How many days of bed rest for acute low back pain? A randomized clinical trial

General practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines

OBJECTIVE

To compare general practitioners' reported management of acute back pain with 'evidence based' guidelines for its management.

DESIGN

Confidential postal questionnaire.

SETTING

One health district in the South and West region.

SUBJECTS

236 general practitioners; 166 (70%) responded.

OUTCOME MEASURES

Examination routinely performed, 'danger' symptoms and signs warranting urgent referral, advice given, and satisfaction with management.

RESULTS

A minority of general practitioners do not examine reflexes routinely (27%, 95% confidence interval 20% to 34%), and a majority do not examine routinely for muscle weakness or sensation. Although most would refer patients with danger signs, some would not seek urgent advice for saddle anaesthesia (6%, 3% to 11%), extensor plantar response (45%, 37% to 53%), or neurological signs at multiple levels (15%, 10% to 21%). A minority do not give advice about back exercises (42%, 34% to 49%), fitness (34%, 26% to 41%), or everyday activities. A minority performed manipulation (20%) or acupuncture (6%). One third rated their satisfaction with management of back pain as 4 out of 10 or less.

CONCLUSIONS

The management of back pain by general practitioners does not match the guidelines, but there is little evidence from general practice for many of the recommendations, including routine examination, activity modification, educational advice, and back exercises. General practitioners need to be more aware of danger symptoms and of the benefits of early mobilisation and possibly of manipulation for persisting symptoms. Guidelines should reference each recommendation and discuss study methodology and the setting of evidence.

The efficacy of amitriptyline and acetaminophen in the management of acute low back pain

Thirty-nine patients with acute low back pain were treated with amitriptyline (150 mg/d) or acetaminophen (2,000 mg/d) in a controlled double-blind design for 5 weeks. Both groups revealed mild depression, normal coping, and increased anxiety at the beginning, with significant improvement in anxiety state and pain at the end of treatment. A repeated measures analysis of variance demonstrated that amitriptyline was more effective than acetaminophen in reducing pain intensity from the second week of treatment. Age and depression were the only significant pretreatment predictors of posttreatment pain. The study evaluates the significance of these findings.

The role of fear of movement/(re)injury in pain disability

It is now well established that in chronic low back pain, there is no direct relationship between impairments, pain, and disability. From a cognitive-behavioral perspective, pain disability is not only influenced by the organic pathology, but also by cognitive-perceptual, psychophysiological, and motoric-environmental factors. This paper focuses on the role of specific beliefs that are associated with avoidance of activities. These beliefs are related to fear of movement and physical activity, which is (wrongfully) assumed to cause (re)injury. Two studies are presented, of which the first examines the factor structure of the Tampa Scale for Kinesiophobia (TSK), a recently developed questionnaire that is aimed at quantifying fear of movement/(re)injury. In the second study, the value of fear of movement/(re)injury in predicting disability levels is analyzed, when the biomedical status of the patient and current pain intensity levels are controlled for. In addition, the determinants of fear of movement/(re)injury are examined. The discussion focuses on the clinical relevance of the fear-avoidance model in relation to risk assessment, assessment of functional capacity, and secondary prevention.

Randomized controlled trials in industrial low back pain relating to return to work. Part 1. Acute interventions

Employers and insurers are interested in being able to use cost-effective interventions for returning injured workers to the workplace. Unfortunately, truly objective information is lacking. The purpose of this and two subsequent review articles was to perform thorough scrutiny and methodologic comparison among all obtainable, published randomized and controlled studies on low back pain (LBP) interventions leading to return to work. The study was confined to English language articles published from 1975 through 1993. Of more than 4,000 LBP citations, more than 500 were chosen for review. Of that number, 35 articles met the selection criteria of randomization, reasonable controls, and work return comparisons. This paper focuses on the 10 articles relating to interventions for acute (less than 4 weeks) LBP, and considers bed rest, exercise, spinal manipulation, back school, and case management. A 26-point quality system was used to compare the methodologic rigor of each article. This literature survey demonstrated the meager scientific foundations on which our industrial rehabilitation programs are based.

Patient education for low back pain in general practice

This comparative study of patient and general practitioner perceptions of patient education for low back pain (LBP) revealed significant differences in perspective. It suggests that although some general practitioners recognise the importance of patient education, they blame patients for its assumed failure as a management strategy. The patients in this study identified a range of reasons which explain their difficulties in following prevention advice which relate to not only limitations in themselves, but also to broader contextual factors over which they have little control. It is argued that both the inadequacy of current professional assumptions and the contextual factors that influence patients' prevention behaviours need to be acknowledged as a first step towards improving patient education for LBP in general practice.

The role of Dutch general practitioners in clinical health promotion

In this contribution it is argued that Dutch general practitioners (GPs) must make the transition from simply giving information to their patients, to providing them with medical education. Dutch GPs are in a prime position to contribute to the aims of health promotion. Instead of focusing health promotion on prevention, they should primarily promote the health of their patients, especially these patients with a chronic disease. In order to provide proper care for their disabled patients, they have to limit the time they spend on caring for people suffering from minor ailments. Again, this aim cannot be achieved by simply providing information. The patients have to overcome their reluctance to change their consultation behaviour, but the GPs also have to change their attitude by adopting new skills in order to influence their patients in this respect.

[Interdisciplinary cooperation in prevention and treatment of low back pain.]

An expert committee of the German Chapter of the IASP has published five recommendations for the prevention and early treatment of low back pain. These refer to an early activation of the patient facilitated by scheduled pain medication and an interdisciplinary treatment including physiotherapy and psychotherapy if risk factors for chronicity are detected.

How emergency physicians approach low back pain: choosing costly options

To determine ways in which emergency physicians approach the diagnosis and treatment of the common presenting complaint of low back pain, responses of emergency physicians to a questionnaire dealing with three hypothetical patients with different types of low back pain were taken from a stratified national random sample of eight medical specialties. For severe acute (with and without sciatica) or chronic low back pain, physicians were asked which tests and consultants they would use in pursuit of the diagnosis, and which treatments and specialty referrals they would recommend in each of the three scenarios. For diagnosis in the acute cases (pain less than 1 week), up to 22% of emergency physicians recommended computed tomography (CT scan) and 36% recommended magnetic resonance imaging (MRI). Specialist consultation would be sought for 61% of the acute sciatica patients, 32% of the acute nonsciatica patients, and 47% of the chronic patients. In approaching treatment, over 75% of emergency physicians would advise bedrest for an average of 3.5 to 4.5 days. Between 16% and 40% suggested physical therapy for the acute patients. Referrals to surgical specialists (orthopedist or neurosurgeon) were highest (81%) for acute sciatica, compared with 52% for chronic low back pain, and 41% for acute nonsciatic low back pain. In conclusion, given that most cases of acute low back pain resolve with minimal intervention, diagnostic imaging, laboratory testing, and early specialist consultation favored by many emergency physicians would add little except expense to understanding its etiology. For treatment, emergency physician recommendations for bedrest were longer than necessary and, for physical therapy, of no proven benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

Low back pain

Low back pain is a common reason for physician visits and is associated with enormous costs to health care and industry. Radiographic abnormalities of the lumbar spine, including disk protrusion, are common in asymptomatic subjects and only loosely associated with symptoms and neurologic examination. Therefore, highly selective evaluation is required to avoid subjecting patients with back pain to unnecessary tests and surgical procedures. Reassurance about the favorable prognosis of low back pain is an important component of therapy. Most patients with simple back pain recover with symptomatic treatment. Plain radiographs are indicated for evaluation of patients with radiculopathy and those with risk factors for underlying medical conditions. The majority of patients with back pain, even those with radiculopathy, improve with conservative management and surgery is unnecessary. Surgical consultation and CT or MR imaging scans are indicated for patients with persistent or progressive neurologic deficits or persistent sciatica with nerve root tension signs. Acute radiculopathy with bilateral neurologic deficits, saddle anesthesia, or urinary symptoms is suggestive of cord compression or cauda equina syndrome and requires urgent surgical referral.

The treatment of acute low back pain--bed rest, exercises, or ordinary activity?

BACKGROUND

Bed rest and back-extension exercises are often prescribed for patients with acute low back pain, but the effectiveness of these two competing treatments remains controversial.

METHODS

We conducted a controlled trial among employees of the city of Helsinki, Finland, who presented to an occupational health care center with acute, nonspecific low back pain. The patients were randomly assigned to one of three treatments: bed rest for two days (67 patients), back-mobilizing exercises (52 patients), or the continuation of ordinary activities as tolerated (the control group; 67 patients). Outcomes and costs were assessed after 3 and 12 weeks.

RESULTS

After 3 and 12 weeks, the patients in the control group had better recovery than those prescribed either bed rest or exercises. There were statistically significant differences favoring the control group in the duration of pain, pain intensity, lumbar flexion, ability to work as measured subjectively, the Oswestry back-disability index, and number of days absent from work. Recovery was slowest among the patients assigned to bed rest. The overall costs of care did not differ significantly among the three groups.

CONCLUSIONS

Among patients with acute low back pain, continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilizing exercises.

Early return to work following an aggressive rehabilitation program initiated one day after spine surgery

In a program designed and conducted in a private rehabilitation center, 38 postoperative cervical or lumbar spine patients were treated with an aggressive rehabilitation regimen. The regimen included an aquatic component, stabilization and flexibility exercises, resistance and aerobic exercises, progressively difficult walks, educational sessions, and limited palliative modalities. Readiness for discharge was evaluated on the basis of clinical observations and submaximal cardiovascular testing, and a computer analysis comparing range of motion, strength, and functional capacity with normative data. No complications developed during the recovery of any patients. After an average of 3.3 days following discharge from the rehab program, 89% returned to their former occupations without restrictions. At follow-up, all patients had been working continuously at their occupation for over 25 months post-discharge. The authors conclude that, based on this retrospective analysis, this is a safe means of potentially reducing hospital time, minimizing postoperative morbidity, and restoring patients to their former occupations. These findings can only be viewed as preliminary, however, and further study in a prospective, controlled clinical trial is needed to draw definitive conclusions regarding the effectiveness of this aggressiveness rehabilitation program in the general population of postoperative spine patients.

Controlled two year follow up of rehabilitation for disorders in the neck and shoulders

OBJECTIVE

To evaluate the effects of an early, active, and multidisciplinary rehabilitation programme for neck and shoulder disorders.

METHODS

Primary health care and industrial health care of a nonrandomised, controlled, cohort was followed up over two years in a geographically defined area. The cohort consisted of working people who consulted a physician about disorders of the neck or shoulders from 1 August 1988 to 31 October 1989. Criteria for acceptance; not chronic symptoms, patients had sick leave of no more than four weeks. Disorders were not caused by trauma, infections, malignancy, rheumatic diseases, abuse, or pregnancy. 107 people qualified for the study, 87% were followed up for two years. They were divided into two groups. One group obtained active, multidisciplinary rehabilitation for eight weeks that comprised physical training, information, education, social interaction, and work place visits. Controls were given traditional treatment; physiotherapy, medication, rest, and sick leave. The main outcome measures were: average number of days of sick leave for the two years after rehabilitation, subjective pain on a visual analogue scale, and ratings on seven subscales of the sickness impact profile.

RESULTS

At 12 and 24 months of follow up effects of the active rehabilitation programme did not differ from traditional treatment in any of the outcome measures. New work task (P < 0.05) or changed work place (P < 0.001) during the follow up period were associated with decreased sick leave, independent of treatment.

CONCLUSIONS

Active, multidisciplinary rehabilitation of neck and shoulder disorders was not more effective than traditional treatment. Changed work conditions were associated with decreased sick leave, independent of type of treatment provided.

Pharmacological management of back pain syndromes

The symptom of back pain may be the result of many different pathologies. As such, patients with back pain require careful assessment to determine whether the cause is from the spine or other systems. For acute mechanical back pain, treatment is often symptomatic. Symptomatic treatment may include analgesics, anti-inflammatories and/or muscle relaxants. Patients may also need hypnotics in the short term to help them sleep at night. However, drug therapy should be reduced and stopped as soon as possible. Furthermore, too much bedrest may be counterproductive. Paracetamol (acetaminophen) is the standard treatment for transient back pain. More severe pain may require the addition of an opioid, such as codeine or dextropropoxyphene. Morphine and pethidine (meperidine) may be necessary in patients with back pain due to neoplastic disease or osteoporotic fracture. However, the opioid analgesics are associated with dependence, tolerance and adverse effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic efficacy comparable with paracetamol. Individual patients respond differently to different NSAIDs, and several agents may have to be tried. Long term therapy with NSAIDs is necessary in diseases with an inflammatory component such as ankylosing spondylitis. Calcitonin reduces bone resorption and bone blood flow, and has been suggested to have central analgesic effects. As such, it has been used successfully in patients with Paget's disease, osteolytic bone disease and osteoporosis. Bisphosphonates also inhibit osteoclastic bone resorption and may be useful in Paget's disease, osteolytic metastases and osteoporotic fractures. Other drugs which may be useful in relieving back pain associated with specific circumstances include the tricyclic antidepressants, anxiolytics, antiepileptic agents, corticosteroids, colchicine and chymopapain.

Musculoskeletal Injuries in the Workplace: Defining Quality Care

Quality health care for a specific medical condition may be defined as adherence to an algorithm in which decision points are based on established medical practice as supported in the literature. The decision points can be considered either a "stan-dard of care" if there is definitive scientific evidence for their validity or a "guide-line for care" if there is only a consensus of medical opinion available. Algorithms for musculoskeletal injuries can be and have been successfully applied to patients in the workers' compensation setting. They can function as a concurrent surveil-lance system and are well accepted by physicians, patients, and industry if imple-mented by unbiased medical experts. A high level of quality care is attained by following such algorithms. Other goals achieved are early functional restoration as measured by return to work, a more efficient use of diagnostic studies, and avoidance of unnecessary therapeutic interventions, with the result that treatment is more cost-effective. Such a program that strives for high-quality care and emphasizes appropriate utilization will realize cost savings that may be far greater and longer lasting than the financial saving seen with arbitrary spending caps and fee controls.

National study of cataract surgery outcomes. Variation in 4-month postoperative outcomes as reflected in multiple outcome measures

BACKGROUND

Although ophthalmologists have long recognized that visual acuity alone is an inadequate measure of visual impairment, the need for and outcomes of cataract surgery historically have been assessed in terms of visual acuity.

PURPOSE

To examine the relation among different cataract surgery outcome measures, including a 14-item instrument designed to measure functional impairment caused by cataract (the VF-14), at 4 months after cataract surgery.

METHODS

The authors performed a longitudinal study of 552 patients undergoing first eye cataract surgery by 1 of 75 ophthalmologists practicing in Columbus, Ohio, St. Louis, Missouri, or Houston, Texas. Patients were interviewed, and clinical data were obtained preoperatively (July 15, 1991-March 14, 1992) and 4 months postoperatively.

RESULTS

The percentage of patients judged to be improved at 4 months after cataract surgery varied by the outcome measure used: Snellen visual acuity (96%); VF-14 score (89%); satisfaction with vision (85%); self-reported trouble with vision (80%); and Sickness Impact Profile score (67%). The change in patients' ratings of their trouble with vision and their satisfaction with vision were correlated more strongly with the change in VF-14 score than with the change in visual acuity (operated eye or better eye). The average change in VF-14 score was unrelated to the preoperative visual acuity in the eye undergoing surgery.

CONCLUSION

Estimates of the proportion of patients benefiting from cataract surgery vary with the outcome measure used to measure benefit. Change in VF-14 score, a measure of functional impairment related to vision, may be a better measure of the benefit of cataract surgery than change in visual acuity.

The impact of managed care on the diagnosis and treatment of low back pain: a preliminary report

Knowing when to use diagnostic testing and surgery in the management of low back pain is often a dilemma for practitioners. This paper reviews the effectiveness of clinical practice guidelines in managing 1,796 cases of low back pain or herniated lumbar disk reviewed by Health Risk Management, Inc. between November 1990 and October 1991. In all cases (except cauda equina syndrome or other rapidly progressing neurological deficit) a trial of conservative treatment, always including physical therapy, was requested prior to recommendation for diagnostic testing or surgery. Ninety-one percent (1,628 cases) had completed an adequate trial of conservative therapy or had a lesion requiring immediate intervention. These cases were recommended for the requested procedure or hospitalization. Of the 168 cases that were not recommended immediately for imaging, surgery, or hospitalization, 84.5% improved with conservative management and neither imaging nor surgery was necessary over a period of at least 12 months following the time of review. Efficacy of conservative management was independent of age, sex, part of the country in which the treatment took place, and primary diagnosis. Net savings realized after subtracting employer costs for the reviews were well over a third of a million dollars in this small group of patients.

Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice

OBJECTIVE

To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes.

DESIGN

Inception cohort study.

SETTING

Primary care.

PATIENTS

103 patients with acute localised non-specific back pain lasting less than 72 hours.

MAIN OUTCOME MEASURES

Complete recovery (disappearance of both pain and disability) and return to work.

RESULTS

90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender.

CONCLUSIONS

The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.

[Current therapeutic options in sciatica caused by disk herniation]

The results of reliable therapeutic trials, experimental studies showing that compression is not the only mechanism of nerve root alterations, and mainly, the favorable spontaneous outcome of 95% of the sciatica command a critical approach of all the treatments of sciatica by disc herniation. A disc herniation can be observed in 20% of asymptomatic population. Except neurological complications requiring an early surgical decompression, the management of sciatica should begin by a 2 to 3 months period of medical treatment including analgesic drugs or NSAID, a 8 to 10 day bed rest, epidural corticosteroid injections validated in controlled studies, and a lumbar brace during 4 to 6 weeks. The reference treatment of disc herniation in patients whose conservative treatment failed is conventional surgery. The average rate of failure following decompressive surgery is 15 to 20% and the need for further surgery ranges from 5 to 15%. The main cause of failure is the absence of true compressive herniation before the initial operation. Microscope removal of disc herniation does not lead to better results than the standard procedure and there is a 20% risk of recurrence when only the herniated fragment is removed. The success rate of chemonucleolysis approaches 65-70% but the procedure need a strict care to prevent severe complications. Manual percutaneous discectomy, whatever the procedure are supported only by uncontrolled studies. The only randomized trial in automated percutaneous discectomy versus chemonucleolysis reported a 37% success rate with a one-year follow-up. Benefit/risk ratio should always be considered before every treatment of sciatica.

Mechanical back pain and the facet joint syndrome

Mechanical back pain is a common disability often associated with the facet joint syndrome. Treatment is based on early, adequate pain relief with simple techniques of regional analgesia. In a few cases this is not enough and more sophisticated methods, such as radiofrequency denervation, cryo-analgesia and possibly intrathecal midazolam, are necessary. However, the main thrust of our approach is to treat the underlying structural disorder with strengthening of the back muscles and correction of postural abnormalities responsible for the mechanical back pain. Our report is based on an analysis of 83 patients who failed to respond to long periods of rest, suitable analgesic and allied drugs and other non-invasive measures. There had been no overriding indication for major surgery. A large number of these patients have been improved by our methods, but further work is in progress to extend the proportion of satisfactory results.

The life situations of patients with primary antibody deficiency untreated or treated with subcutaneous gammaglobulin infusions

The life situations of 25 patients with hypogammaglobulinaemia were studied before and after the initiation of subcutaneous replacement therapy by using medical records, data registers and questionnaires (a study and a disease-specific questionnaire, the Sickness Impact Profile and the General Health Rating Index). Before treatment, the patients perceived more dysfunctions with regard to ambulation, mobility, emotional behaviour, social interaction, sleep and rest, household management, work and recreation or pastime activities compared with a Swedish reference group (P = 0.0001). A significant increase in the perceived frequency of infections was also seen in untreated patients compared with a group of healthy individuals (P = 0.0001). After 18 months of weekly subcutaneous infusions of an intramuscular gammaglobulin preparation (100 mg/kg), the patients reported a significantly increased, health-related function and improved self-rated health. A significantly higher pre-infusion IgG level was also found.

Simple low back pain: rest or active exercise?

Images

Low back pain

The studies reviewed here show that the duration and severity of individual episodes of back pain can be lessened, reducing recurrences and their cost in terms of suffering and lost work. Frank examines differential diagnosis; acute, chronic, and intractable pain; and service implications. Modern management emphasises self care, and bed rest should usually not be longer than 48 hours. A return to physical fitness and other activities, including employment, is actively encouraged. Medication has a role in facilitating these objectives. Two points are especially emphasised: strategies to manage low back pain must be long term and preventive; and the responsibility to keep fit, maintain an exercise programme, and remain relaxed so as to avoid physically stressing the spine is that of the individual, not of the professionals.

Severe low-back pain. I: Clinical assessment of two weeks conservative therapy

A standard clinical examination was performed by two independent investigators, before and after two weeks of conservative therapy, on 33 patients with severe low-back pain. Kappa coefficients indicated a higher reproducibility of neurological tests than of e.g. muscular tenderness or scoliosis. All patients were diagnosed by CT-scan and a disc herniation was found in 20. The clinical diagnosis was more in agreement with the CT-diagnosis after than before treatment. By discriminant analyses six variables were found to classify the clinical diagnosis correctly in 32 of the 33 patients: sensory loss, ankle jerk, soreness of back extensors, lumbosacral soreness, radiating pain and back extension test. Similarly, the CT-diagnosis was classified in 25 of 33 patients by the variables: sensory loss and limping.

Determining medical necessity of outpatient physical therapy services

A patient referred for physical therapy may attend one or several therapy visits or may continue to receive ongoing therapy services several times weekly for several months. The question of the continued medical necessity of those services arises often. Determination of medical necessity for continued therapy services requires knowledge of the natural history of diseases that may require therapy services, familiarity with the effectiveness of treatment alternatives for those diseases, and awareness of community practice patterns. Accurate and complete documentation from the therapist or referring physician is required for the physician advisor or utilization review consultant to make an accurate determination of medical necessity. A structured format for providing this documentation is suggested.

Acute low back pain and economics of therapy: the iterative loop approach

We use the measurement iterative loop as a conceptual framework to examine the economics of common therapies for acute non-specific low back pain. The measurement iterative loop systematically assesses the interlocking facets of an illness from the community health perspective, including quantifying burden of illness, etiology, assessment of therapeutic effectiveness, and economic evaluation of therapies. The iterative loop reveals that: (1) burden of illness, although known to be substantial, is so far inaccurately measured, (2) little is known about such factors as provider and patient compliance; and (3) the economics of therapy can guide us in this time of clinical uncertainty when no therapy appears clearly superior. For therapies with at least some support from randomized controlled trials, bedrest appears to be economically superior. Besides burden of illness, compliance, and current therapies, future research should address such "therapeutic" options as early return to work and patient self-management.

Overdiagnosis and overtreatment of low back pain: Long-term effects

Low back pain and subsequent disability remain a concern in terms of both cost and impact upon industry let alone the adverse effects on the patients involved. The causes of low back pain remain elusive. There has been extensive focus on the intervertebral disc with treatment ranging from passive modalities to multiple surgery. Current experience suggests that misinformation, inadequate patient examination, medication abuse, over use of passive modalities, focus on pain rather than function and excessive reliance on radiological imaging and specialist referrals are contributing factors. Indeed, one is drawn to the conclusion that low back disability may well be an iatrogenic disorder in many cases.

Evaluating primary practice: proposals for a modified model suited to chiropractic care

Although chiropractic care is not yet considered to have achieved scientific validity, it enjoys widespread public acceptance. It is hypothesised that one of the barriers to chiropractic establishing scientific validity is the propensity of researchers to frame their randomized controlled clinical trials according to a biomedical rather than a biopsychosocial model. It is proposed that while chiropractic care should be required to establish a cause--effect relationship between spinal manipulation and clinical response, subjective patient--valued outcomes should also be monitored. For chiropractic care to be adequately assessed recognition needs to be given to the usefulness of qualitative measurements in health care. Interventions selected solely upon the basis of statistical significance run the risk of overlooking clinically meaningful outcomes.