STUDIES THAT SUPPORT CHIROPRACTIC CARE

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: 

•     Adjusted mean Roland-Morris Disability Questionnaire scores were significantly better in the standard medical care plus chiropractic manipulative therapy group than in the standard medical care group at both week two (8.9 vs. 12.9; p = <0.001) and week four (8.0 vs. 12.0; p = 0.004),
•     Mean Numerical Pain Rating Scale (0-10) scores were significantly improved in the group that received chiropractic manipulative therapy when compared to standard medical care alone at both week two (3.9 vs. 6.1; p = <0.001) and week four (3.9 vs. 5.2; p = < 0.02),
•     Seventy-three percent of participants in the standard medical care plus chiropractic manipulative therapy group rated their global improvement as pain completely gone, much better or moderately better, compared to 17 percent in the standard medical care group.

 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:

•     Cynthia R. Long, PhD, Palmer Center for Chiropractic Research
•     Maria A. Hondras, DC, MPH, Palmer Center for Chiropractic Research
•     Richard Petri, MD, Physical Medicine and Integrative Care Services, Ft. Bliss, Texas
•     Roxana Delgado, MS, Samueli Institute
•     Dana J. Lawrence, DC, M.Med.Ed, MA, Palmer College of Chiropractic
•     Edward F. Owens Jr., MS, DC, TriMax Direct, St. Paul, Minn.
•     William C. Meeker, DC, MPH, Palmer College of Chiropractic, West Campus
• 
  

 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
13 weeks).  

 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 discretion. 

 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 instrument (CROM). 

 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 their report: 

 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
necessity).  

 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 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 license."

 "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 intervention.

 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 Task

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
daily. 

 § 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 52 weeks. 

 "Spinal manipulation therapy and [home exercise advice] led to
similar 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(1Pt 1):1-10. 

 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. 

 Study Parameters 

 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.