Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain

OBJECTIVES

To measure changes in pain and disability for chronic low-back pain patients receiving treatment with medication-assisted manipulation (MAM) and to compare these to changes in a group only receiving spinal manipulation.

STUDY DESIGN

Prospective cohort study of 68 chronic low-back pain patients.

METHODS

Outcomes were measured using the 1998 Version 2.0 American Association of Orthopaedic Surgeons/Council of Musculoskeletal Specialty Societies/Council of Spine Societies Outcomes Data Collection Instruments. The primary outcome variable was change in pain and disability. All patients received an initial 4- to 6-week trial of spinal manipulation therapy (SMT), after which 42 patients received supplemental intervention with MAM and the remaining 26 patients continued with SMT.

RESULTS

Low back pain and disability measures favored the MAM group over the SMT-only group at 3 months (adjusted mean difference of 4.4 points on a 100-point scale, 95% confidence interval [CI] -2.2 to 11.0). This difference attenuated at 1 year (adjusted mean difference of 0.3 points, 95% CI -8.6 to 9.2). The relative odds of experiencing a 10-point improvement in pain and disability favored the MAM group at 3 months (odds ratio 4.1, 95% CI 1.3-13.6) and at 1 year (odds ratio 1.9, 95% CI 0.6-6.5).

CONCLUSION

Medication-assisted manipulation appears to offer some patients increased improvement in low back pain and disability. Further investigation of these apparent benefits in a randomized clinical trial is warranted.

A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002-03

BACKGROUND

Scientifically rigorous general population-based studies comparing chiropractic with primary-care medical patients within and between countries have not been published. The objective of this study is to compare care seekers of doctors of chiropractic (DCs) and general practitioners (GPs) in the United States and Canada on a comprehensive set of sociodemographic, quality of life, and health-related variables.

METHODS

Data are from the Joint Canada/U.S. Survey of Health (JCUSH), 2002-03, a random sample of adults in Canada (N = 3505) and the U.S. (N = 5183). Respondents were categorized according to their pattern of health-care use in the past year. Distributions, percentages, and estimates (adjusted odds ratios) weighted to reflect the complex survey design were produced.

RESULTS

Nearly 80% of respondents sought care from GPs; 12% sought DC care. Compared with GP only patients, DC patients in both countries tend to be under 65 and white, with arthritis and disabling back or neck pain. U.S. DC patients are more likely than GP only patients to be obese and to lack a regular doctor; Canadian DC patients are more likely than GP only patients to be college educated, to have higher incomes, and dissatisfied with MD care. Compared with seekers of both GP and DC care, DC only patients in both countries have fewer chronic conditions, take fewer drugs, and have no regular doctor. U.S. DC only patients are more likely than GP+DC patients to be uninsured and dissatisfied with health care; Canadian DC only patients are more likely than GP+DC patients to be under 45, male, less educated, smokers, and not obese, without disabling back or neck pain, on fewer drugs, and lacking a regular doctor.

CONCLUSION

Chiropractic and GP patients are dissimilar in both Canada and the U.S., with key differences between countries and between DC patients who do and do not seek care from GPs. Such variation has broad and potentially far-reaching health policy and research implications.

A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care.

SUMMARY OF BACKGROUND DATA

Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking.

METHODS

A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms.

RESULTS

Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.

CONCLUSIONS

Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.

A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study

Background

While it is widely held that non-surgical management should be the first line of approach in patients with lumbar spinal stenosis (LSS), little is known about the efficacy of non-surgical treatments for this condition. Data are needed to determine the most efficacious and safe non-surgical treatment options for patients with LSS. The purpose of this paper is to describe the clinical outcomes of a novel approach to patients with LSS that focuses on distraction manipulation (DM) and neural mobilization (NM).

Methods

This is a prospective consecutive case series with long term follow up (FU) of fifty-seven consecutive patients who were diagnosed with LSS. Two were excluded because of absence of baseline data or failure to remain in treatment to FU. Disability was measured using the Roland Morris Disability Questionnaire (RM) and pain intensity was measured using the Three Level Numerical Rating Scale (NRS). Patients were also asked to rate their perceived percentage improvement.

Results

The mean patient-rated percentage improvement from baseline to the end to treatment was 65.1%. The mean improvement in disability from baseline to the end of treatment was 5.1 points. This was considered to be clinically meaningful. Clinically meaningful improvement in disability from baseline to the end of treatment was seen in 66.7% of patients. The mean improvement in "on average" pain intensity was 1.6 points. This did not reach the threshold for clinical meaningfulness. The mean improvement in "at worst" pain was 3.1 points. This was considered to be clinically meaningful.

The mean duration of FU was 16.5 months. The mean patient-rated percentage improvement from baseline to long term FU was 75.6%. The mean improvement in disability was 5.2 points. This was considered to be clinically meaningful. Clinically meaningful improvement in disability was seen in 73.2% of patients. The mean improvement in "on average" pain intensity from baseline to long term FU was 3.0 points. This was considered to be clinically meaningful. The mean improvement in "at worst" pain was 4.2 points. This was considered to be clinically meaningful. Only two patients went on to require surgery.

No major complications to treatment were noted.

Conclusion

A treatment approach focusing on DM and NM may be useful in bringing about clinically meaningful improvement in disability in patients with LSS.

Satisfaction as a predictor of clinical outcomes among chiropractic and medical patients enrolled in the UCLA low back pain study

STUDY DESIGN

Observational study conducted within a randomized clinical trial.

OBJECTIVES

The objective of this study is to estimate the effects of patient satisfaction on subsequent changes in pain and disability among low back pain patients randomized to chiropractic or medical care in a managed-care practice setting.

SUMMARY OF BACKGROUND DATA

Recent studies of low back pain treatments have shown chiropractic patients to be more satisfied with their care than medical patients. However, little is known about the relation between patient satisfaction and clinical outcomes.

METHODS

A total of 681 low back pain patients presenting to three southern California healthcare clinics and screened for serious spinal pathology and contraindications were randomized to medical care with and without physical therapy, and chiropractic care with and without physical modalities, and followed for 18 months. Satisfaction with back care was measured on a 40-point scale and observed at 4 weeks following randomization. The primary outcome variables, observed between 6 weeks and 18 months of follow-up, are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire, and remission from clinically meaningful pain and disability. Perceived change in low back symptoms was a secondary outcome.

RESULTS

Greater satisfaction increased the odds of remission from clinically meaningful pain and disability at 6 weeks (adjusted odds ratio [OR] for 10-point increase in satisfaction = 1.61, 95% confidence interval [CI] = 0.99, 2.68), but not at 6, 12, or 18 months (6 months: adjusted OR = 1.05, 95% CI = 0.73, 1.52; 12 months: adjusted OR = 0.94, 95% CI = 0.67, 1.32; 18 months: adjusted OR = 1.07; 95% CI = 0.76, 1.50). Perception of improvement was greater among highly satisfied than less satisfied patients throughout the 18-month follow-up period. The estimated effects of satisfaction on clinical outcomes were similar for medical and chiropractic patients.

CONCLUSIONS

Patient satisfaction may confer small short-term clinical benefits for low back pain patients. Long-term perceived improvement may reflect, in part, perceived past improvement as measured by satisfaction.

Effects of recreational physical activity and back exercises on low back pain and psychological distress: findings from the UCLA Low Back Pain Study

OBJECTIVES

We sought to estimate the effects of recreational physical activity and back exercises on low back pain, related disability, and psychological distress among patients randomized to chiropractic or medical care in a managed care setting.

METHODS

Low back pain patients (n=681) were randomized and followed for 18 months. Participation in recreational physical activities, use of back exercises, and low back pain, related disability, and psychological distress were measured at baseline, at 6 weeks, and at 6, 12, and 18 months. Multivariate logistic regression modeling was used to estimate adjusted associations of physical activity and back exercises with concurrent and subsequent pain, disability, and psychological distress.

RESULTS

Participation in recreational physical activities was inversely associated--both cross-sectionally and longitudinally--with low back pain, related disability, and psychological distress. By contrast, back exercise was positively associated--both cross-sectionally and longitudinally--with low back pain and related disability.

CONCLUSIONS

These results suggest that individuals with low back pain should refrain from specific back exercises and instead focus on nonspecific physical activities to reduce pain and improve psychological health.

Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To document the types and frequencies of adverse reactions associated with the most common chiropractic treatments for neck pain, and to identify possible clinical predictors of adverse reactions to chiropractic treatment.

SUMMARY OF BACKGROUND DATA

Chiropractic care is frequently sought by patients for relief from neck pain; however, adverse reactions related to its primary modes of treatment have not been well examined.

METHODS

A total of 336 patients with neck pain presenting to 4 southern California health care clinics were randomized in a balanced 2 x 2 x 2 factorial design to manipulation with or without heat, and with or without electrical muscle stimulation (EMS); and mobilization with or without heat and with or without EMS. Discomfort or unpleasant reactions from chiropractic care were self-assessed at 2 weeks after the randomization/baseline visit.

RESULTS

Of the 280 participants (83%) who responded, 85 (30.4%) had 212 adverse symptoms as a result of chiropractic care. Increased neck pain or stiffness was the most common symptom, reported by 25% of the participants. Less common were headache and radiating pain. Patients randomized to manipulation were more likely than those randomized to mobilization to have an adverse symptom occurring within 24 hours of treatment (adjusted odds ratio [OR] = 1.44, 95% confidence interval [CI] = 0.83, 2.49). Heat and EMS were only weakly associated with adverse symptoms (heat: OR = 0.94, 95% CI = 0.54, 1.62; EMS: OR = 1.09, 95% CI = 0.63, 1.89). Moderate-to-severe neck disability at baseline was strongly associated with adverse neurologic symptoms (OR = 5.70, 95% CI = 1.49, 21.80).

CONCLUSIONS

Our results suggest that adverse reactions to chiropractic care for neck pain are common and that despite somewhat imprecise estimation, adverse reactions appear more likely to follow cervical spine manipulation than mobilization. Given the possible higher risk of adverse reactions and lack of demonstrated effectiveness of manipulation over mobilization, chiropractors should consider a conservative approach for applying manipulation to their patients, especially those with severe neck pain.

Economic Evaluation of Four Treatments for Low-Back Pain

OBJECTIVE

We sought to compare total outpatient costs of 4 common treatments for low-back pain (LBP) at 18-months follow-up.

METHODS

Our work reports on findings from a randomized controlled trial within a large medical group practice treating HMO patients. Patients (n = 681) were assigned to 1 of 4 treatment groups, ie, medical care only (MD), medical care with physical therapy (MDPt), chiropractic care only (DC), or chiropractic care with physical modalities (DCPm). Total outpatient costs, excluding pharmaceuticals, were measured at 18 months. We did not perform a cost-effectiveness analysis because previously published findings showed no clinically meaningful difference in outcomes among the 4 treatment groups. Thirty-seven participants were lost to follow-up at 18 months, leaving a final sample size of n = 654.

RESULTS

Adjusting for covariates, DC was 51.9% more expensive than MD (P < 0.001), DCPm 3.2% more expensive than DC (P = 0.76), and MDPt 105.8% more expensive than MD (P < 0.001). The adjusted mean outpatient costs per treatment group were 369 US dollars for MD, 560 US dollars for DC, 579 US dollars for DCPm, and 760 US dollars for MDPt.

CONCLUSIONS

This study is the first randomized trial to show higher costs for chiropractic care without producing better clinical outcomes, but our findings are likely to understate the costs of medical care with or without physical therapy because of the absence of pharmaceutical data. Physical therapy provided in combination with medical care and physical modalities provided in combination with chiropractic care do not appear to be cost-effective strategies for treatment of LBP; they produce higher costs without clinically significant improvements in outcome.

Acculturation and reported intimate partner violence among Latinas in Los Angeles

This study sought to understand the relationship between acculturation and reporting intimate partner violence (IPV) among Latinas. A cross-sectional interviewer-administered survey was conducted at public health care clinics throughout Los Angeles County. Logistic regression was used to estimate the effect of acculturation on reporting IPV. An increasing trend of reporting IPV was observed among Latinas who were more acculturated (chi-square = 41.02, p = .0006). Highly acculturated Latinas were more likely to report IPV compared with least acculturated Latinas (prevalence odds ration = 2.18, 95% confidence level = 0.98, 4.89) and moderately acculturated Latinas were more likely to report IPV compared with least acculturated Latinas (prevalence odds ration = 1.29, 95% confidence level = 0.69, 2.43). Culturally competent IPV prevention programs may be the key to significantly reducing the number of women exposed to this serious public health problem.

Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study

BACKGROUND

Minor side effects associated with chiropractic are common. However, little is known about their predictors or the effects of reactions on satisfaction and clinical outcomes.

OBJECTIVE

The objectives of this study are to compare the relative effects of cervical spine manipulation and mobilization on adverse reactions and to estimate the effects of adverse reactions on satisfaction and clinical outcomes among patients with neck pain.

METHODS

Neck pain patients were randomized to receive cervical spine manipulation or mobilization. At 2 weeks, subjects were queried about possible treatment-related adverse reactions and followed for 6 months with assessments for pain and disability at 2, 6, 13, and 26 weeks. Numerical rating scales and the Neck Disability Index were used to measure pain and disability. Perceived improvement and satisfaction with care were assessed at 4 weeks.

RESULTS

Of 960 eligible patients, 336 enrolled and 280 responded to the adverse event questionnaire. Thirty percent of respondents reported at least 1 adverse symptom, most commonly increased pain and headache. Patients randomized to manipulation were more likely than those randomized to mobilization to report an adverse reaction (adjusted odds ratio = 1.44, 95% confidence interval = 0.85, 2.43). Subjects reporting adverse reactions were less satisfied with care and less likely to have clinically meaningful improvements in pain and disability.

CONCLUSIONS

Adverse reactions are more likely to be reported following cervical spine manipulation than mobilization. Chiropractors may reduce iatrogenesis and increase satisfaction and perhaps clinical outcomes by mobilizing rather than manipulating their neck pain patients.

The effectiveness of assessment and referral on immunization coverage in the special supplemental nutrition program for women, infants, and children

BACKGROUND

The use of immunization assessment and referral (A/R) in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been shown to produce dramatic improvements in vaccination coverage when coupled with parental incentive; however, data are lacking to support the use of A/R alone.

OBJECTIVE

To determine the effectiveness of A/R in increasing immunization coverage among WIC participants.

DESIGN

Participating WIC centers were assigned to1 of 3 interventions that delivered A/R of varying frequency or a control group.

SETTING

Twenty of the largest Public Health Foundation Enterprises-WIC centers in Los Angeles County.

PARTICIPANTS

Children continuously enrolled in participating WIC centers from 6 to 24 months of age.

INTERVENTION

Assessment of child's vaccination status followed by referral to a health care provider for those lacking indicated vaccinations.

MAIN OUTCOME MEASURE

Up-to-date (UTD) status at 24 months of age for all recommended vaccines.

RESULTS

Baseline coverage rates were similar among all study sites (overall, 77% UTD). After the study period, compared with the controls (88% UTD), we found no differences in immunization coverage among WIC centers that administered A/R at every visit (every 2 months) to all children (90% UTD; adjusted odds ratio [OR], 1.02; 95% confidence interval [CI], 0.54-1.94), every 6 months to all children (89% UTD; OR, 0.98; 95% CI, 0.62-1.56), or every visit to children found to be behind at 8 months of age (89% UTD; OR, 0.89; 95% CI, 0.48-1.68).

CONCLUSION

In this urban population of WIC children with high baseline immunization coverage, A/R was not effective in increasing immunization coverage.

Do asthma and physical inactivity influence the associations of personal and job stressors with perceived stress and depression? Findings from the 1998-1999 California Work and Health Survey

PURPOSE

The purpose of the study is to estimate the associations of personal and job stressors with perceived stress and depression, and to determine if these associations are modified by asthma and physical inactivity.

METHODS

Data from 2,902 adult respondents of the 1998-1999 California Work and Health Survey (CWHS) were used. The CWHS included items on asthma, exercise, personal stressors, psychological and physical job demands, and perceived stress and depression. Multivariable logistic regression modeling was used to estimate cross-sectional and longitudinal associations.

RESULTS

The estimated joint effects of high stressor scores and asthma on stress are compatible with greater than multiplicative effects in both cross-sectional and longitudinal analyses. Asthma did not appear to modify stressor-depression associations, and physical inactivity modified neither stressor-stress nor stressor-depression associations. Among the employed, the cross-sectional joint effects of personal stressors and physical inactivity on stress and depression are compatible with greater than multiplicative effects, as are the effects of low decision latitude and asthma on perceived stress.

CONCLUSIONS

Asthma and physical inactivity may augment the effects of stressors, suggesting that the increasing prevalence of asthma may contribute to greater stress perception and depression, and that exercise may ameliorate these conditions by dampening stressor effects.

Predictors and outcomes of scleroderma renal crisis: the high-dose versus low-dose D-penicillamine in early diffuse systemic sclerosis trial

OBJECTIVE

The reported frequency of scleroderma M01-R renal crisis (SRC) in diffuse systemic sclerosis (SSc; scleroderma) is 15-20%. Early use of angiotensin-converting enzyme (ACE) inhibitors has markedly improved outcome. The present analysis reexamines the prognostic factors for and outcome of SRC in a prospective cohort of patients with early diffuse SSc.

METHODS

We retrospectively evaluated the cohort of SSc patients who participated in the High-Dose Versus Low-Dose D-Penicillamine in Early Diffuse SSc trial. Patients with diffuse cutaneous scleroderma were enrolled if their disease duration was <18 months. Because the trial failed to show a difference between treatment groups, the data were pooled.

RESULTS

One hundred thirty-four SSc patients entered the observation period a mean +/- SD of 0.8 +/- 0.3 years after onset of SSc. SRC occurred in 18 patients a mean +/- SD of 0.9 +/- 1.1 years after entry. During a mean +/- SD 4.0 +/- 1.1 years of followup after entry, 9 of the 18 patients died (mean +/- SD 0.6 +/- 0.9 years after SRC onset). Baseline characteristics that predicted SRC included a modified Rodnan skin thickness score of >or=20 (P < 0.01), enlarged cardiac silhouette on radiograph (P = 0.04), large joint contractures (wrist, elbow, knee) (P = 0.008), and prednisone use at entry (P = 0.01). Baseline characteristics that did not predict SRC included age, sex, race, Health Assessment Questionnaire score, fist closure, handspread, lung involvement, muscle weakness, erythrocyte sedimentation rate, and platelet count. In 5 of 10 subjects for whom at least 2 sequential skin scores were available, skin scores increased significantly (P = 0.012) in the 6 months before onset of SRC.

CONCLUSION

SRC occurred in 13% of patients soon (mean 11 months) after entry into the cohort. Predictors of SRC identified in this study included higher than average skin score, prednisone use at study entry, large joint contractures, and heart enlargement. Our data suggest, however, that low-dose prednisone alone was not associated with the onset of SRC, except in the appropriate clinical setting. Although ACE inhibitors and dialysis are now readily available, SRC continues to be associated with poor survival (in this study, 50% of patients with SRC died).

The impact of treatment confidence on pain and related disability among patients with low-back pain: results from the University of California, Los Angeles, low-back pain study

BACKGROUND CONTEXT

Although many researchers and practitioners believe that patients' positive expectations of their treatment favorably influence clinical outcomes, there is little scientific evidence to support this belief.

PURPOSE

To describe the level of patients' initial confidence in the success of their assigned treatment, by treatment group and other factors; and to estimate the effects of treatment confidence on subsequent changes in low-back pain and related disability. STUDY DESIGN AND PATIENT SAMPLE: Randomized clinical trial involving 681 patients treated for low-back pain in a managed-care facility in Southern California.

OUTCOME MEASURES

Treatment confidence; and changes in three clinical measures of low-back pain: average pain, most severe pain and back-pain-related disability.

METHODS

Patients were randomly assigned to one of four treatment groups: medical care with and without physical therapy, and chiropractic care with and without physical modalities. Information was collected by questionnaires at baseline, 2 weeks, 6 weeks and 6 months. Treatment confidence was measured just after randomization on a scale of 0 to 10.

RESULTS

Treatment confidence was lowest, on average, for patients assigned to medical care only and highest for patients assigned to medical care plus physical therapy. Other predictors of high treatment confidence were having acute pain and being older, female and nonwhite. Although treatment confidence was only weakly associated with subsequent changes in low-back pain or disability in the total sample, high treatment confidence was associated with greater improvement among patients assigned to medical care plus physical therapy.

CONCLUSIONS

Initial confidence in treatment for low-back pain varies by type of care and other factors. Higher confidence may have some beneficial effect on the course of low-back pain in certain patients, but this effect may depend on the type of interaction between client and provider.

A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study

STUDY DESIGN

A randomized clinical trial.

OBJECTIVES

To compare the effectiveness of medical and chiropractic care for low back pain patients in managed care; to assess the effectiveness of physical therapy among medical patients; and to assess the effectiveness of physical modalities among chiropractic patients.

SUMMARY OF BACKGROUND DATA

Despite the burden that low back pain places on patients, providers, and society, the relative effectiveness of common treatment strategies offered in managed care is unknown.

METHODS

Low back pain patients presenting to a large managed care facility from October 30, 1995, through November 9, 1998, were randomly assigned in a balanced design to medical care with and without physical therapy and to chiropractic care with and without physical modalities. The primary outcome variables are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire.

RESULTS

Of 1,469 eligible patients, 681 were enrolled; 95.7% were followed through 6 months. The mean changes in low back pain intensity and disability of participants in the medical and chiropractic care-only groups were similar at each follow-up assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95% confidence interval, -0.32-0.86; average pain, 0.22, -0.25-0.69; and disability, 0.75, -0.29-1.79). Physical therapy yielded somewhat better 6-month disability outcomes than did medical care alone (1.26, 0.20-2.32).

CONCLUSIONS

After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study

OBJECTIVES

This study compared the relative effectiveness of cervical spine manipulation and mobilization for neck pain.

METHODS

Neck-pain patients were randomized to the following conditions: manipulation with or without heat, manipulation with or without electrical muscle stimulation, mobilization with or without heat, and mobilization with or without electrical muscle stimulation.

RESULTS

Of 960 eligible patients, 336 enrolled in the study. Mean reductions in pain and disability were similar in the manipulation and mobilization groups through 6 months.

CONCLUSIONS

Cervical spine manipulation and mobilization yield comparable clinical outcomes.

Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA low-back pain study

OBJECTIVES

This study examined the difference in satisfaction between patients assigned to chiropractic vs medical care for treatment of low back pain in a managed care organization.

METHODS

Satisfaction scores (on a 10-50 scale) after 4 weeks of follow-up were compared among 672 patients randomized to receive medical or chiropractic care.

RESULTS

The mean satisfaction score for chiropractic patients was greater than the score for medical patients (crude difference = 5.5; 95% confidence interval = 4.5, 6.5). Self-care advice and explanation of treatment predicted satisfaction and reduced the estimated difference between chiropractic and medical patients' satisfaction.

CONCLUSIONS

Communication of advice and information to patients with low back pain increases their satisfaction with providers and accounts for much of the difference between chiropractic and medical patients' satisfaction.

Patients using chiropractors in North America: who are they, and why are they in chiropractic care?

SUMMARY OF BACKGROUND DATA AND OBJECTIVES

Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why.

METHODS

The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patient's reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors.

RESULTS

More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care.

CONCLUSION

These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

Second Prize: The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: findings from the UCLA low back pain study

BACKGROUND

Although chiropractors often use physical modalities with spinal manipulation, evidence that modalities yield additional benefits over spinal manipulation alone is lacking.

OBJECTIVE

The purpose of the study was to estimate the net effect of physical modalities on low back pain (LBP) outcomes among chiropractic patients in a managed-care setting.

METHODS

Fifty percent of the 681 patients participating in a clinical trial of LBP treatment strategies were randomized to chiropractic care with physical modalities (n = 172) or without physical modalities (n = 169). Subjects were followed for 6 months with assessments at 2, 4, and 6 weeks and at 6 months. The primary outcome variables were average and most severe LBP intensity in the past week, assessed with numerical rating scales (0-10), and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire.

RESULTS

Almost 60% of the subjects had baseline LBP episodes of more than 3 months' duration. The 6-month follow-up was 96%. The adjusted mean differences between groups in improvements in average and most severe pain and disability were clinically insignificant at all follow-up assessments. Clinically relevant improvements in average pain and disability were more likely in the modalities group at 2 and 6 weeks, but this apparent advantage disappeared at 6 months. Perceived treatment effectiveness was greater in the modalities group.

CONCLUSIONS

Physical modalities used by chiropractors in this managed-care organization did not appear to be effective in the treatment of patients with LBP, although a small short-term benefit for some patients cannot be ruled out.

Immediate and longterm effects of immune stimulation: hypothesis linking the immune response to subsequent physical and psychological wellbeing

We hypothesize that antigenic stimuli in susceptible persons during key developmental life stages alters neuroendocrine-immune organization and leads to the development of aberrant immune and neuroendocrine responses to subsequent environmental stressors, with longterm physical and psychological consequences. The release of interleukin-1beta (IL-1beta) and other proinflammatory cytokines associated with the immune response during times when individuals are most vulnerable to the effects of environmental influences activates the hypothalamic-pituitary-adrenal (HPA) axis and leads to maladaptive responses to subsequent stressors. The primed HPA axis is reactivated by proinflammatory cytokines, resulting in the secretion of corticotropin-releasing hormone (CRH) and cortisol, followed by physical and psychological effects that feedback on the HPA axis to produce an array of outcomes affecting general wellbeing. Through the release of histamine and other mediators and their effects on the mast cell-leukocyte cytokine cascade, immune stimuli in susceptible persons increase allergic inflammation and magnify stressors' effects through the release of HPA-axis-activating cytokines, such as IL-1beta, that drive the axis and reinforce the physiological and behavioral effects. Thus, specific proinflammatory cytokines and allergic reactions initiate, promote, and maintain immune-stimulus-associated HPA axis activity, and with CRH and cortisol, participate in a positive feedback loop, resulting in aberrant, maladaptive responses to physical or psychological stressors, with outcomes such as depression, hyperalgesia, and pain-related behavior.

The Disability Index of the Health Assessment Questionnaire is a predictor and correlate of outcome in the high-dose versus low-dose penicillamine in systemic sclerosis trial

OBJECTIVE

To explore the clinical implications of a score of > or =1.0 on the Disability Index of the Health Assessment Questionnaire (HAQ DI) at the first patient visit, and to examine the implications of improvement in HAQ DI score over 2 years in a cohort of systemic sclerosis (SSc) patients with diffuse cutaneous scleroderma.

METHODS

SSc skin and visceral involvement was assessed in 134 SSc patients with diffuse scleroderma (mean +/- SD disease duration of 10 +/- 4 months) when they entered a multicenter drug trial and again 2 years later. Mortality and the occurrence of scleroderma renal crisis were assessed for a mean +/- SD of 4.0 +/- 1.1 years. Logistic and linear regression analyses were used to examine the relationship of the baseline HAQ DI score to morbidity, mortality, and visceral involvement, as well as the relationship of changes in the HAQ DI score to changes in physical examination, laboratory, and functional variables over 2 years.

RESULTS

A baseline HAQ DI score of > or =1.0 was predictive of mortality (odds ratio 3.22, 95% confidence interval 1.097-9.468) over 4 years. Multivariate linear regression demonstrated that a model which included the erythrocyte sedimentation rate at baseline (P = 0.005) and changes at 2 years in the swollen joint count (P = 0.002), total skin score (P = 0.005), and white blood cell count (P = 0.005) best explained the change in HAQ DI score over 2 years (R2 = 0.528). The HAQ DI score and total skin score at baseline were highly correlated (correlation coefficient 0.368), as were changes in the HAQ DI score and the total skin score over 2 years (correlation coefficient 0.492). Although the HAQ DI score was heavily influenced by hand dysfunction at baseline and at 2 years, improvement (reduction) in the HAQ DI score over 2 years was related to factors other than hand dysfunction.

CONCLUSION

A baseline HAQ DI score of > or =1.0 predicted mortality over 4 years. Improvement in the HAQ DI score in these patients with diffuse scleroderma was associated with improvement in skin thickening, hand function, oral aperture, lung function, signs of arthritis, serum creatinine level, and the investigator's global assessment of improvement. The HAQ DI is a self-administered questionnaire that SSc patients can complete easily and rapidly and that gives the practicing physician important information about prognosis, patient status, and changes in disease course over time.

Skin thickness score as a predictor and correlate of outcome in systemic sclerosis: high-dose versus low-dose penicillamine trial

OBJECTIVE

To study the clinical implications of a skin thickness score > or =20 at first visit and of softening of sclerodermatous skin in a cohort of systemic sclerosis (SSc) patients with diffuse cutaneous scleroderma.

METHODS

Skin and visceral involvement were assessed in 134 SSc patients with diffuse scleroderma (mean +/- SD duration of SSc 10 +/- 4 months) as they entered a multicenter drug trial and again at 2 years of followup. Advent of mortality and scleroderma renal crisis (SRC) were assessed during a followup of 4.0 +/- 1.1 years (mean +/- SD). Logistic and linear regression were used to examine the relationship of baseline skin score to morbidity, mortality, and visceral involvement and the relationship of changes in skin score to changes in physical examination, laboratory, and functional variables over 2 years.

RESULTS

A baseline skin score > or =20 was associated with heart involvement at baseline (odds ratio [OR] 3.10, 95% confidence interval [95% CI] 1.25-7.70) and was predictive of mortality (OR 3.59, 95% CI 1.23-10.55) and SRC (OR 10.00, 95% CI 2.21-45.91) over 4 years. Multivariate linear regression demonstrated that a model with skin score at baseline (P = 0.0078) and changes in large joint contractures (P = 0.0072), tender joint counts (P = 0.0119), handspread (P = 0.0242), and Health Assessment Questionnaire disability index (HAQ-DI) (P = 0.0244) explained the change in skin score over 2 years (R2 = 0.567). Multivariate logistic regression demonstrated that the investigator's global assessment of improvement was best explained by a model with skin score and HAQ-DI (R2 = 0.455).

CONCLUSION

A baseline skin score > or =20 was associated with heart involvement at baseline and predicted mortality and SRC over the subsequent 4 years. Improvement in skin score in these patients with diffuse cutaneous scleroderma was associated with improvement in hand function, inflammatory indices, joint contractures, arthritis signs, overall functional ability, and the examining investigator's global assessment of improvement.

Effects of diphtheria-tetanus-pertussis or tetanus vaccination on allergies and allergy-related respiratory symptoms among children and adolescents in the United States

BACKGROUND

Findings from animal and human studies confirm that diphtheria and tetanus toxoids and pertussis (DTP) and tetanus vaccinations induce allergic responses; associations between childhood vaccinations and subsequent allergies have been reported recently.

OBJECTIVE

The association of DTP or tetanus vaccination with allergies and allergy-related respiratory symptoms among children and adolescents in the United States was assessed.

METHODS

Data were used from the Third National Health and Nutrition Examination Survey on infants aged 2 months through adolescents aged 16 years. DTP or tetanus vaccination, lifetime allergy history, and allergy symptoms in the past 12 months were based on parental or guardian recall. Logistic regression modeling was performed to estimate the effects of DTP or tetanus vaccination on each allergy.

RESULTS

The odds of having a history of asthma was twice as great among vaccinated subjects than among unvaccinated subjects (adjusted odds ratio, 2.00; 95% confidence interval, 0.59 to 6.74). The odds of having had any allergy-related respiratory symptom in the past 12 months was 63% greater among vaccinated subjects than unvaccinated subjects (adjusted odds ratio, 1.63; 95% confidence interval, 1.05 to 2.54). The associations between vaccination and subsequent allergies and symptoms were greatest among children aged 5 through 10 years.

CONCLUSIONS

DTP or tetanus vaccination appears to increase the risk of allergies and related respiratory symptoms in children and adolescents. Although it is unlikely that these results are entirely because of any sources of bias, the small number of unvaccinated subjects and the study design limit our ability to make firm causal inferences about the true magnitude of effect.

Cross-sectional associations of asthma, hay fever, and other allergies with major depression and low-back pain among adults aged 20-39 years in the United States

Although low-back pain and depression are common comorbidities, the mechanisms responsible for their association remain unclear. The effects of proinflammatory cytokines on the hypothalamic-pituitary-adrenal (HPA) axis lead to the hypothesis that allergic reactions, as markers for inflammation-associated activation of the HPA axis, result in aberrant responses to subsequent stressors. Data from 6,836 US adults 20-39 years old from the Third National Health and Nutrition Examination Survey (1988-1994) were used. Subjects responded to questions regarding low-back pain in the past 12 months and history of asthma, hay fever, and other allergies. The history and onset of major depression were obtained from the Diagnostic Interview Schedule. Logistic regression modeling was used to estimate the associations between allergies and depression and low-back pain. Subjects with a history of any allergy were more likely to report low-back pain (odds ratio = 1.51; 95% confidence interval: 1.16, 1.96), to be diagnosed with major depression (odds ratio = 1.58; 95% confidence interval: 1.13, 2.21), and much more likely to have both major depression and low-back pain (odds ratio = 3.03; 95% confidence interval: 1.32, 6.92). Hypersensitivity reactions may prime the HPA axis to respond aberrantly to stressors, resulting in physical and behavioral consequences.

Correlates of the disability index of the health assessment questionnaire: a measure of functional impairment in systemic sclerosis

OBJECTIVE

To evaluate functional impairment in systemic sclerosis (SSc) patients with diffuse cutaneous scleroderma at the time of entry into a trial of a therapeutic intervention (D-penicillamine).

METHODS

The 20-item Disability Index of the Health Assessment Questionnaire (HAQ-DI) was administered to 134 patients as they entered a multicenter trial of high-dose versus low-dose D-penicillamine. All patients had diffuse SSc of < 18 months' duration. SSc patients who had severe organ system involvement and recent renal crisis and who were receiving prednisone > 10 mg/day were excluded from entry. Logistic regression modeling was used to examine the relationship of HAQ-DI scores to SSc skin and organ system involvement. Odds ratios (OR) and 95% confidence intervals (95% CI) were used to estimate effects.

RESULTS

The mean (+/-SD) HAQ-DI score at entry was 1.04 +/- 0.67. Fifty-three percent of patients had HAQ-DI scores > or = 1.0 (signifying moderate-to-severe functional impairment). Multivariate logistic regression demonstrated that impaired fist closure > or = 23 mm (OR 4.24, 95% CI 1.68-10.70), reduced handspread < or = 175 mm (OR 4.5, 95% CI 1.80-11.24), joint tenderness count > or = 1.0 (OR 2.93, 95% CI 1.16-7.40), age > or = 43 years (OR 2.44, 95% CI 1.01-5.95), platelet count > or = 330,000/mm3 (OR 2.30, 95% CI 0.96-5.57), and female sex (OR 2.43, 95% CI 0.77-7.73) were the most important correlates of HAQ-DI scores > or = 1.0.

CONCLUSION

Increased HAQ-DI scores at baseline were correlated with reduced fist closure, reduced hand-spread, elevated platelet count, presence of tender joints, older age, and female sex. The most important contributor to functional impairment was hand dysfunction. Even within the first 18 months after SSc onset, moderate-severe functional impairment (HAQ-DI scores > or = 1.0) was frequent (53%) in this group of diffuse SSc patients. In early diffuse SSc, the self-administered HAQ-DI is therefore a valuable assessment of function that correlates with objective physical and laboratory measures of SSc disease involvement. Abnormal HAQ-DI scores may support patient claims of functional impairment, help to focus physician attention on implementing measures to reduce functional impairment, and be useful in reflecting the disease course over time.

The effect of comorbidity on care seeking for back problems in the United States

PURPOSE

We assess the effect of comorbidity on self-reported use of health care for back problems in the United States.

METHODS

Data from the 1989 National Health Interview Survey (NHIS) were used to perform cross-sectional analyses of adults who reported a back-related condition. The presence of one or more nonback-related conditions (and associated disability and health care) were the primary predictor variables. Weighted logistic regression modeling was performed to estimate odds ratios (ORs) adjusted for the effects of covariates.

RESULTS

The 1989 NHIS included 84,572 adults, of which 4790 (5.7%) reported at least one back-related condition. Of these, 931 (19.6%) sought health care for their back condition during the 2-week reference period. Among all adults with reported back problems, those with disabling comorbidities and those who sought care for their comorbidities during the reference period were less likely to have sought back care than were those with no comorbidities. Subjects with back-related disabilities who reported nondisabling comorbidities without associated health care were much more likely to have sought back care than were similar subjects without any comorbidities.

CONCLUSIONS

The decision to seek care for a back problem is a complex process that depends upon the presence and impact of other conditions and the use of care for these conditions. Comorbid back problem sufferers may not seek back care when afflicted with other disabling conditions or conditions that may be perceived to be more amenable to care.

Interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on magnetic resonance imaging and association of high-intensity zone with pain and anular disruption

STUDY DESIGN

Retrospective analysis of a spine imaging center's records of patients with chronic low back pain referred by tertiary care facilities.

OBJECTIVES

1) To assess the interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on T2-weighted magnetic resonance imaging, and 2) to assess the relation between high-intensity zone and discography or post-computed tomography in symptomatic patients with low back pain.

SUMMARY OF BACKGROUND DATA

Two of the three previous studies on this subject found an association between high-intensity zone and the presence of Grade 4 anular disruption with discographic reproduction of patients' exact low back pain.

METHODS

Records of patients with low back pain who had undergone lumbar spine discography injection and post-computed tomography from June 1995 to August 1996 were reviewed. Two independent observers were asked to identify the presence of an high-intensity zone from the T12-L1 disc to L5-S1 on T2-weighted magnetic resonance images. With this data, interobserver reliability was assessed with the kappa statistic. Concordant high-intensity zone results were then compared with the Dallas Discogram rating for anular disruption and to patients' subjective pain response to discography injection. With this data, the sensitivity, specificity, and predictive values of high-intensity zone for detecting disc disruption and pain response were calculated.

RESULTS

The interobserver reliability for detecting a high-intensity zone in a given disc was fair to good (kappa = 0.57; 95% confidence interval = 0.44, 0.70). The sensitivity of high-intensity zone for detecting Grade 4 anular disruption and exact pain was poor (31%) but its specificity was relatively high (90%). The positive predictive value of a high-intensity zone was low (40%) for a severely disrupted and exactly painful disc.

CONCLUSIONS

The interobserver reliability of detecting a high-intensity zone and the positive predictive value of the presence of a high-intensity zone for detecting a severely disrupted and exactly painful disc were much lower than previous studies have shown. The relatively low positive predictive value may be attributable to differences in sample characteristics or procedural variations, or suggest that a high-intensity zone is not indicative of exactly painful internal intervertebral disc disruption.

Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America

BACKGROUND

Recent U.S. practice guidelines recommend spinal manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking.

OBJECTIVE

To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain.

DESIGN

Retrospective review of chiropractic office records against preset criteria for appropriateness that were developed from a systematic review of the literature and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit.

SETTING

131 of 185 (71%) chiropractic offices randomly sampled from sites in the United States and Canada.

PATIENTS

10 randomly selected records of patients presenting with low back pain from each office (1310 patients total).

MEASUREMENTS

Sociodemographic data on patients and chiropractors; use of health care services by patients; assessment of the decision to initiate spinal manipulation as appropriate, uncertain, or inappropriate.

RESULTS

Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases. Patients who did not undergo spinal manipulation were less likely to have a presentation judged appropriate and were more likely to have a presentation judged inappropriate than were patients who did undergo spinal manipulation (P = 0.01).

CONCLUSIONS

The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.

Use of chiropractic services from 1985 through 1991 in the United States and Canada

OBJECTIVES

The purpose of this paper is to describe the demographic and clinical characteristics of chiropractic patients and to document chiropractic visit rates in 6 sites in the United States and Canada.

METHODS

Random samples of chiropractors from 5 US sites and 1 Canadian site were selected. A record abstraction system was developed to obtain demographic and clinical data from office charts.

RESULTS

Of the 185 eligible chiropractors sampled, 131 (71%) participated. Sixty-eight percent of the selected charts showed that care was sought for low back pain, while 32% recorded care for other reasons. Spinal manipulative therapy was recorded in 83% of all charts. There was a greater than 2-fold difference in the median number of visits related to low back pain per episode of care across sites. The chiropractic visit rates in the US sites and Ontario are estimated to be 101.2 and 140.9 visits per 100 person-years, respectively.

CONCLUSIONS

The chiropractic use rate in these sites is twice that of estimates made 15 years ago. The great majority of patients receive care for musculoskeletal conditions of the back and neck. The number of visits per episode varies appreciably by site.

Use of acupuncture by American physicians

OBJECTIVES

Little is known about the characteristics of American physicians who currently practice acupuncture. We asked: (1) Do the demographics of physicians practicing acupuncture differ from the general physician population? (2) Do these physicians use or endorse other alternative therapies? (3) For which conditions is acupuncture most commonly used? (4) For which conditions is acupuncture perceived to be most efficacious?

DESIGN

Mailed survey of physicians who incorporate acupuncture into their practice.

PARTICIPANTS

Membership of the American Academy of Medical Acupuncture (AAMA).

OUTCOME MEASURES

Demographic information regarding physicians and practice characteristics; specific illnesses treated, and perceived efficacy; use of other complementary modalities; personal reasons for practicing acupuncture.

RESULTS

Compared with national data, respondents were more likely to be nonspecialists, in private practice, and age 35 to 54. There was an equal proportion of men and women. Most had been doing acupuncture for < 5 years; most use it on < 25% of their patients. Endorsement or use of other complementary methods (spinal manipulation, herbal medicine, supplements, homeopathy) was common. Acupuncture was more commonly used for pain conditions than general medical problems or addiction management. Reasons for use included: efficacy of the technique, an alternative in cases of inadequacy of standard medical approach, and a multidimensional approach to health care.

CONCLUSIONS

Physicians surveyed in this study who incorporate acupuncture into their practice do so mainly to treat pain problems. They are more likely to be in the 35 to 54 age group, nonspecialists, and in private practice when compared with national averages. These physicians are also more likely to use or endorse other complementary modalities.

The effects of comorbidity and other factors on medical versus chiropractic care for back problems

STUDY DESIGN

This study is a cross-sectional analysis of adults in the United States who reported at least one back-related visit to a health care professional during a 2-week reference period.

OBJECTIVES

To estimate and compare the effects of comorbidity and other factors on self-reported use of medical and chiropractic care for back problems in the United States.

SUMMARY OF BACKGROUND DATA

Although back pain is the second most frequent primary symptom reported by patients seeking medical care and the most frequent primary symptom among chiropractic patients, there is a dearth of research on the predictors of chiropractic and medical care among back pain patients.

METHODS

Data from the 1989 National Health Interview Survey were used to perform a cross-sectional analysis of adults who sought care for a back-related condition. The primary predictor variables included comorbidity and associated disability, sociodemographic variables, and back-problem-related variables. Weighted logistic regression modeling was performed to estimate odds ratios adjusted for the effects of covariates.

RESULTS

Of the 4790 adults with reported back problems, 931 sought health care for their back condition during the 2-week reference period. Adults with disabling comorbidities and back-related restricted-activity days were relatively less likely to use chiropractic care than primary medical care. Those who were male, high-school educated, single, employed, and with more than nine doctor visits during the previous 12 months were relatively more likely to use chiropractic care than primary medical care.

CONCLUSIONS

The presence of comorbidity-related or back-related disability, as well as other factors, affect the type of care sought for back conditions among adults in the United States.

Correlates of back problems and back-related disability in the United States

The purpose of this study is to identify correlates of back problems and back disability in the adult population of the United States. Cross-sectional analyses were performed using data from the 1989 National Health Interview Survey (NHIS). Weighted polytomous logistic regression modeling was performed to estimate odds ratios adjusted for the effects of covariates. The prevalence of a disabling back condition, vs. no back condition, was relatively higher among subjects aged 25-64 years, male, non-high-school graduates, unemployed, living in the West, with disabling non-back morbidities, and with body mass index and weight above the 50th percentile. Among workers, those in technical, sales, clerical, private household, service, precision production and repair, or transportation occupations were relatively more likely to report disabling back conditions, compared to workers in professional occupations. Among adults with back problems, age greater than 34 years, weight above the 50th percentile, and history of back trauma were associated with chronic back disability. Although the magnitudes of the associations are not large, they may have enormous public health implications because of the high prevalence of back problems and related disability.

Manipulation and mobilization of the cervical spine. A systematic review of the literature

STUDY DESIGN

Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present.

OBJECTIVES

To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache.

SUMMARY OF BACKGROUND DATA

Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache.

METHODS

A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients' pain status.

RESULTS

Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.

CONCLUSIONS

Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.

The appropriateness of chiropractic spinal manipulation for low back pain: a pilot study

OBJECTIVE

Spinal manipulation is an efficacious therapy for some patients with low back pain (LBP). In this pilot study, we tested the feasibility of assessing the appropriateness of chiropractic spinal manipulation for patients with LBP.

METHODS

Criteria for the appropriate and inappropriate use of spinal manipulation for low back pain were developed using the RAND/UCLA appropriateness method. Two separate expert panels, one multidisciplinary and one all chiropractic, each rated a comprehensive array of clinical scenarios for appropriateness. A random sample of practicing chiropractors was selected, and data were collected from ten randomly selected office records from each participating clinician. Assessment of the appropriateness for the use of spinal manipulation was made by comparing the care delivered with the appropriateness criteria determined by each expert panel.

RESULTS

Eight of thirteen (62%) eligible chiropractors agreed to participate. For the remainder, by the multidisciplinary panel's criteria, 38% of care was appropriate and 26% of care was inappropriate. By the all-chiropractic panel's criteria, the same cases were judged 74% appropriate and 7% inappropriate. The two panel's appropriateness ratings were in agreement on 48% of all cases.

CONCLUSIONS

In this geographic area, the rate of appropriate care is between 38% and 74% and the rate of inappropriate care is between 7% and 19%, depending on the criteria used to assess appropriateness. Data from other geographic areas of the U.S. will be needed before inferences to a larger population may be drawn, and we have demonstrated that such a study is feasible.

The relative impact of chiropractic vs. medical management of low back pain on health status in a multispecialty group practice

PURPOSE

The objective of the study was to compare chiropractic management and medical management of low back pain of musculoskeletal etiology in a multispecialty group practice.

STUDY DESIGN

The design was a retrospective cohort study in which the subcohorts were defined by source of low back pain care and identified before follow-up was complete. Data collection occurred at the end of the third month following their initial visits. One hundred and three chiropractic patients and 187 medical patients aged 16 or greater who had not been treated within the preceding month of their initial visit participated.

MAIN FINDINGS

A greater proportion of chiropractic than medical patients perceived their treatment to be successful (RR = 1.91, 95% CI = 1.29, 2.82), had 0 days with low back pain during the week preceding the evaluation (RR = 1.60, 95% CI = 1.00, 2.59), and had no functional impairment due to low back pain after 3 months following their initial visit according to the Roland-Morris Disability Questionnaire (RR = 1.42, 95% CI = 0.81, 2.50). General health status was similar for both chiropractic and medical patients.

CONCLUSIONS

Chiropractic care was at least as effective as medical care in reducing low back pain and functional disability due to low back pain. Chiropractic patients were more likely to perceive their treatment to be successful in reducing low back pain compared to medical patients.

Spinal manipulation for low-back pain

PURPOSE

To review the use, complications, and efficacy of spinal manipulation as a treatment for low-back pain.

DATA IDENTIFICATION

Articles were identified through a MEDLINE search, review of articles' bibliographies, and advice from expert orthopedists and chiropractors.

STUDY SELECTION

All studies reporting use and complications of spinal manipulation and all controlled trials of the efficacy of spinal manipulation were analyzed. Fifty-eight articles, including 25 controlled trials, were retrieved.

DATA ANALYSIS

Data on the use and complications of spinal manipulation were summarized. Controlled trials of efficacy were critically appraised for study quality. Data from nine studies were combined using the confidence profile method of meta-analysis to estimate the effect of spinal manipulation on patients' pain and functional outcomes.

RESULTS OF DATA SYNTHESIS

Chiropractors provide most of the manipulative therapy used in the United States for patients with low-back pain. Serious complications of lumbar manipulation, including paraplegia and death, have been reported. Although the occurrence rate of these complications is unknown, it is probably low. For patients with uncomplicated, acute low-back pain, the difference in probability of recovery at 3 weeks favoring treatment with spinal manipulation is 0.17 (for example, increase in recovery from 50% to 67%; 95% probability limits of estimate, 0.07 to 0.28). For patients with low-back pain and sciatic nerve irritation, the difference in probabilities of recovery at 4 weeks is 0.098 (probability limits, -0.016 to 0.209).

CONCLUSIONS

Spinal manipulation is of short-term benefit in some patients, particularly those with uncomplicated, acute low-back pain. Data are insufficient concerning the efficacy of spinal manipulation for chronic low-back pain.

Chiropractic in the yellow pages: a content analysis study

This paper presents a content analysis of advertisements by chiropractors in the yellow pages. Information was gathered from 13 cities in the United States for the years 1985 and 1986. Results were categorized by size, number and content of the ads. Estimated expenditures for each city were calculated and a total cost for advertising for the entire chiropractic profession was estimated. Of the 5456 chiropractors listed in the yellow pages in this study, 14.7% bought additional space in the regular listing section, and 11.6% purchased large display advertisements. The remaining 73.7% listed only their name and telephone number. Of those who bought additional space, 10.8% advertised techniques, 11.6% symptoms, 14.7% injuries, 3% professional affiliations and 4% advertised free services. The average annual expenditure for the chiropractor was $2474.00. Future research needs to address the attitudes of the profession and patients toward advertising, and the cost-effectiveness of advertising. The value of the distribution of resources for advertising by chiropractors is questioned.

Spectrum of neurological deficits in experimental CNS ischemia. A quantitative study

The sequence of events in focal cerebral ischemia has been difficult to study quantitatively in humans. Experimental investigation of these phenomena has been impeded because reproducible animals models that simulate human stroke are lacking. We have developed a rabbit spinal cord ischemia model that resembles human stroke patterns in many respects. Using this model, we have found that (1) brief ischemia produces completely reversible neurological deficits; (2) intermediate ischemic periods may produce transiently reversible deficits that later progress without further manipulation; (3) prolonged ischemia produces irreversible lesions in all animals. The model should be useful for studies of the pathophysiological mechanisms of CNS ischemia.