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Military personnel with acute low back pain receiving a combination of chiropractic manipulative therapy and standard medical care experienced a statistically and clinically significant reduction in their back pain and improved physical functioning when compared to those receiving standard medical care alone, reports an article in the April 15 issue of Spine.
The pragmatic, patient-centered, two-arm, randomized, controlled trial pilot study was funded by a grant from Samueli Institute, Alexandria Va., and conducted from February 2008 to June 2009 at William Beaumont Army Medical Center (WBAMC), Fort Bliss, El Paso, Texas. Participants were 91 active-duty military personnel between the ages of 18 and 35 years old.
"While a number of studies have shown spinal manipulation to be effective in treating low back pain in research settings, the appropriate role of chiropractic care in treating low back pain within the health care delivery system, including the military, has not been clearly established," said study Principal Investigator Christine Goertz, DC, PhD, vice chancellor for research and health policy for Palmer College of Chiropractic. "We know very little about the impact of chiropractic manipulative therapy on diverse populations in real-world settings. This study is the first step in filling that gap in our knowledge."
"It is critical that we explore drug-less approaches to reduce pain," said Wayne B. Jonas, M.D., president and CEO of Samueli Institute. "Chiropractic manipulation is an important option to consider for musculoskeletal disorders, which is the most prevalent pain complaint in the military."
Study highlights include:
Col. Richard Petri is the chief of the Interdisciplinary Pain Management Center (IPMC) at WBAMC. "This is a significant step for recognizing the value of chiropractic care in the military," he said. "Continued research in this area will ultimately result in better healthcare delivery systems as well as the improved health of our beneficiaries."
"While these findings are exciting, they need to be confirmed with additional research that replicates this study on a larger scale," Dr. Goertz added. "Palmer College, the RAND Corporation and Samueli Institute received a $7.4 million, four-year grant from the Department of Defense last year to conduct a similar multi-site clinical trial, this time with a sample size of 750 active-duty military personnel."
Additional study authors are:
The Palmer Center for Chiropractic Research, headquartered on the Palmer College of Chiropractic campus in Davenport, Iowa, is the largest institutional chiropractic research effort in the world, promoting excellence and leadership in scientific research. The PCCR has the largest budget for research in a chiropractic college, receiving grants from the National Institutes of Health, National Center for Complementary and Alternative Medicine, the U.S. Health Resources and Services Administration, and now the Congressionally Directed Medical Research Program. Since 2000, these grant awards have totaled more than $35 million.
Samueli Institute is a nonprofit research organization supporting the scientific investigation of healing processes and their role in medicine and health care. The project was funded by the institute out of grant #MDA905-03-C-0003, received from Uniformed Services University of the Health Sciences. The views, opinions and/or findings contained in this report are those of the author(s) and should not be construed as an official Department of the Army position, policy or decision unless so designated by other documentation.
Source: Palmer College of Ch
New Research Shows Manipulation Superior Drugs
By Editorial Staff
A randomized, controlled clinical trial just published in Spine1 reveals
that chiropractic "manipulation" is superior to both drugs and acupuncture
in the treatment of chronic spinal pain (people with pain lasting more than
The study, conducted at a multidisciplinary spinal pain outpatient unit
(MSPU) in an Australian public hospital, involved 115 patients randomly
assigned to receive one of three interventions: medication, needle
acupuncture or chiropractic manipulation.
Patients randomized to the acupuncture or spinal manipulation group were
given an initial physical examination by the treating clinician to determine
which form of acupuncture needle placement and needling would take place, or
what type of spinal manipulation would be performed, respectively. Patients
randomized to the medication group were given Celebrex, unless the patient
had used it previously. The next drug of choice was Vioxx, followed by
paracetamol (up to 4g/day). Doses were left to the sports physician's
Chiropractors administered "high-velocity, low-amplitude" manipulations.
Chiropractic patients were given two treatments per week.
The patients were assessed four times: at the initial visit, and two, five
and nine weeks after the initial treatment. The Oswestry Questionnaire for
low back and thoracic spine pain ("back" pain), the Neck Disability Index
(NDI) for neck pain, and the Short-Form-36 Health Survey questionnaire
(SF-36) were self-administered. Visual analog scales (VAS) were used to
assess subjective pain intensity.
Objective measurements included straight-leg raising, recorded using a
protractor with a plumb-bob to measure the angle. Lumbar spine ranges of
movement also were measured using a calibrated Perspex device; cervical
spine ranges of movement were measured using a cervical range-of-motion
While a number of patients didn't finish the study, due to noncompliance or
treatment changes, the statistical significance of the results was
maintained for most outcomes. At the end of the study, the group receiving
manipulation experienced the most recovered patients (9) compared with three
for the acupuncture group and only two for the medication group. This was
significant, considering the nature of chronic spine pain.
Patient assessments for the three groups also indicated superiority for
chiropractic manipulation for all tests except the VAS for neck pain. This
superiority is demonstrated in the percentage of improvement that patients
in each of the three groups experienced as measured by the assessment tools
(see charts above).
One of the study's most remarkable findings was that patients in the
manipulation group reported a 47 percent improvement on the SF-36
questionnaire, compared to only 15 percent for the acupuncture group and 18
percent for the medication group. This finding is all the more significant
because the SF-36 does not measure back pain per se, but gives a perception
of the level of one's overall health.
In addition to these results, the authors included the following comments in
"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 nine
weeks, achieved asymptomatic status for every fourth patient (27%). 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. ...
"The results of this study can be generalized because the study sample had a
broad socioeconomic background and a wide age range. ...
"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."
Chiropractic Before Spine Surgery for Chronic LBP
University of Pittsburgh Medical Center Health Plan mandates conservative
care before considering surgery for chronic LBP cases.
The University of Pittsburgh Medical Center (UPMC) Health Plan, a health
maintenance organization affiliated with the university's School of
Medicine, has adopted landmark guidelines for the
management of chronic low back pain.
As of Jan. 1, 2012, candidates for spine surgery must receive "prior
authorization to determine medical necessity," which includes verification
that the patient has "tried and failed a 3-month course of conservative
management that included physical therapy, chiropractic therapy, and
medication." Surgery candidates also must be graduates of the plan's LBP
health coaching program. The program features a Web-based decision-making
tool designed to help plan members "understand the pros and cons of surgery
and high-tech radiology." It is the first reported implementation of such a
policy by a health care plan.
Putting a Clamp on the Soaring Rates of Spine Surgery
According to the December 2011 issue of the UPMC Health Plan Physician
Partner Update,which informed participating providers of the new guidelines
and the rationale for their implementation, "We feel strongly that this
clinical initiative will improve the quality of care for members who are
considering low back surgery, and that it will facilitate their involvement
in the decision-making process." The update also noted, "Surgical procedures
for low back surgery performed without prior authorization will not be
reimbursed at either the specialist or the hospital level."
A Conservative Strategy for Managing Chronic LBP
. PCP discussion related to self-care consisting of rest, ice, compression
and elevation (RICE)
. Screening for psychosocial factors or "yellow flags" and incorporate
behavioral interventions as appropriate with other treatment interventions
. Education on self-management techniques - functional ability assessment
and education on return to work / usual activity and function
. Enrollment and graduation from UPMC Health Plan Health Coach's Low Back
Pain Program (mandatory) which may also include participation in other
programs such as weight loss, physical activity, tobacco cessation,
depression and/or stress
. Early referral to chiropractor or physical therapist, but before advanced
imaging, for manipulation/mobilization; stabilization exercises; directional
preference strategies - member and/or provider movements that abolish or
cause centralization of pain (McKenzie self-treatment repeated movements
that centralize pain)
. Detailed documentation of extent and response to conservative treatment
including chiropractor/physical therapy documentation
SOURCE: UPMC Health Plan Policy and Procedure Manual, October 2011: Surgical
Management of Low Back Pain
(partial list of considerations prior to spine surgery to determine medical
Commenting on the UPMC Health Plan guidelines, Gerard Clum, DC, former
president of the World Federation of Chiropractic and Life Chiropractic
College West, and current executive committee member of the Foundation for
Chiropractic Progress, stated:
"The UPMC should be congratulated for its leadership is establishing
policies to assure that the least invasive and most likely to be successful
care strategies, including chiropractic care, are applied for a meaningful
period of time before surgical considerations are made. This decision is
both an important recognition of the value of chiropractic care in the acute
low back pain environment as well as a recognition of the clinical and
economic downsides to spinal surgery in this situation."
Headquartered in Pittsburgh, the <http://www.upmchealthplan.com/> UPMC
Health Plan covers insureds in 15 counties in western Pennsylvania. The plan
integrates 20 hospitals, 400 doctors' offices and outpatient sites.
Chiropractic Services: What the UPMC Health Plan Covers
"It is the policy of UPMC Health Plan to recognize chiropractic services and
adjunctive procedures as appropriate and consistent with good medical
practice and will provide coverage when the services are medically necessary
and covered by the member's benefit plan for the specific indications
detailed in this policy. Coverage is limited to medically necessary services
provided by a licensed doctor of chiropractic, within the scope of his/her
"Covered chiropractic services include evaluation and management,
manipulation, spinal X-rays, therapeutic exercise, and adjunctive procedures
that are appropriate and medically necessary for neuromusculoskeletal
conditions. ... Indications for Chiropractic Services: Indicated for
primary, neuro-musculoskeletal symptoms involving the spine, para-spinal
soft tissues, and extremities. Indications for Manipulation: Manipulation is
appropriate to restore function that has been reduced or lost by illness or
injury. Indications for Adjunctive Procedures: Adjunctive procedures are
appropriate to restore function and prevent disability following injury.
Indications for Therapeutic Exercise: Indicated for improvement or to
restore functional status by building strength, endurance and flexibility of
the affected region."
Conservative Care Beats Medication for Neck Pain
Study: Spinal manipulation and exercise are more effective than OTC pain
relievers, narcotics and muscle relaxants.
A study published in theannals.org/ Jan. 3, 2012 issue
of the Annals of Internal Medicine and widely reported by mainstream media
suggests conservative care consisting of either spinal manipulation or home
exercise is more effective than over-the-counter and prescription medication
for relieving acute and subacute neck pain.
Spinal manipulative therapy was more effective than medication in both the
short and long term, as was home exercise in the form of self-mobilization
of the neck and shoulder joints a point media outlets were quick to
emphasize in a classic attempt to downplay the value of the chiropractic
The study, conducted by Northwestern Health Sciences University under the
direction of NHSU Vice President of Research, Dr. Gert Bronfort, and Dean of
Research, Dr. Roni Evans, involved 272 adults ages 18-65 with nonspecific
mechanical neck pain of two to 12 weeks' duration. Participants were
recruited from a university research center and a pain management clinic in
Minnesota. Other inclusion criteria included pain equivalent to grade I or
grade II according to the Bone and Joint Decade's
Force on Neck Pain and Its Associated Disorders; and neck pain score of 3 or
greater on a 0-10 scale. Exclusion criteria included cervical spine
instability, fracture, neck pain referred from peripheral joints or viscera,
progressive neurologic deficits, diffuse idiopathic hyperostosis,
inflammatory or destructive changes of the cervical spine, previous cervical
spine surgery, and blood-clotting disorders, among other criteria.
neck pain Subjects were randomized at their second baseline appointment to
one of three groups for 12 weeks:
§ A spinal manipulative therapy group, which received "manipulation of
areas of the spine with segmental hypomobility by using diversified
techniques, including low-amplitude spinal adjustments ... and
mobilization." According to the study, six chiropractors, each with at least
five years' experience, provided treatment, with the specific spinal level
to be treated and the number of treatments rendered left to the discretion
of the individual chiropractor.
§ A home exercise advice group, "with advice provided [by six therapists]
in two 1-hour sessions one to two weeks apart. Recommended mobilization
exercises included "neck retraction, extension, flexion, rotation, lateral
bending motions, and scapular retraction, with no resistance." Participants
received a booklet and laminated cards of prescribed exercises, and were
advised to perform 5-10 repetitions of each exercise six to eight times
§ A medication group monitored by a licensed medical physician, with
nonsteroidal anti-inflammatory drugs acetaminophen, or both serving as the first line of pharmacological therapy.With patients who did not respond to or could not tolerate these drugs, narcotic medications and muscle relaxants were prescribed. With each
patient, the MD determined the type of medication administered and the
number of patient visits.
Self-reported outcomes, including pain, were measured six times during the
12-week treatment period in all three groups: at both baseline appointments;
two, four, eight and 12 weeks after randomization; and on two occasions
post-treatment (weeks 26 and 52). Objective measures of cervical spine
motion were measured at four and 12 weeks by seven trained examiners blinded
to treatment assignment.
Of the 272 participants, essentially equally assigned to the three treatment
groups (91 SMT, 91 home exercise and 90 medication), "improvement in
participant-rated pain significantly differed with SMT compared with
medication at 12 weeks ... and in longitudinal analyses that incorporated
pain ratings every two weeks from baseline to 12 weeks. At 12 weeks, a
significantly higher proportion of the SMT group experienced reductions of
pain of at least 50% [compared to the medication group]. Differences in
participant-related pain improvement between the SMT and [home exercise]
groups were smaller and not statistically significant."
Specifically, at week 12, more than 82 percent of the SMT group reported a
50 percent or greater reduction in pain; 57 percent reported at least a 75
percent reduction and 32 percent reported a 100 percent reduction. By
comparison, the home exercise group reported pain reductions of 77 percent,
48 percent and 30 percent, respectively, while the medication group reported
reductions of only 69 percent, 33 percent and 13 percent.
In terms of long-term improvement, 75 percent of the SMT group reported at
least a 50 percent reduction in pain after 26 weeks, while nearly 81 percent
reported at least a 50 percent reduction at 52 weeks. At 26 and 52 weeks, 71
percent and 69 percent of the home exercise group, respectively, reported at
least a 50 percent reduction in pain. In long-term follow-up, the medication
group's improvement fluctuated from 59 percent reporting pain reduction of
50 percent or more at 26 weeks to 69 percent reporting the same reduction at
"Spinal manipulation therapy and [home exercise advice] led to
short- and long-term outcomes," stated the authors, "but participants who
received medication seemed to fare worse, with a consistently higher use of
pain medications for neck pain throughout the trial's observational period."
Source: Bronfort G, Evans R Anderson AV, Svendsen KH, Bracha Y, Grimm RH.
Spinal manipulation, medication or home exercise with advice for acute and
subacute neck pain: a randomized trial. Ann Intern Med, Jan. 3, 2012;156(1
Chiropractic vs. Medicine for Acute LBP: No Contest
Acute low back pain patients demonstrate significantly greater improvement
with chiropractic than "usual care."
With the publication of the Chiropractic Hospital-based Interventions
Research Outcomes (CHIRO) Study1 ifrequently cited spine research journals in the world,2 the health care community at large may finally appreciate what the chiropractic profession has known for more than a century: Patients with acute mechanical low back
pain enjoy significant improvement with chiropractic care, but little to no
improvement with the usual care they receive from a family physician.
The Spine Journal, the study found that after 16 weeks of care, patients referred to medicaldoctors saw almost no improvement in their disability scores, were likely to
still be taking pain drugs and saw no benefit with added physical therapy -
and yet were unlikely to be referred to a doctor of chiropractic.
The study is "the first reported randomized controlled trial comparing full
CPG [clinical practice guidelines]-based treatment, including spinal
manipulative therapy administered by chiropractors, to family
physician-directed UC [usual care] in the treatment of patients with AM-LBP
(acute mechanical low back pain)." (Evidence-based clinical practice
guidelines have been established for acute mechanical low back pain in many
countries around the world, but sadly, most primary care medical doctors
don't follow these guidelines.) Researchers found that "treatment including
CSMT [chiropractic spinal manipulative therapy] is associated with
significantly greater improvement in condition-specific functioning" than
usual care provided by a family physician.
cheese king downThe Chiropractic Hospital-based Interventions Research
Outcome (CHIRO) initiative was "designed to evaluate the outcomes of spinal
pain patient management strategies that involve a component of chiropractic
assessment and/or spinal manipulative therapy, administered in a
hospital-based spine program outpatient clinic." The study utilized the
CHIRO framework "to examine the effectiveness of current evidence-based
CPG-recommended treatments for patients with AM-LBP pain."
CPG "study care" (SC) was compared with the usual care (UC) provided by
family physicians. Patients were first seen by a spine physician and then
randomly assigned to either the SC group or the UC group.
Patients in the SC group received acetaminophen, a "progressive walking
program" and up to four weeks of lumbar chiropractic spinal manipulative
therapy. The manipulative therapy was provided "using conventional
side-posture, high-velocity, low-amplitude techniques" to the lumbar region
only, and only by a chiropractor.
Patients assigned to the UC group were referred back to their family
physician, who was "simply advised to treat at their own discretion."
Patients in this group received treatment from "a variety of professionals
including family physicians, massage therapists, kinesiologists, and/or
All care was provided at a hospital-based spine program outpatient clinic.
The primary outcome measure was the Roland-Morris Disability Questionnaire
(RDQ), administered at the beginning of care and at 16 weeks, when acute low
back pain is considered to become chronic. The RDQ was also administered at
eight and 24 weeks.
Other Important Findings
After 16 weeks, "78% of patients in the UC group were still taking narcotic
analgesic medications on either a daily or as needed basis." (Only 6 percent
of this group received chiropractic care.)
Condition-specific improvement after 16 weeks "clearly favored the SC group,
with mean RDQ improvement scores of 2.7 in the SC group compared with only
0.1 in the UC group (p=.003)."
While the difference in improvement "was not quite significant at 8 weeks,"
it was found to be "clearly significant at 24 weeks of follow-up (0.004)."
Both groups showed improvement in bodily pain and physical functioning, but
"patients in the UC group uniquely showed no improvement whatsoever in
back-specific functioning (RDQ scores) throughout the entire study period."
The inclusion of NSAIDs and manipulation/mobilization performed by physical
therapists were no more effective in treating patients than family doctors
who offered patients advice and acetaminophen. The study found: "[T]he
addition of NSAIDs and a form of spinal manipulative therapy or mobilization
administered by a physiotherapist to the lumbar spine, thoracic spine,
sacroiliac joint, pelvis, and hip (compared with a detuned ultrasound as
placebo manipulative therapy), to family physician 'advice' and
acetaminophen were shown to have no clinically worthwhile benefit when
compared with advice and acetaminophen alone." [Italics ours]
The study criticizes a 2007 report that had derided the efficacy of spinal
manipulation by pointing out that the older report based its conclusions on
the outcomes of therapies performed by non-chiropractors. The 2007 study concluded that patients "do not recover more quickly with the addition of diclofenac or
spinal manipulative therapy."3 By contrast, the CHIRO study noted: "Although
spinal-manipulative therapy is currently administered by many different
healthcare professionals, including: chiropractors, osteopaths, orthopedic
surgeons, family physicians, kinesiologists, naturopaths, and
physiotherapists, the levels of training and clinical acumen vary widely.
The study design used by Hancock, et al., therefore, differs from our study
because [their study] did not use chiropracticspinal manipulation, and
current guideline based care does not endorse any forms of spinal
manipulation administered by any other practitioners." [Italics ours]
1. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic
Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized
controlled trial on the effectiveness of clinical practice guidelines in the
medical and chiropractic management of patients with acute mechanical low
back pain. Spine Journal, 2010;10:1055-1064.
2. Brunarski D.
of the Chiropractic Literature." Dynamic Chiropractic, Dec. 2, 2010;28(25).
3. Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO,
Spindler MF, McAuley JH. Assessment of diclofenac or spinal manipulative
therapy, or both, in addition to recommended first-line treatment for acute
low back pain: a randomised controlled trial. Lancet, 2007 Nov
Consumer Reports Survey Rates DCs Higher Than MDs
ConsumerReports survey of its readers found that "hands-on" therapies, led by
chiropractic care, were the top-rated treatments for people suffering from
back pain. The massive survey also found that chiropractors were given the
highest "satisfaction with care" ratings, well above those given to medical
doctors who administered various forms of care to back pain sufferers.
The survey, which included 14,000Consumer Reports subscribers and was
reported in the publication's May 2009 issue, found that more than half of
the respondents had "pain (that) severely limited their daily routine for a
week or longer, and 88 percent said it recurred throughout the year." The
report stated that while many go to a primary care physician first for
diagnosis and treatment, the majority were disappointed with the results.
On the other hand, 59 percent reported that they were "highly satisfied"
with the care they received from chiropractors. The next highest rated
practitioners were physical therapists (55 percent) and acupuncturists (53
percent), followed by "specialized" physicians (44 percent) and primary care
physicians (34 percent).
Consumer Report SurveyRespondents were also asked to rate the types of
treatments they received. Again, chiropractic/spinal manipulation got top
honors, with 58 percent rating it as "helping a lot." Spinal injections were
next highest, rated at 51 percent, followed by massage (48 percent) and
physical therapy (46 percent). Other highly rated treatments included
prescription medications (45 percent), yoga (44 percent), movement therapy
and acupuncture (both 41 percent).
In a sidebar article to the main story, Dr. Orly Avitzur, a board-certified
neurologist and medical advisor to Consumers' Union, said that half of the
survey respondents who reported they had been given a prescription drug for
pain-relief were treated with opioids, including Vicodin. This, she said,
was "despite the fact that there is very little research to support the use
of opioids for acute low back pain." She further said that the use of these
drugs results in adverse effects for about half of the people who take them.
However, their use is increasing thanks to "pharmaceutical-industry
marketing and promotion of drugs."
Dr. Avitzur also stated that the survey showed "hands-on" therapies, which
include chiropractic care, are "very successful and I almost always
Historically, Consumer Reports has not been seen as friendly to the profession. However, in 2005, the publication produced a more favorable report, again using a reader survey as a springboard to describe respondents' use and opinion of conventional and alternative medicine. According to a DynamicChiropractic article on that report, "Chiropractic ranked first out of 11 treatments, including massage, acupuncture, and exercise, in its ability to treat back pain. More readers said that chiropractic 'helped me feel much better' than any of the other therapies." Prescription drugs and over-the-counter drugs ranked eighth and 10th, respectively. The 2005 DC
article also stated that the Consumer Reports' editors called manipulation
of the neck risky and said that evidence relating to the effectiveness of
chiropractic treatment was mixed.
Somewhat similar "cautions" were included in the 2009 report, and they were
not confined to chiropractic. Many of the details are available only to
Consumer Reports subscribers, but the publication agreed to give DC access
to them. (See our annotated version of the findings included with this
In a section on "Treatment Ratings for Lower-Back Pain," Consumer Reports
included a brief discussion of medical evidence for each treatment type. In
addition, the editors also assigned their own recommendations and cautions.
These recommendations were based on reader reports and the medical evidence
examined. As part of this section, the editors stipulated that any treatment
receiving more than a 39 percent rating of "helping a lot" (chiropractic
received the top rating of 58 percent) "probably reflected real patient
benefits, compared with a placebo effect."As part of their recommendations and cautions section, the publication'seditors stated this about chiropractic: "Both our survey respondents and thepublished clinical evidence suggest that spinal manipulation can be helpfulfor lower-back pain in the short-term." However, the editors then cautioned that "some experts think that this treatment could make a herniated disk
On the other hand, the publication was even more cautious about prescription
medications, which are typically a primary course of treatment prescribed by
medical doctors: "Although 45 percent of the respondents who tried
prescription medications said that they were helpful, our experts recommend
that these drugs be used with caution and for a short duration with counsel
from your doctor. The evidence suggests that while many of these drugs can
decrease pain, they can also have significant side effects."
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