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1.  The chiropractic profession in Norway 2011 
Background
The chiropractic profession in Norway has increased five-fold in the last two decades. As there is no academic graduate program in Norway, all chiropractors have been trained outside of Norway, in either Europe, America or Australia. This might have given Norwegian chiropractors heterogenic characteristics concerning practice routines and clinical settings. However, little is known about what characterizes this profession and how it compares to other chiropractic professions in Europe. The aim of this survey was to describe major characteristics of the chiropractic profession in Norway.
Method
Two surveys were distributed to all 530 registered chiropractors in Norway in 2011. One survey was for all chiropractors (Survey 1) and the other for clinic owners (Survey 2). Results have been reported as tables and as approximate percentages in the text for ease of reading.
Result
Response rates were 61% (Survey 1, N = 320) and 71% (Survey 2, N = 217). More than two-thirds of the chiropractors in Norway had been in practice for under a decade. Only one in four chiropractors worked in solo practice and the majority shared premises with at least one colleague, typically at least one physiotherapist and one additional health practitioner. Today, only one in five clinics possessed radiologic equipment and one in ten had access to diagnostic ultrasound equipment. The majority of the chiropractors reported to apply mainly similar treatment modalities. More than 90% reported to use manipulation techniques on most patients, with soft tissue techniques and exercise modalities being almost as common. More than 3/4 of the profession reported that their clinical practice was in accordance with available clinical guidelines and about one third were positive about participating in future clinical research.
Conclusion
The Norwegian chiropractic profession is relatively young and members report being satisfied with their work conditions. There is a clear difference from the earlier practice pattern in that intra- and inter-professional collaboration is more common and it is considered desirable. The profession seems to follow the modern trends in evidence-based practice by using X-rays more sparingly than previously, adhering to guidelines and being positive about research.
doi:10.1186/s12998-014-0044-5
PMCID: PMC4258816  PMID: 25489483
2.  Back pain in children surveyed with weekly text messages - a 2.5 year prospective school cohort study 
Background
Back pain is reported to occur already in childhood, but its development at that age is not well understood. The aims of this study were to describe BP in children aged 6–12 years, and to investigate any sex and age differences.
Methods
Data on back pain (defined as pain in the neck, mid back and/or lower back) were collected once a week from parents replying to automated text-messages over 2.5 school years from 2008 till 2011. The prevalence estimates were presented as percentages and 95% confidence intervals. Differences between estimates were considered significant if confidence intervals did not overlap. A test for trend, using a multi-level mixed-effects logistic regression extended to the longitudinal and multilevel setting, was performed to see whether back pain reporting increased with age.
Results
Depending on the age group, 13-38% children reported back pain at least once per survey year, and 5-23% at least twice per survey year. The average weekly prevalence estimate ranged between 1% and 5%. In the final survey year more girls than boys reported back pain at least twice. The prevalence estimates did not increase monotonically with age but showed a greater increase in children younger than 9/10, after which they remained relatively stable up to the age of 12 years.
Conclusions
We found that back pain was not a common problem in this age group and recommend health professionals be vigilant if a child presents with constant or recurring back pain. Our results need to be supplemented by a better understanding of the severity and consequences of back pain in childhood. It would be productive to study the circumstances surrounding the appearance of back pain in childhood, as well as, how various bio-psycho-social factors affect its onset and later recurrence. Knowledge about the causes of back pain in childhood might allow early prevention.
Electronic supplementary material
The online version of this article (doi:10.1186/s12998-014-0035-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12998-014-0035-6
PMCID: PMC4237741  PMID: 25414789
Children; Back pain; Text messages
3.  Is puberty a risk factor for back pain in the young? a systematic critical literature review 
Background
Back pain is a common condition that starts early in life and seems to increase markedly during puberty. A systematic review was performed in order to investigate the link between puberty and back pain, using some Bradford Hill criteria for causality.
Objectives
We sought to obtain answers to the following questions: 1) Is there an association between puberty and back pain? If so, how strong is this association? And do the results remain unchanged also when controlling for age and sex? 2) Are the results of the studies consistent? 3) Is there a dose–response, showing a link between the increasing stages of puberty and the subsequent prevalence of back pain? 4) Is there a temporal link between puberty and back pain?
Design
A systematic critical literature review.
Methods
Systematic searches were made in March 2014 in PubMed, Embase, CINAHL and PsycINFO including longitudinal or cross-sectional studies on back pain for subjects <19 years, written in French or English. The review process followed the AMSTAR recommendations. Interpretation was made using some of the Bradford-Hill criteria for causality.
Results
Four articles reporting five studies were included, two of which were longitudinal. 1) Some studies show a weak and others a strong positive association between puberty and back pain, which remains after controlling for age and sex; 2) Results were consistent across the studies; 3) There was a linear increase of back pain according to the stage of puberty 4) Temporality has not been sufficiently studied.
Conclusion
All our criteria for causality were fulfilled or somewhat fulfilled indicating the possibility of a causal link between puberty and back pain. Future research should focus on specific hypotheses, for example investigating if there could be a hormonal or a biomechanical aspect to the development of back pain at this time of life.
Electronic supplementary material
The online version of this article (doi:10.1186/s12998-014-0027-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12998-014-0027-6
PMCID: PMC4200222  PMID: 25328668
Back pain; Puberty; Adolescent; Cause; Aetiology; Systematic review
4.  Prevention of low back pain: effect, cost-effectiveness, and cost-utility of maintenance care – study protocol for a randomized clinical trial 
Trials  2014;15:102.
Background
Low back pain (LBP) is a prevalent condition and a socioeconomic problem in many countries. Due to its recurrent nature, the prevention of further episodes (secondary prevention), seems logical. Furthermore, when the condition is persistent, the minimization of symptoms and prevention of deterioration (tertiary prevention), is equally important. Research has largely focused on treatment methods for symptomatic episodes, and little is known about preventive treatment strategies.
Methods/Design
This study protocol describes a randomized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care (chiropractic maintenance care) in a population of patients with recurrent or persistent LBP.
Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden. The primary outcome is the number of days with bothersome pain over 12 months. Secondary measures are self-rated health (EQ-5D), function (the Roland Morris Disability Questionnaire), psychological profile (the Multidimensional Pain Inventory), pain intensity (the Numeric Rating Scale), and work absence.
The primary utility measure of the study is quality-adjusted life years and will be calculated using the EQ-5D questionnaire. Direct medical costs as well as indirect costs will be considered.
Subjects are randomly allocated into two treatment arms: 1) Symptom-guided treatment (patient controlled), receiving care when patients feel a need. 2) Preventive treatment (clinician controlled), receiving care on a regular basis. Eligibility screening takes place in two phases: first, when assessing the primary inclusion/exclusion criteria, and then to only include fast responders, i.e., subjects who respond well to initial treatment. Data are collected at baseline and at follow-up as well as weekly, using SMS text messages.
Discussion
This study investigates a manual strategy (chiropractic maintenance care) for recurrent and persistent LBP and aims to answer questions regarding the effect and cost-effectiveness of this preventive approach. Strict inclusion criteria should ensure a suitable target group and the use of frequent data collection should provide an accurate outcome measurement. The study utilizes normal clinical procedures, which should aid the transferability of the results.
Trial registration
Clinical trials.gov; NCT01539863, February 22, 2012. The first patient was randomized into the study on April 13th 2012.
doi:10.1186/1745-6215-15-102
PMCID: PMC3984260  PMID: 24690201
Chiropractic; Low back pain; Maintenance care; Manual therapy; Prevention; Randomized controlled trial; Secondary prevention; Spinal manipulation; Tertiary prevention
5.  Management of patients with low back pain: a survey of French chiropractors 
Background
Little is known about the level of consensus within the French chiropractic profession regarding management of clinical issues. A previous Swedish study showed that chiropractors agreed relatively well on the management strategy for nine low back pain scenarios. We wished to investigate whether those findings could be reproduced among French chiropractors.
Objectives
1. To assess the level of consensus among French chiropractors regarding management strategies for nine different scenarios of low back pain. 2. To assess whether the management choices of the French chiropractors appeared reasonable for the low back pain scenarios. 3. To compare French management patterns with those described in the previous survey of Swedish chiropractors.
Method
A postal questionnaire was sent to a randomly selected sample of 167 French chiropractors in 2009. The questionnaire described a 40-year old man with low back pain, and presented nine hypothetical short-term outcome scenarios and six possible management strategies. For each of the nine scenarios, participants were asked to choose the management strategy that they would recommend. The percentages of respondents choosing the different management strategies were identified for each scenario. Appropriateness of the chosen management strategy was assessed using predetermined “best practice” for each scenario. Consensus was arbitrarily defined as “moderate” when 50- 69% of respondents agreed on the same management choice for a scenario, and “excellent” when 70% or more provided the same answer.
Results
Excellent consensus was achieved for only one scenario, and moderate consensus for two scenarios. For five of the nine scenarios, the most common answers were in agreement with the “best practice” management strategies. Consensus between the French and Swedish responses on the most appropriate management was seen in five of the nine scenarios and these were all in agreement with the expected answer.
Conclusion
There was reasonable consensus among the French chiropractors in their choice of treatment strategy for low back pain and choices were generally in line with “best practice”. The differences in response between the French and Swedish chiropractors suggest that cultural and/or educational differences influence the conceptual framework within which chiropractors practice.
doi:10.1186/2045-709X-22-13
PMCID: PMC4121951  PMID: 24678595
Survey; Chiropractors; Consensus; Low back pain
7.  Absence of low back pain in the general population followed fortnightly over one year with automated text messages 
Background
Over one year, the majority of patients with low back pain (LBP) from the secondary care sector could not report a single week without LBP and few could report a non-episode, defined as at least one month without LBP. Presumably, non-episodes would be more common in the general population. The aim of this study was to assess the usefulness of this definition of ´”non-episodes”, by studying their presence over one year in the general population. Specifically, we wanted to: 1) determine the prevalence of non-episodes, 2) identify the proportion of study participants who could be classified as being in a non-episode at the end of the observation period, and 3) estimate the proportion of participants classified as having at least two separate non-episodes.
Methods
Danes, aged 49/50, who previously participated in a population-based study on LBP received fortnightly automated text (SMS) messages over one year. Each time, participants reported the number of days with LBP in the preceding fortnight. Fortnights with 0 days of LBP were defined as ‘zero-fortnights’ and two such fortnights in a row (one month) were defined as a ‘non-episode’. Estimates are reported as percentages with their 95% confidence intervals in brackets.
Results
Two hundred and ninety-three people were invited to participate. Of these, 16 declined participation and 16 were excluded because they failed to return their text message at least 20 of the 26 times, leaving 261 in the current analyses. Of these, 11% (2-22) never reported a zero-fortnight. In all, 83% (78-88) had at least one non-episode throughout the study period and the proportion of participants classified as being in a non-episode at the end of the study was 59% (53-65). The percentage of individuals with at least two non-episodes was 52% (46-58).
Conclusions
It is possible to differentiate people from the general population as having or not having episodes of LBP using the definition of absence of LBP over one month as the measure. Non-episodes were far more common in the general population than in the secondary care sector, suggesting it to be a potentially useful definition in research.
doi:10.1186/2045-709X-22-1
PMCID: PMC3892070  PMID: 24405834
Low back pain; General population; Population study; Episodes; Epidemiology; Text messages; Longitudinal; Prospective; Survey
8.  Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI 
European Spine Journal  2012;21(11):2271-2279.
Purpose
Modic changes (MCs) have been suggested to be a diagnostic subgroup of low back pain (LBP). However, the clinical implications of MCs remain unclear. For this reason, the aims of this study were to investigate how MCs developed over a 14-month period and if changes in the size and/or the pathological type of MCs were associated with changes in clinical symptoms in a cohort of patients with persistent LBP and MCs.
Methods
Information on LBP intensity and detailed information from MRI on the presence, type and size of MCs was collected at baseline and follow-up. Changes in type (Type I, II, III and mixed types) and size of MCs were quantified at both time points according to a standardised evaluation protocol. The associations between change in type, change in size and change in LBP intensity were calculated using odds ratios (ORs).
Results
Approximately 40 % of the MCs followed the expected developmental path from Type I (here Type I or I/II) to Type II (here Type II or II/III) or Type I to Type I/II. In general, the bigger the size of the MC at baseline, the more likely it was that it remained unchanged in size after 14 months. Patients who had MC Type I at both baseline and 14-month follow-up were less likely to experience an improvement in their LBP intensity as compared to patients who did not have Type I changes at both time points (OR 7.2, CI 1.3–37). There was no association between change in size of MCs Type I and change in LBP intensity.
Conclusions
The presence of MCs Type I at both baseline and follow-up is associated with a poor outcome in patients with persistent LBP and MCs.
doi:10.1007/s00586-012-2309-9
PMCID: PMC3481109  PMID: 22526703
Low back pain; Modic changes; Magnetic resonance imaging; Association
9.  Stability of low back pain reporting over 8 years in a general population aged 40/41 years at base-line: data from three consecutive cross-sectional surveys 
Background
A recent review on the natural course of low back pain (LBP) in the general population indicated that the LBP reporting pattern is fairly constant over time. Furthermore, the LBP status at baseline (yes/no) seems to be predictive of the future course. When fluctuations occur, they seem most common between the nearest categories. However, in the majority of articles, non-responders were not taken into account in the analyses or interpretation of data, meaning that estimates may have been biased. Further, all reviewed studies included study participants of many different age groups. Data from three cross-sectional surveys over 8 years of the same cohort made it possible to answer the following questions: 1) Would the prevalence estimates of LBP be stable over time? 2) How would results change when taking into account non-responders? 3) Is the LBP reporting over the three survey periods stable at an individual level, taking into account also the non-responding group?
Methods
Data from three subsequent cross-sectional surveys of a study sample were available and questions about LBP were asked at baseline and also 4 and 8 years later. Study participants were 40/41 years at base-line and initially randomly selected from the general Danish population. Data were analyzed with STATA/IC 12, and presented with percentages and 95% confidence intervals.
Results
The majority of participants reported to have had LBP in the preceding year but not having taken sick leave in relation to this pain. LBP was stable or relatively stable for the study participants as they progressed through their fifth decade. This was true on a population basis and also on an individual level. When non-responders were taken into account the results did not change.
Conclusions
This study confirmed the results from our recent review; both presence and absence of LBP seem to be predictive for the future course. The percentage of non-responders in this type of study may not be as important as previously thought in relation to the presence/absence of LBP.
doi:10.1186/1471-2474-14-270
PMCID: PMC3852295  PMID: 24053477
Epidemiology; General population; Cohort; Cross-sectional study; Prevalence; Low back pain; Trajectory; Non-responders
10.  Evidence-based classification of low back pain in the general population: one-year data collected with SMS Track 
Background
It was previously assumed that low back pain (LBP) is a disorder that can be classified as acute, subacute and chronic. Lately, the opinion seems to have veered towards a concept of it being a more recurrent or cyclic condition. Interestingly, a recent review of the literature indicated that LBP in the general population is a rather stable condition, characterized as either being present or absent. However, only one of the reviewed studies had used frequent data collection, which would be necessary when studying detailed course patterns over time. It was the purpose of this study to see, if it was possible to identify whether LBP, when present, is rather episodic or chronic/persistent. Further, we wanted to see if it was possible to describe any specific course profiles of LBP in the general population.
Methods
In all, 293 49/50-yr old Danes, who previously participated in a population-based study on LBP were invited to respond to 26 fortnightly text-messages over one year, each time asking them the number of days they had been bothered by LBP in the past two weeks. The course patterns for these individuals were identified through manual analysis, by observing the interplay between non-episodes and episodes of LBP. A non-episode of LBP was defined as a period of at least one month without LBP as proposed by de Vet et al. A fortnight with at least one day of pain was defined as a pain fortnight (FN). At least one pain FN surrounded by a non-episode on each side was defined as an episode of LBP. After some preliminary observations of the spread of data, episodes were further classified as brief (consisting of only one pain FN) or longer (if there were at least 2 pain FNs in a row). An episode of at least 6 pain FNs in a row (i.e. 3 months) was defined as a long-lasting episode.
Results
In all, 261 study subjects were included in the analyses, for which 7 distinct LBP subsets could be identified. These could be grouped into three major clusters; those mainly without LBP (35%), those with episodic LBP (30%) and those with persistent LBP (35%). There was a positive association between number of episodes and their duration.
Conclusion
In this study population, consisting of 50-yr old persons from the general population, LBP, when present, could be classified as either ‘episodic’ or ‘mainly persistent’. About one third was mainly LBP-free throughout the year of study. More information is needed in relation to their relative proportions in various populations and the clinical relevance of these subgroups.
doi:10.1186/2045-709X-21-30
PMCID: PMC3766189  PMID: 24139224
Low back pain; Epidemiology; Trajectories; Subgroups; Episodes; Text-messages
11.  How to proceed when evidence-based practice is required but very little evidence available? 
Background
All clinicians of today know that scientific evidence is the base on which clinical practice should rest. However, this is not always easy, in particular in those disciplines, where the evidence is scarce. Although the last decades have brought an impressive production of research that is of interest to chiropractors, there are still many areas such as diagnosis, prognosis, choice of treatment, and management that have not been subjected to extensive scrutiny.
Discussion
In this paper we argue that a simple system consisting of three questions will help clinicians deal with some of the complexities of clinical practice, in particular what to do when clear clinical evidence is lacking. Question 1 asks: are there objectively tested facts to support the concept? Question 2: are the concepts that form the basis for this clinical act or decision based on scientifically acceptable concepts? And question three; is the concept based on long-term and widely accepted experience? This method that we call the “Traffic Light System” can be applied to most clinical processes.
Summary
We explain how the Traffic Light System can be used as a simple framework to help chiropractors make clinical decisions in a simple and lucid manner. We do this by explaining the roles of biological plausibility and clinical experience and how they should be weighted in relation to scientific evidence in the clinical decision making process, and in particular how to proceed, when evidence is missing.
doi:10.1186/2045-709X-21-24
PMCID: PMC3717011  PMID: 23837495
Chiropractic; Evidence-based practice; Biological plausibility
12.  Conducting practice-based projects among chiropractors: a manual 
Introduction
Practice-based research is a challenge as clinicians are busy with their patients and any participation in research activities will be secondary to the needs of the patients and the clinic. As a result, it is difficult to obtain high compliance among clinicians. A method to enhance compliance in multicentre practice-based research has been developed and refined for use in the chiropractic setting and possibly also by other researchers in different settings.
Method
This manual provides a stringent step-by-step approach for conducting clinic-based research. It describes the competencies and requirements of an effective working group, how to recruit participating clinicians and how to empower, encourage and support these clinicians to obtain good compliance.
Discussion
The main advantage of the method is the high compliance of participating clinicians compared to many other clinical studies. Difficulties with the method are described and suggestions for solutions are presented.
Conclusions
This manual is a description of a method that may be of use for clinical researchers in the chiropractic setting.
doi:10.1186/2045-709X-21-8
PMCID: PMC3577479  PMID: 23369259
Clinical study; Compliance; Multicentre
13.  The natural course of low back pain: a systematic critical literature review 
Background
Most patients in the secondary care sector consulting for low back pain (LBP) seem to have a more or less constant course of pain during the ensuing year. Fewer patients with LBP in the primary care sector report continual pain over a one-year period. However, not much is known about the long-term course of LBP in the general population. A systematic critical literature review was undertaken in order to study the natural course of LBP over time in the general population.
Methods
A search of articles was performed in Pubmed, Cinahl and Psychinfo using the search terms ‘epidemiology’; ‘low back pain’ or ‘back pain’; ‘prospective study’ or ‘longitudinal study’; ‘follow-up’, ‘natural course’, ‘course’ or ‘natural history’; ‘general population’ or ‘working population’. Inclusion criteria were that one of the objectives was to study the course of (L)BP in the adult population, that the period of follow-up was at least 3 months, and that there were three points of observation or more. The review was undertaken by two independent reviewers using three checklists relating to description of studies, quality and outcomes. The course of LBP was established in relation to those who, at baseline, were reported not to have LBP or to have LBP. Would this course be stable, fluctuating, worsening, or improving over time? A synthesis of results in relation to common patterns was presented in a table and interpreted in a narrative form.
Results
Eight articles were included. Articles were different on time span, the number of surveys, and the definition of LBP. In six of the seven relevant studies, for those with no LBP at baseline, relatively substantial stable subgroups of people who continued to be LBP free were identified. In six of the seven relevant studies, definite stable subgroups of continued LBP were noted and improvement (becoming pain free) was never reported to be a common finding.
Conclusion
The status of LBP in individuals of the general population appears to be relatively stable over time, perhaps particularly so for those without LBP at baseline.
doi:10.1186/2045-709X-20-33
PMCID: PMC3599187  PMID: 23075327
Low back pain; Course; General population; Prospective study; Review
14.  Study protocol. The Childhood Health, Activity, and Motor Performance School Study Denmark (The CHAMPS-study DK) 
BMC Pediatrics  2012;12:128.
Background
An increasingly passive life-style in the Western World has led to a rise in life-style related disorders. This is a major concern for all segments of society. The county council of the municipality of Svendborg in Denmark, created six Sport Schools with increased levels of suitable physical activities, which made it possible to study the health outcomes in these children whilst comparing them to children who attended the ‘normal’ schools of the region using the design of a “natural experiment”.
Methods
Children from the age of 6 till the age of 10, who accepted to be included in the monitoring process, were surveyed at baseline with questionnaires, physical examinations and physical and biological testing, including DXA scans. The physical examination and testing was repeated during the early stage of the study. Every week over the whole study period, the children will be followed with an automated mobile phone text message (SMS-Track) asking questions on their leisure time sports activities and the presence of any musculoskeletal problems. Children who report any such problems are monitored individually by health care personnel. Data are collected on demography, health habits and attitudes, physical characteristics, physical activity using accelerometers, motor performance, fitness, bone health, life-style disorders, injuries and musculoskeletal problems. Data collection will continue at least once a year until the children reach grade 9.
Discussion
This project is embedded in a local community, which set up the intervention (The Sport Schools) and thereafter invited researchers to provide documentation and evaluation. Sport schools are well matched with the ‘normal’ schools, making comparisons between these suitable. However, subgroups that would be specifically targeted in lifestyle intervention studies (such as the definitely obese) could be relatively small. Therefore, results specific to minority groups may be diluted. Nonetheless, the many rigorously collected data will make it possible to study, for example, the general effect that different levels of physical activity may have on various health conditions and on proxy measures of life-style conditions. Specifically, it will help answer the question on whether increased physical activity in school has a positive effect on health in children.
doi:10.1186/1471-2431-12-128
PMCID: PMC3483192  PMID: 22906115
15.  The Nordic Maintenance Care Program: Maintenance care – what happens during the consultation? Observations and patient questionnaires 
Background
Because maintenance care (MC) is frequently used by chiropractors in the management of patients with back pain, it is necessary to define the rationale, frequency and indications for MC consultations, and the contents of such consultations. The objectives of the two studies described in this article are: i) to determine the typical spacing between visits for MC patients and to compare MC and non-MC patients, ii) to describe the content of the MC consultation and to compare MC and non-MC patients and iii) to investigate the purposes of the MC program.
Method
In two studies, chiropractors who accepted the MC paradigm were invited to assist with the data collection. In study 1, patients seen by seven different chiropractors were observed by two chiropractic students. They noted the contents of the observed consultations. In study 2, ten chiropractors invited their MC patients to participate in an anonymous survey. Participants filled in a one page questionnaire containing questions on their view of the purposes and contents of their MC consultations. In addition, information was obtained on the duration between appointments in both studies.
Results
There were 178 valid records in study 1, and in study 2 the number of questionnaires received was 373. The time interval between MC visits was close to nine weeks and for non-MC consultations it was two weeks.
The content of the consultations in study 1 was similar for MC and non-MC patients with treatment being the most time-consuming element followed by history taking/examination. MC consultations were slightly shorter than non-MC consultations.
In study 2, the most common activities reported to have taken place were history taking and manipulative therapy. The most commonly reported purposes were to prevent recurring problems, to maintain best possible function and /or to stay as pain free as possible.
Conclusions
The results from these two studies indicate that MC consultations commonly take place with around two months intervals, and that history taking, examination and treatment are as important components in MC as in non-MC consultations. Further, the results demonstrate that most patients consider the goal to be secondary or tertiary prevention.
doi:10.1186/2045-709X-20-25
PMCID: PMC3502115  PMID: 22883475
Chiropractic; Maintenance care; Back pain; Consultation
16.  Does back and neck pain become more common as you get older? A systematic literature review 
Background
It is generally believed that the prevalence of back pain increases with age and as the proportion of elderly will keep rising we may be facing serious public health concerns in the future.
Aim
The aim of this systematic literature review is to establish whether back pain (i.e. neck, mid-back and/or low back pain) becomes increasingly common in the older population, specifically to study 1) whether there is a significant increase in the prevalence of back pain after middle age, and 2) whether there is a significant gradually increasing prevalence of back pain with continued old age.
Methods
A systematic literature search was conducted in Pubmed on articles in English, published between January 2000 and July 2011. Non-clinical studies from the developed countries with prevalence estimates on elderly people (60+) on any type of self-reported back pain and on different age groups with adequate sample sizes were included in the review. The included articles were extracted for information by two independent reviewers.
Results
A total of 12 articles were included covering the entire spine. Neck pain was studied nine times, low back pain eight times, back pain three times, upper back two times and neck/shoulders once. All studies showed no significant increase of back pain with age, neither when passing from middle age (i.e. 45+ years of age) into the sixties, nor later in life. In contrast, most studies reported a decline for the oldest group.
Conclusions
Back pain is no more common in the elderly population (>60 years) when compared to the middle age population. Back pain does not increase with increasing age, but seems to decline in the oldest people.
doi:10.1186/2045-709X-20-24
PMCID: PMC3526387  PMID: 22883425
Systematic literature review; Elderly population; Back pain; Low back pain; Neck pain
17.  The effect of spinal manipulative therapy on experimentally induced pain: a systematic literature review 
Background
Although there is evidence that spinal manipulative therapy (SMT) can reduce pain, the mechanisms involved are not well established. There is a need to review the scientific literature to establish the evidence-base for the reduction of pain following SMT.
Objectives
To determine if SMT can reduce experimentally induced pain, and if so, if the effect is i) only at the level of the treated spinal segment, ii) broader but in the same general region as SMT is performed, or iii) systemic.
Design
A systematic critical literature review.
Methods
A systematic search was performed for experimental studies on healthy volunteers and people without chronic syndromes, in which the immediate effect of SMT was tested. Articles selected were reviewed blindly by two authors. A summary quality score was calculated to indicate level of manuscript quality. Outcome was considered positive if the pain-reducing effect was statistically significant. Separate evidence tables were constructed with information relevant to each research question. Results were interpreted taking into account their manuscript quality.
Results
Twenty-two articles were included, describing 43 experiments, primarily on pain produced by pressure (n = 27) or temperature (n = 9). Their quality was generally moderate. A hypoalgesic effect was shown in 19/27 experiments on pressure pain, produced by pressure in 3/9 on pain produced by temperature and in 6/7 tests on pain induced by other measures. Second pain provoked by temperature seems to respond to SMT but not first pain. Most studies revealed a local or regional hypoalgesic effect whereas a systematic effect was unclear. Manipulation of a “restricted motion segment” (“manipulable lesion”) seemed not to be essential to analgesia. In relation to outcome, there was no discernible difference between studies with higher vs. lower quality scores.
Conclusions
These results indicate that SMT has a direct local/regional hypoalgesic effect on experimental pain for some types of stimuli. Further research is needed to determine i) if there is also a systemic effect, ii) the exact mechanisms by which SMT attenuates pain, and iii) whether this response is clinically significant.
doi:10.1186/2045-709X-20-26
PMCID: PMC3527169  PMID: 22883534
18.  The effect of spinal manipulative therapy on spinal range of motion: a systematic literature review 
Background
Spinal manipulative therapy (SMT) has been shown to have an effect on spine-related pain, both clinically and in experimentally induced pain. However, it is unclear if it has an immediate noticeable biomechanical effect on spinal motion that can be measured in terms of an increased range of motion (ROM).
Objective
To assess the quality of the literature and to determine whether or not SMT is associated with an immediate increase in ROM.
Design
A systematic critical literature review.
Method
Systematic searches were performed in Pubmed, the Cochrane Library and EMBASE using terms relating to manipulation, movement and the spine. Selection of articles was made according to specific criteria by two independent reviewers. Two checklists were created based on the needs of the present review. Articles were independently reviewed by two reviewers. Articles were given quality scores and the data synthesized for each region treated in the literature. Findings were summarized in tables and reported in a narrative fashion.
Results
Fifteen articles were retained reporting on experiments on the neck, lumbar spine, hip and jaw. The mean quality score was 71/100 (ranges 33/100 - 92/100). A positive effect of SMT was reported in both studies where mouth opening was assessed after cervical manipulation. In five of the nine studies on cervical ROM a positive effect was reported, whereas the remaining four studies did not show improvement. None of the three studies of the lumbar spine showed an effect of SMT on lumbar ROMs and one study of sacroiliac manipulation reported no effect on the ROM of the hip joint.
In relation to the quality score, the seven highest ranked studies, showed significant positive effects of SMT on ROM. Continuing down the list, the other studies reported no significant differences in the outcomes between groups.
Conclusion
SMT seems sometimes to have a small effect on ROM, at least in the cervical spine. Further research should concentrate on areas of the spine that have the potential of actually improving to such a degree that a change can be easily uncovered.
doi:10.1186/2045-709X-20-23
PMCID: PMC3487906  PMID: 22866816
19.  Pain in the three spinal regions: the same disorder? Data from a population-based sample of 34,902 Danish adults 
Background
Studies of back pain are typically based on the assumption that symptoms from different parts of the spine are distinctive entities. Recently, however, the assumption that back pain is a site-specific disorder has been challenged, suggesting that localized back pain should be seen as part of a general musculoskeletal syndrome.
Objectives
To describe and compare the patterns of reporting of pain and consequences of pain in the three spinal regions.
Methods
In all, 34,902 (74%) twin individuals representative of the general Danish population, aged 20 to 71, participated in a cross-sectional nation-wide survey. Identical questions from the Standardised Nordic Questionnaire for each of the three spinal regions were used for lumbar, mid-back and neck pain respectively: Pain past year, pain ever, radiating pain, and consequences of back pain (care-seeking, reduced physical activities, sick-leave, change of work/work duties and disability pension). The relative prevalence estimates of these variables were compared for the three spinal regions.
Results
The relative proportions of individuals with pain ever, who also reported to have had pain in the past year varied between 75% and 80%, for the three spinal regions. The proportions of individuals with pain in the past year and for various pain durations were also very similar. Regardless if pain was reported in the lumbar, thoracic or cervical regions, the proportions of individuals reporting radiating pain were equally large. The relative number of consequences was the same across the spinal regions, as were the relative proportions of each these consequences. However, low back pain resulted more often in some kind of consequence compared to the consequences of pain in the neck and mid back.
Conclusions
Back pain and its consequences share many characteristics and may, at least in a general population, be regarded as the same condition regardless of where the pain happens to manifest itself. However, because some exceptions were noted for the lumbar spine, separate entities for a smaller group of individuals with back pain cannot be ruled out.
doi:10.1186/2045-709X-20-11
PMCID: PMC3368748  PMID: 22480304
20.  Absence of low back pain in patients followed weekly over one year with automated text messages 
Background
In order to define the onset of a new episode of low back pain (LBP), the definition of a "non-episode" must be clear. De Vet et al reviewed the scientific literature but found no evidence-based definitions of episodes or non-episodes of LBP. However, they suggested that pain-based episodes should be preceded and followed by a period of at least one month without LBP. As LBP is an episodic disease, it is not clear whether a sufficient number of patients with LBP will be LBP-free for at least one month ("non-episode") to justify the use of this duration in the definition of pain free episode.
Objectives
Two clinical populations were followed weekly over one year making it possible 1) to determine the maximum numbers in a row of weeks without LBP, 2) to determine the prevalence of non-episodes throughout a one-year period, and 3) to find the prevalence of patients who reported to be in a non-episode of LBP at the end of the study.
Methods
Secondary data were used from two recent clinical studies, in which weekly automated text messages (SMSes) had been collected on the number of days with LBP in the preceding week for one year. Weeks with 0 days of LBP were defined as "zero-weeks" and four zero-weeks in a row were defined as a period without LBP (a"non-episode") according to de Vet et al's suggestion. The study participants, all from the secondary care sector, consisted of: study 1) patients with LBP and Magnetic Resonance Imaging-identified Modic changes and study 2) patients without obvious acute disc problems, Modic changes or other pathologies, who therefore were assumed to have non-specific LBP. Both studies were two-armed intervention studies without a significant difference in outcome between intervention groups. The number of zero-weeks was identified in each participant. Thereafter the numbers of participants who reported at least one non-episode during the study period were identified. Finally, the numbers of participants who had a non-episode at the end of the study were counted. Estimates are reported with their 95% confidence intervals.
Results
The numbers of participants included in the analyses were 80 and 209. Most commonly, no zero weeks were reported, by 65% (55-75) and 56% (49-63) of patients, respectively. The percentages of study participants with at least one non-episode at some time during the course of the study were 20% (11-29) and 18% (15-21. The percentages of participants who were identified as being in a non-episode at the time of the last week of the study were, 5% (95% CI: 0-10) and 4% (1-7) respectively.
Conclusions
The vast majority of these secondary care sector patients had a profile of more or less constant LBP. The estimates for non-episodes during the study period and at the end of the study were very similar for participants with LBP who also had Modic changes and those with non-specific LBP. It is possible that a definition of pain-free periods is pointless in patients seeking care in the secondary care sector.
doi:10.1186/2045-709X-20-9
PMCID: PMC3373362  PMID: 22455757
21.  A systematic critical review on MRI in spondyloarthritis 
Introduction
Magnetic resonance imaging (MRI) has been proven capable of showing inflammatory and structural changes in patients with spondyloarthritis (SpA) and has become widely used in the diagnosis of SpA. Despite this, no systematic reviews evaluate the diagnostic utility of MRI for SpA. Therefore, the objective of this systematic review was to determine the evidence for the utility of MRI in the clinical diagnosis of SpA. The aims were to identify which MRI findings are associated with the diagnosis of SpA and to quantify this association.
Methods
MEDLINE and EMBASE were electronically searched. Inclusion criteria were cross-sectional or longitudinal case-control or cohort MRI studies. The studies required a group with either SpA or inflammatory back pain (IBP) and a non-case group without SpA or IBP. Each group required a minimum of 20 participants. The included articles had to report results containing raw numbers suitable for the construction of two-by-two tables or report results by sensitivity and specificity for cross-sectional studies or odds ratios, relative risk ratios, or likelihood ratios for longitudinal studies. Method quality was assessed by using criteria based on the QUADAS tool.
Results
In total, 2,395 articles were identified in MEDLINE and EMBASE before November 2011. All articles were reviewed by title and abstract. Seventy-seven articles were reviewed by full text, and 10 met the inclusion criteria. Two were considered of high quality: one evaluated the sacroiliac joints, and the other, the spine. Because of the small number of high-quality studies, a meta-analysis was not performed. The two high-quality studies found a positive association between MRI findings (bone marrow edema, erosions, fat infiltrations, global assessment of sacroiliitis, and ankylosis) and the diagnosis of IBP and SpA.
Conclusion
In this review, several MRI findings were found to be associated with SpA. However, because of the small number of high-quality studies, the evidence for the utility of MRI in the diagnosis of SpA must be considered limited. Therefore, caution should be taken to ensure that inflammatory and structural MRI findings are not interpreted as being more specific for SpA than is supported by research.
doi:10.1186/ar3768
PMCID: PMC3446421  PMID: 22405031
22.  Rest versus exercise as treatment for patients with low back pain and Modic changes. a randomized controlled clinical trial 
BMC Medicine  2012;10:22.
Background
Clinical experience suggests that many patients with Modic changes have relatively severe and persistent low back pain (LBP), which typically appears to be resistant to treatment. Exercise therapy is the recommended treatment for chronic LBP, however, due to their underlying pathology, Modic changes might be a diagnostic subgroup that does not benefit from exercise. The objective of this study was to compare the current state-of-the art treatment approach (exercise and staying active) with a new approach (load reduction and daily rest) for people with Modic changes using a randomized controlled trial design.
Methods
Participants were patients from an outpatient clinic with persistent LBP and Modic changes. They were allocated using minimization to either rest therapy for 10 weeks with a recommendation to rest for two hours daily and the option of using a flexible lumbar belt or exercise therapy once a week for 10 weeks. Follow-up was at 10 weeks after recruitment and 52 weeks after intervention and the clinical outcome measures were pain, disability, general health and global assessment, supplemented by weekly information on low back problems and sick leave measured by short text message (SMS) tracking.
Results
In total, 100 patients were included in the study. Data on 87 patients at 10 weeks and 96 patients at one-year follow-up were available and were used in the intention-to-treat analysis. No statistically significant differences were found between the two intervention groups on any outcome.
Conclusions
No differences were found between the two treatment approaches, 'rest and reduced load' and 'exercise and staying active', in patients with persistent LBP and Modic changes.
Trial Registration
ClinicalTrials.gov: NCT00454792
doi:10.1186/1741-7015-10-22
PMCID: PMC3348080  PMID: 22376791
23.  Case management of chiropractic patients with cervical brachialgia: A survey of French chiropractors 
Background
Not much is known about the French chiropractic profession on, for example, level of consensus on clinical issues.
Objectives
The first objective was to investigate if French chiropractors' management choices appeared reasonable for various neck problem scenarios. The second objective was to investigate if there was agreement between chiropractors on the patient management. The third objective was to see to which degree and at what stages chiropractors would consider to interact with other health-care practitioners, such as physiotherapists, general practitioners and specialists.
Method
A questionnaire was sent to a randomly selected sample of all French chiropractors known to the national chiropractic college. It consisted of an invitation to participate in the study, a brief case description, and drawings of five stages of how a case of neck pain gradually evolves into a brachialgia to end up with a compromised spinal cord. Each stage offered five management choices. Participants were asked at what stages patients would be treated solely by the chiropractor and when patients would be referred out for second opinion or other care without chiropractic treatment, plus an open ended option, resulting in a "five-by-six" table. The percentages of respondents choosing the different management strategies were identified for the different scenarios and the 95% confidence intervals were calculated. There was a pre hoc agreement on when chiropractic care would or would not be suitable. Consensus was arbitrarily defined as "moderate" when 50- 69% of respondents agreed on the same management choice and as "excellent" when 70% or more provided the same answer. It was expected that inter professional contacts would be rare.
Results
The response rate was 53% out of 254 potential participants. The first two uncomplicated cases would generally have been treated by the chiropractors. As the patient worsened, the responses tended towards external assistance and for the most severe case, the majority of respondents would have referred the patient out. There was excellent consensus for the two extreme cases (the most benign and the most severe), moderate consensus for the cases next to these two and least agreement relating to the "middle" case. Inter-professional collaboration was contemplated mainly for the severe case.
Conclusion
The French chiropractors who participated in this study seem to have a similar approach to patients with neck pain that gradually develops into a brachialgia and worsens. However, it is not known if the large group of non-participants in the study would agree with this treatment strategy.
doi:10.1186/2045-709X-19-23
PMCID: PMC3204265  PMID: 21943490
24.  Is the presence of Modic changes associated with the outcomes of different treatments? A systematic critical review 
Background
Modic changes (MCs) have been identified as a diagnostic subgroup associated with low back pain (LBP). The aetiology of MCs is still unknown and there is no effective treatment available. If MCs constitute a specific subgroup of LBP, it seems reasonable to expect different effects from different treatments. The objective of this systematic critical literature review was therefore to investigate if there is evidence in the literature that the presence of MCs at baseline is associated with a favourable outcome depending on the treatment provided for LBP.
Methods
The databases MEDLINE and EMBASE were searched for relevant articles from 1984 to December 2010. A checklist including items related to the research questions and quality of the articles was used for data extraction and quality assessment. Of the 1650 articles found, five (six studies) were included in this review but because the studies were so heterogeneous, the results have been reported separately for each study.
Results
The treatments studied were: lumbar epidural steroid injections (n = 1), lumbar intradiscal steroid injections (n = 2), lumbar disc replacement (n = 1), fusion surgery (n = 1) and exercise therapy (n = 1). One of the two studies investigating treatment with intradiscal steroid injections and the study investigating fusion surgery reported that MCs were positively associated with the outcomes of pain and disability. The other study on lumbar intradiscal steroid injections and the study on lumbar epidural steroid injections reported mixed results, whereas the study on lumbar disc replacement and the study on exercise therapy reported that MCs were not associated with the outcomes of pain and disability.
Conclusions
The available studies on the topic were too few and too heterogeneous to reach a definitive conclusion and it is therefore still unclear if MCs may be of clinical importance when guiding or prescribing the 'right' treatment for a patient with LBP.
doi:10.1186/1471-2474-12-183
PMCID: PMC3162945  PMID: 21831312
25.  Clustering patients on the basis of their individual course of low back pain over a six month period 
Background
Several researchers have searched for subgroups in the heterogeneous population of patients with non-specific low back pain (LBP). To date, subgroups have been identified based on psychological profiles and the variation of pain.
Methods
This multicentre prospective observational study explored the 6- month clinical course with measurements of bothersomeness that were collected from weekly text messages that were sent by 176 patients with LBP. A hierarchical cluster analysis, Ward's method, was used to cluster patients according to the development of their pain.
Results
Four clusters with distinctly different clinical courses were described and further validated against clinical baseline variables and outcomes. Cluster 1, a "stable" cluster, where the course was relatively unchanged over time, contained young patients with good self- rated health. Cluster 2, a group of "fast improvers" who were very bothered initially but rapidly improved, consisted of patients who rated their health as relatively poor but experienced the fewest number of days with bothersome pain of all the clusters. Cluster 3 was the "typical patient" group, with medium bothersomeness at baseline and an average improvement over the first 4-5 weeks. Finally, cluster 4 contained the "slow improvers", a group of patients who improved over 12 weeks. This group contained older individuals who had more LBP the previous year and who also experienced most days with bothersome pain of all the clusters.
Conclusions
It is possible to define clinically meaningful clusters of patients based on their individual course of LBP over time. Future research should aim to reproduce these clusters in different populations, add further clinical variables to distinguish the clusters and test different treatment strategies for them.
doi:10.1186/1471-2474-12-99
PMCID: PMC3125255  PMID: 21586117

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