than conventional treatment.” [Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Arch Intern Med. 1998;158:2215-2224].

“Chiropractic treatment is associated with a relatively low risk level, on par with conventional medical treatments” for complications.

“Comprehensive overview of the literature reveals that it is essentially unanimous in reporting that chiropractic care is associated with significantly higher patient satisfaction compared with patients who receive conventional treatments.”

COST EFFECTIVENESS OF CHIROPRACTIC CARE

Several studies (mostly workers’ compensation studies) have shown the cost-effectiveness of chiropractic compared with medical management for neuromuscular conditions in a review of current literature.

A 1996 cost comparison study, higher total costs (30% to 217% higher) and higher outpatient costs (27% to 94% higher) of medical treatment relative to chiropractic treatment.

ACCESS TO CHIROPRACTIC CARE

“Chiropractors now represent the third largest segment of health care practitioners in the United States, with 50,000 practitioners in 2000 according to the Bureau of Labor Statistics.”

“21 million to 28 million people now receive chiropractic services each year, with approximately 192 million annual visits to DCs: between 1990 and 1997, chiropractic use increased from 10% to 11%.”

“With growing public demand, the profession is also expected to increase 21% to 35% by 2008.”

“Chiropractic insurance coverage is now being offered to most American workers who are covered by health insurance and is increasingly being offered in all health plan types.”

METHODS STUDY POPULATION

In this study, patients had direct access to a DC without the need of a physician referral.

The patient co-pay for a chiropractic office visit was the same as it would be in a medical clinic.

The chiropractic benefit allowed for a maximum of 40 office visits to a DC per year.”

STUDY DESIGN

These authors reviewed categories of NMS conditions, including disorders of the neck, lower back, thoracic spine and rib disorders, headache, upper extremity and lower extremity disorders. The severity of neck and lower back problems was designated by complicated or uncomplicated conditions.

“Any claims for back surgery were excluded from the analysis, because such cases are likely to have complications for which chiropractic care would not be appropriate.”

“Claims separated by 45 days or more were considered separate episodes.”

OVERALL EXPENDITURES AND UTILIZATION

The health care expenditures considered for this study included inpatient and outpatient services, plain radiographs, and magnetic resonance (MR) images,

“Prescription claims and physical therapy claims were not included during this phase of the ongoing study, and therefore pharmacy and physical therapy costs were not included in health care costs.”

[This is extremely important: these authors excluded the costs of drugs and physical therapy when comparing chiropractic to medical care; and chiropractic was still the best way to go. Potentially, the costs of drugs and physical therapy are the most expensive component of medical care, and again, these costs were excluded from the comparison.]

RESULTS

“Year 2000 claims for 707,690 health plan members with chiropractic coverage and 1,001,995 members without chiropractic coverage were compared.”

“The per-member-per-year (PMPY) cost of members with chiropractic coverage was $1,463, which was $208 lower than the PMPY cost of members without the coverage ($1,671).”

“This translates to a 12% reduction in annual costs incurred by the managed care organization on members with chiropractic coverage.”

“The 141,616 patients with NMS conditions who had chiropractic coverage were also compared to 189,923 NMS patients without chiropractic coverage.” “The PMPY cost of NMS patients with chiropractic coverage was $2345, which was $361 lower than the PMPY cost of NMS patients without the coverage ($2706).”

“This translates to a 13% reduction in annual costs incurred by the health plan on NMS patients with chiropractic coverage.”

“Annual per capita hospital cost for NMS patients with chiropractic coverage ($1224) was $210 lower or 15% than that for NMS patients without chiropractic coverage.” The annual per capita ambulatory cost for NMS patients with chiropractic coverage ($1121) was 12% lower than the corresponding cost for NMS patients without chiropractic coverage ($1272).”

“The annual per capita cost of providing chiropractic care was $31, which amounted to only 1%of the total dollar value of resources consumed ($2376) by NMS patients between the 2 cohorts.”

“Patients with neuromusculoskeletal conditions who had chiropractic coverage were associated with $330 lower per-member-per-year (PMPY) total health care expenditures for the year 2000. The lower cost is derived from both lower hospital cost by $210 and lower ambulatory cost by $151.”

“The regression results indicate that the presence of chiropractic insurance coverage was systematically associated with an approximately 1.6% lower average total health care cost of members, after controlling for differences in age, sex, and the number of comorbidities.”

“The average cost per back pain episode for patients with chiropractic coverage was $289, which was $110 or 28% lower than for back pain patients without chiropractic coverage.”

“Aggregating episodes for each patient during the 4-year period, the average cost of back pain treatment for patients with chiropractic coverage was $522, which was

$45 or 8% lower than the corresponding back pain treatment cost for patients without chiropractic coverage.”

“Utilization rates for back pain episodes indicate significantly lower utilization of resources across all major high-cost areas for NMS patients with chiropractic insurance coverage compared with those without.”

“Back pain patients with chiropractic coverage had fewer inpatient stays than did those without chiropractic coverage (9.3 vs 15.6 stays per 1000 patients).”

“The MR image rate was also lower for back pain patients with chiropractic coverage compared with those without chiropractic coverage (43.2 vs 68.9 MR images per 1000 patients).”

“The rate of lower back surgery among patients with chiropractic coverage was lower as well (3.3 vs 4.8 surgical procedures per 1000 patients).”

“Back pain patients with chiropractic coverage also received fewer radiographs (17.5 vs 22.7 per 1000 patients) than did back pain patients without chiropractic coverage.”

COMMENT BY AUTHORS

“There is growing evidence for the low risks associated with chiropractic spinal manipulation in most cases and favorable evidence for its effectiveness in treating low back pain.”

“Patients treated for back pain by DCs tend to be more satisfied than patients treated by MDs.”

“Despite this evidence for safety, effectiveness, and growing public demand, health insurance coverage for chiropractic care continues to remain restricted, relative to other health services, particularly in the managed care sector.”

“Chiropractic care is becoming increasingly prevalent in the American health care system. The increasing acceptance of chiropractic care as a source of comprehensive complementary care for NMS problems is reflected in that the chiropractic field is the fastest growing among all doctoral-level health professions.”

“Potential employees, particularly those who maintain a healthier lifestyle may have been more likely to seek employment in companies that offer benefits covering complementary care (eg, chiropractic or acupuncture) that can be perceived as less aggressive treatment modalities.”

“This study found that members with chiropractic coverage had a 12% lower annual medical care cost, not adjusting for member risk characteristics.”

“After controlling for the cost-saving effects associated with favorable demographic and medical risk factors, the regression analysis found a statistically significant 1.6% reduction in total medical care costs that can be isolated to the presence of chiropractic coverage.”

“Most of this 1.6% reduction in the plan’s total medical costs is likely derived from the 13% reduction in the total medical costs observed for the subset of members with NMS conditions who also had chiropractic coverage.”

“In our study population of 0.7 million members who had chiropractic coverage in the medical plan, we estimated an annual reduction of approximately $16 million as a result of lower utilization of high-cost items.” “This is a conservative estimate of the cost savings for the plan that can be associated with members in the medical plan using their supplementary benefits to seek chiropractic treatment of their NMS problems.”

“The estimated cost saving appears to more than offset the amount spent to cover the associated costs of the chiropractic benefit.”

“Our analysis found that patients with chiropractic coverage had significantly lower rates of use of resource-intensive technologies, such as x-ray examinations, MR image, and surgery, and lower use of more expensive patient care settings, such as inpatient care.”

“This is reflected in the significantly lower cost, at both the episode level and the patient level, of providing care for back pain.”

“The substitution of chiropractic for physician care evident from the shift in the case distribution between physicians and DCs when chiropractic coverage was present also contributed to the conservation of health care resources.”

“This study found evidence that a substantial portion of the chiropractic care sought by the members with insurance coverage was more often substituted for medical care rather than add-on care.”

KEY POINTS FROM THIS ARTICLE

1) Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations.

2) In the US, back pain is the second leading cause of physician visits and is second only to childbirth for hospitalizations.

3) Back pain is the most prevalent chronic medical problem, the number one cause of long-term disability, and the second most common cause of restricted activity and use of prescription and nonprescription drugs.

4) In this study, chiropractic resulted in:

A)) Lower annual total health care expenditures.

B)) A 1.6% decrease in total annual health care costs.

C)) Reduced use of x-rays, low back surgery, hospitalizations, and MRIs.

D)) Lower average back pain episode–related costs.

E)) A $330 lower per-member-per-year total health care expenditures for the year 2000, derived from both lower hospital cost by $210 and lower ambulatory cost by $151.

5) Chiropractic reduces overall health care expenditures because it substitutes for traditional medical care, and is more conservative, less invasive than medical alternatives.

6) Chiropractic treatments for low back pain and other conditions are better than conventional medical treatments.

7) Chiropractic treatment is associated with a relatively low risk for complications as compared to conventional medical treatments.

8) It is unanimous in reporting that chiropractic care has significant higher patient satisfaction compared with patients who receive medical treatments.

9) Chiropractic is the third largest segment of health care practitioners in the United States with 50,000 practitioners.

10) 21 million to 28 million people now receive chiropractic services each year.

11) There are approximately 192 million annual visits to chiropractors.

12) Between 1990 and 1997, chiropractic use increased from 10% to 11% of the population.

13) Chiropractic is expected to increase 21% to 35% by 2008.

14) Chiropractic insurance coverage is now being offered to most American workers who are covered by health insurance and is increasingly being offered in all health plan types.

15) This study excluded the costs of drugs and physical therapy when comparing chiropractic to medical care; and we were still the best way to go. This is important because the costs of drugs and physical therapy can be the most expensive component of medical care.

16) Despite this evidence for safety, effectiveness, and growing public demand, health insurance coverage for chiropractic care continues to remain restricted.

17) Chiropractic care is becoming increasingly prevalent in the American health care system.

18) Chiropractic is the fastest growing among all doctoral-level health professions.

19) Employees who maintain a healthier lifestyle may be more likely to seek employment in companies that offer benefits covering complementary care like chiropractic or acupuncture.

20) This study found that members with chiropractic coverage had a 12% lower annual medical care cost.

21) The cost saving afforded by chiropractic more than offset the amount spent to cover the associated costs of the chiropractic the benefit.

22) A substantial portion of the chiropractic care sought by the members with insurance coverage was more often substituted for medical care rather than add-on care.

British Medical Journal;326:911; April 26, 2003

Ingeborg B C Korthals-de Bos, Jan L Hoving, Maurits W van Tulder, Maureen P M H Rutten-van Mölken, Herman J Adèr, Henrica C W de Vet, Bart W Koes, Hindrik Vondeling, Lex M Bouter,

FROM ABSTRACT:

Objective: To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain.

Design: Economic evaluation alongside a randomized controlled trial.

Participants: 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilization), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counseling, education, and drugs).

Main outcome measures: Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life.

Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year.

Results: The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks.

The total costs of manual therapy were around one third of the costs of physiotherapy and general practitioner care.

These differences were significant.

The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care.

Conclusions: Manual therapy (spinal mobilization) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.

Manual therapy is more effective and less costly than physiotherapy or care by a general practitioner for treating neck pain.

Patients undergoing manual therapy recovered more quickly than those undergoing the other interventions.

THESE AUTHORS ALSO NOTE:

Neck pain is a common condition, affecting about a sixth of men and a quarter of women.

There is a need to determine the most cost effective intervention for neck pain.

These authors used a sample size that would clinically detect important difference of 25% in perceived recovery between groups.

In this study, manual therapy consisted of hands-on techniques (muscular mobilization, specific articular mobilization, coordination or stabilization).

“Spinal mobilization was defined as low velocity passive movements within or at the limit of joint range of motion.”

“Spinal manipulation (low amplitude, high velocity techniques) was not provided.”

“Chiropractors, osteopaths, and physiotherapists use mobilization and manipulation techniques.”

“In our trial, manual therapy was applied by six registered manual therapists who had followed a 3 year curriculum in manual therapy after training in physiotherapy. Treatment sessions lasting 45 minutes were scheduled once a week, with a maximum of six sessions.”

“Physiotherapy was applied by five physiotherapists and consisted of individualized exercise therapy, including active and postural or relaxation exercises, stretching, and functional exercises.”

“Treatment sessions lasting 30 minutes were scheduled twice a week, with a maximum of 12 sessions.”

General practitioner care as to encouraged the patient to wait for spontaneous recovery, given Cox-2 inhibitor drugs or non-steroidal anti-inflammatory drugs.

“Clinical outcomes were perceived recovery, intensity of pain, functional disability, and utility.”

EFFECTS OF INTERVENTIONS

“Manual therapy was the most effective treatment.”

Recovery rates after seven weeks in the manual therapy group was 68%.

Recovery rates after seven weeks in the physiotherapy group was 51%.

Recovery rates after seven weeks in the general practitioner care group was 36%.

During the follow up period of 52 weeks, 37% of the patients in the manual therapy group took over the counter drugs compared with almost 50% of patients in both the physiotherapy group and the general practitioner care groups. [Manual therapy resulted in reduced drug use].

“Nine patients in the manual therapy group reported absenteeism from paid work owing to neck pain compared with 12 patients in the physiotherapy group and 15 patients in the general practitioner care group.” [Again, manual therapy was best].

“Absenteeism from unpaid work was reported by 11 patients in the manual therapy group, 18 patients in the physiotherapy group, and 15 patients in the general practitioner care group.”

“The total costs in the manual therapy group were around one third of the costs in the physiotherapy and general practitioner care groups.” [IMPORTANT]

“Total direct, indirect, and total costs were statistically significantly lower in the manual therapy group than in the physiotherapy and general practitioner care groups.” [IMPORTANT]

“Manual therapy is associated with a larger improvement in pain and lower costs.” [IMPORTANT]

“Manual therapy for the treatment of neck pain was more cost effective than physiotherapy or care by a general practitioner.” [IMPORTANT]

“Manual therapy had significantly lower costs and slightly better effects at 52 weeks compared with physiotherapy and general practitioner care.” [IMPORTANT]

“The clinical outcome measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care up to 26 weeks.”

“The acceptability curve for pain intensity comparing manual therapy with physiotherapy showed that at a ceiling ratio of zero there was still a 98% probability that manual therapy was cost effective.”

“Our economic evaluation alongside a pragmatic randomized controlled trial showed manual therapy to be more cost effective than physiotherapy and continued care provided by a general practitioner in the treatment of non-specific neck pain.”

KEY POINT FROM THIS ARTICLE

(1) Manual therapy achieves the best recovery rates, the lowest use of drugs, the least time off work, and is more cost effective compared to drugs and physiotherapy directed active exercises.

The Journal of Orthopaedic Medicine
Volume 21(l), 1999, pp. 22-25

 

S Khan, J Cook, M Gargan G Bannister
University Department of Orthopaedic Surgery, Bristol, UK

FROM INCLUDED ABSTRACT

Objective:
To determine which patients with chronic whiplash will benefit from chiropractic treatment.

Design:
Retrospective review by structured telephone interviews of 93 consecutive patients seen in chiropractic clinic.

Setting:
Independent chiropractic clinic in a large city.

Subjects:
93 patients, 68 female.

Main outcome measure:
Gargan and Bannister grading pre and post treatment.

Results:
Three groups of patients were recognized.

Group 1 consisted of patients with isolated neck pain associated with a restricted range of neck movement.

Group 2 consisted of patients with neurological symptoms or signs associated with a restricted range of movement.

Group 3 comprised patients who described severe neck pain but all of whom had a full range of neck movement. Patients in this group often described an unusual group of symptoms, with a bizarre, non- dermatomal pain distribution.

Conclusion:
Whiplash injuries are common.

Chiropractic is the only proven effective treatment in chronic [whiplash] cases.

Our study enables patients to be classified at initial assessment in order to target those patients who will benefit from such treatment.

THESE AUTHORS ALSO NOTE:

Whiplash injuries result from indirect injury to the cervical spine and produce a syndrome comprising of headache, neck and interscapular pain, peripheral paraesthesia or a combination of these.

The accumulated literature suggests 57% of injured patients will make a full recovery. [Implying that 43% do not make a full recovery].

The resolution of symptoms will have occurred within two years of injury.

Eight (8%) of patients will remain disabled by their symptoms.

“Conventional treatment of patients with whiplash symptoms is disappointing.”

“In chronic cases, no conventional treatment has proved successful.”

The authors cite a retrospective study from the journal Injury in 1996, that demonstrated that chiropractic treatment benefited 26 of 28 patients (93%) suffering from chronic whiplash syndrome.

Their aim was to refine the indications for treatment of chronic whiplash syndrome with chiropractic.

This study reviewed 100 consecutive patients who were referred for chiropractic treatment for chronic whiplash symptoms. Seven (7) patients were lost to follow up, therefore 93 patients were assessed.

Initial symptoms, range of neck movement, and focal neurological signs of specific myotomes, dermatomes, or peripheral nerves were documented. Pain drawings were recorded.

All patients underwent spinal manipulation, a high velocity, low amplitude thrust to a specific vertebral segment by15 year chiropractor J. Cook.

Patients underwent a mean of 19.3 treatments (range 1 – 53), over a period of 4.1 months.

Author SK contacted each patient to determine whether chiropractic treatment had been of any benefit. This was assessed using the Gargan and Bannister classification of whiplash symptoms:

Absent symptoms = Grade A

Nuisance symptoms = Grade B

Intrusive symptoms = Grade C

Disabling symptoms = Grade D

Of the seven patients who were lost to follow up, five were in group 1 and two were in group 2. Their records of chiropractic treatment showed that all seven had undergone successful treatment and been discharged with resolved or improved symptoms, but as this could not be confirmed by telephone they were omitted from our study.

The patients in this study were referred for chiropractic treatment after a mean of 1.2-7 months (0-82) after injury.

Group 1 contained 50 patients (50/93 = 54%) and consisted of those with neck pain radiating in a ‘coat-hanger’ distribution, associated with a restricted range of neck movement but with no neurological deficit.

Before Treatment:

B = 15

C = 24

D = 11

After Treatment:
D = 0	C = 0	B = 8	A = 7
D = 0	C = 4	B = 15	A = 5
D = 2	C = 2	B = 7	A = 0

In this group:

36 patients (72%) gained benefit from chiropractic spinal manipulation

12 (24%) became asymptomatic

and 12 (24%) improved by 2 grades

————————————————————————————

Group 2 contained 32 patients (34/93 = 34%) who had neurological signs and / or symptoms in association with neck pain and a restricted range of neck movement, including tingling, numbness, pins and needles in a dermatomal distribution in the arm or hand as well as both hypo and hyperaesthesia.

Before Treatment:

B = 4

C = 23

D = 5

After Treatment:
D = 0	C = 0	B = 2	A = 2
D = 0	C = 0	B = 13	A = 10
D = 0	C = 2	B = 3	A = 0

In this group, 30 patients (94%) responded positively to chiropractic manipulation with 12 (38%) becoming asymptomatic and 13 (43%) improving by 2 grades.

[This is a remarkable response, considering that these patients had neurological involvement.]

————————————————————————————

Group 3 contained 11 patients (11/93 = 12%) who described severe neck pain but all of whom had a full range of neck movement and no neurological symptoms or signs in a specific myotome or dermatome. In addition it was noted that these patients commonly described an unusual complex of symptoms, including blackouts, visual disturbance, nausea, vomiting and chest pain, along with non-dermatomal distribution of pain.

Before Treatment:

B = 1

C = 6

D = 4

After Treatment:
D = 0	C = 1	B = 0	A = 0
D = 0	C = 5	B = 1	A = 0
D = 2	C = 1	B = 1	A = 0

In this group, only 3 of the 11 patients (27%) improved following treatment, with no patient becoming asymptomatic and only one improved by 2 grades.

————————————————————————————

THESE AUTHORS STATE:

“Our results confirm the efficacy of chiropractic, with 69 of our 93 patients (74%) improving following treatment.”

“… whilst the majority of patients did benefit from such [chiropractic] treatment, a particular group of patients failed to respond,” represented by our group 3.

[Actually 3/11 = 27% did show improvement.]

“Whilst other studies have suggested that neurological signs (our classification Group 2) have a poorer prognosis, this was not the case amongst our patients. Indeed, such patients showed the greatest improvement in disability.”

“Several recent papers have provided much evidence to support the conclusion that chronic pain from a whiplash injury is organic, and that this organic pain causes the psychological distress often associated with chronic symptoms, rather than being a result of it.”

“The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms.”

KEY POINTS FROM THIS ARTICLE

1) “Chiropractic is the only proven effective treatment in chronic [whiplash] cases.”

2) The accumulated literature suggests 57% of injured patients will make a full recovery. [Implying that 43% do not make a full recovery].

3) The resolution of whiplash symptoms can take two years after injury.

4) Eight (8%) of whiplash patients will remain disabled by their symptoms 2 years after injury.

5) “Conventional treatment of patients with whiplash symptoms is disappointing.”

6) “In chronic [whiplash] cases, no conventional treatment has proved successful.”

7) A retrospective study from the journal Injury in 1996 demonstrated that chiropractic treatment benefited 26 of 28 patients (93%) suffering from chronic whiplash syndrome.

8) The chiropractic treatment in this study was a mean of 19.3 treatments (range 1 – 53), over a period of 4.1 months.

9) 72% of whiplash patients with neck pain radiating in a ‘coat-hanger’ distribution, associated with a restricted range of neck movement but with no neurological deficit, gained benefit from chiropractic spinal manipulation

10) 94% of whiplash patients with neurological signs and / or symptoms in association with neck pain and a restricted range of neck movement, including tingling, numbness, pins and needles in a dermatomal distribution in the arm or hand as well as both hypo and hyperaesthesia, responded positively to chiropractic manipulation.

11) 27% of whiplash patients with severe neck pain but with a full range of neck movement and no neurological symptoms or signs in a specific myotome or dermatome, improved following treatment. These patients also commonly described an unusual complex of symptoms, including blackouts, visual disturbance, nausea, vomiting and chest pain, along with non-dermatomal distribution of pain.

12) “Whilst other studies have suggested that neurological signs (our classification Group 2) have a poorer prognosis, this was not the case amongst our patients. Indeed, such patients showed the greatest improvement in disability.”

13) “Chronic pain from a whiplash injury is organic, and this organic pain causes the psychological distress often associated with chronic symptoms, rather than being a result of it.”

14) “The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms.”

Gargan and Bannister are very well known for their continued publishing of long-term somatic and psychological whiplash outcomes. Their contribution to this article on chiropractic for chronic whiplash gives the study tremendous credibility, as did their contribution to the 1996 article they reference from the journal Injury.

Injury
Volume 27, Issue 9, November 1996, Pages 643-645

N. Woodward, J. C. H. Cook, M. F. Gargan and G. C. Bannister

University Department of Orthopaedic Surgery, Bristol, UK

FROM ABSTRACT

Forty-three percent of patients will suffer long-term symptoms following ‘whiplash’ injury, for which no conventional treatment has proven to be effective.

A retrospective study was undertaken to determine the effects of chiropractic in a group of 28 patients who had been referred with chronic ‘whiplash’ syndrome.

The severity of patients’ symptoms was assessed before and after treatment using the Gargan and Bannister (1990) classification.

Twenty-six (93%) patients improved following chiropractic treatment.

The encouraging results from this retrospective study merit the instigation of a prospective randomized controlled trial to compare conventional with chiropractic treatment in chronic ‘whiplash’ injury.

The Gargan and Bannister Whiplash Classification

GROUP	SYMPTOMS
A	None
B	Nuisance
C	Intrusive
D	Disabling

 

THESE AUTHORS ALSO NOTE:

43% of those injured in whiplash will experience long-term symptoms.

“If [whiplash] patients are still symptomatic after 3 months then there is almost a 90% chance that they will remain so.”

“No conventional treatment has proven to be effective in these established chronic cases.”

The 28 chronic whiplash patients in this study were treated by chiropractor J. Cook, using “specific spinal manipulation, proprioceptive neuromuscular facilitation, and cryotherapy.” The treatment was evaluated by an independent orthopedic surgeon, M. Woodward, who was blinded as to the treatment.

“Spinal manipulation is a high-velocity low-amplitude thrust to a specific vertebral segment aimed at increasing the range of movement in the individual facet joint, breaking down adhesions and stimulating production of synovial fluid.”

The 28 patients in this study had initially been treated with anti-inflammatories, soft collars and physiotherapy. These patients had all become chronic, and were referred for chiropractic at an average of 15.5 months (range was 3 – 44 months) after their initial injury. 27/28 (96%) patients were classified as category C or D symptoms at the time of initial chiropractic treatment.

Following chiropractic 93% of the patients had improved: 16/28 (57%) by one symptom group and 10/28 (36%) by two symptom groups.

DISCUSSION

“The whiplash syndrome is a cause of long-term symptoms for which conventional medicine has failed to discover an effective treatment.”

Chiropractic has been shown to be advantageous compared to conventional medicine in the treatment of low back pain.

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”

Complications from cervical manipulations are rare, and when they are reported in the literature, they often “arose as a result of spinal manipulation performed by non-chiropractors, who had been misrepresented in the literature as being trained chiropractors.”

KEY POINTS FROM THIS ARTICLE

1) 43% of those injured in whiplash will experience long-term symptoms. In this study, at least one patient had ongoing symptoms 3 years 8 months following whiplash injury.

2) “If [whiplash] patients are still symptomatic after 3 months then there is almost a 90% chance that they will remain so.”

3) “No conventional treatment has proven to be effective in these established chronic cases.”

4) “Spinal manipulation is a high-velocity low-amplitude thrust to a specific vertebral segment aimed at increasing the range of movement in the individual facet joint, breaking down adhesions and stimulating production of synovial fluid.”

5) In this study, chiropractic improved the symptom category of 93% chronic whiplash patients. This is particularly important considering that 96% of these patients had intrusive symptoms that handicapped their work and leisure activities and required frequent use of pain drugs, or they were severely disabled, having lost jobs and required continued medical interventions with constant use of pain drugs.

6) “The whiplash syndrome is a cause of long-term symptoms for which conventional medicine has failed to discover an effective treatment.”

7) Chiropractic has been shown to be advantageous compared to conventional medicine in the treatment of low back pain.

8) Complications from cervical manipulations are rare, and when they are reported in the literature, they often “arose as a result of spinal manipulation performed by non-chiropractors, who had been misrepresented in the literature as being trained chiropractors.”