Craig Schulz

Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial

BACKGROUND CONTEXT Several conservative therapies have been shown to be beneficial in the treatment of chronic low back pain (CLBP), including different forms of exercise and spinal manipulative therapy (SMT). The efficacy of less time-consuming and less costly self-care interventions, for example, home exercise, remains inconclusive in CLBP populations. PURPOSE The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP. STUDY DESIGN/SETTING An observer-blinded and mixed-method randomized clinical trial conducted in a university research clinic in Bloomington, MN, USA. PATIENT SAMPLE Individuals, 18 to 65 years of age, who had a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain to the lower extremity were included in this trial. OUTCOME MEASURES Patient-rated outcomes were pain, disability, general health status, medication use, global improvement, and satisfaction. Trunk muscle endurance and strength were assessed by blinded examiners, and qualitative interviews were performed at the end of the 12-week treatment phase. METHODS This prospective randomized clinical trial examined the short- (12 weeks) and long-term (52 weeks) relative efficacy of high-dose, supervised low-tech trunk exercise, chiropractic SMT, and a short course of home exercise and self-care advice for the treatment of LBP of at least 6-week duration. The study was approved by local institutional review boards. RESULTS A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term. CONCLUSIONS For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favored the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.

Spinal manipulative therapy and exercise for seniors with chronic neck pain

BACKGROUND CONTEXT Neck pain, common among the elderly population, has considerable implications on health and quality of life. Evidence supports the use of spinal manipulative therapy (SMT) and exercise to treat neck pain; however, no studies to date have evaluated the effectiveness of these therapies specifically in seniors. PURPOSE To assess the relative effectiveness of SMT and supervised rehabilitative exercise, both in combination with and compared to home exercise (HE) alone for neck pain in individuals ages 65 years or older. STUDY DESIGN/SETTING Randomized clinical trial. PATIENT SAMPLE Individuals 65 years of age or older with a primary complaint of mechanical neck pain, rated ≥3 (0-10) for 12 weeks or longer in duration. OUTCOME MEASURES Patient self-report outcomes were collected at baseline and 4, 12, 26, and 52 weeks after randomization. The primary outcome was pain, measured by an 11-box numerical rating scale. Secondary outcomes included disability (Neck Disability Index), general health status (Medical Outcomes Study Short Form-36), satisfaction (7-point scale), improvement (9-point scale), and medication use (days per week). METHODS This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration. Linear mixed model analyses were used for comparisons at individual time points and for short- and long-term analyses. Blinded evaluations of objective outcomes were performed at baseline and 12 weeks. Adverse event data were collected at each treatment visit. RESULTS A total of 241 participants were randomized, with 95% reporting primary outcome data at all time points. After 12 weeks of treatment, the SMT with home exercise group demonstrated a 10% greater decrease in pain compared with the HE-alone group, and 5% change over supervised plus home exercise. A decrease in pain favoring supervised plus HE over HE alone did not reach statistical significance. Compared with the HE group, both combination groups reported greater improvement at week 12 and more satisfaction at all time points. Multivariate longitudinal analysis incorporating primary and secondary patient-rated outcomes showed that the SMT with HE group was superior to the HE-alone group in both the short- and long-term. No serious adverse events were observed as a result of the study treatments. CONCLUSIONS SMT with HE resulted in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone. Supervised exercise sessions added little benefit to the HE-alone program.

Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: A trial with adaptive allocation

Context Few studies evaluate the comparative effectiveness of conservative treatments for back-related leg pain. Contribution This randomized trial, involving 192 adults with subacute or chronic back-related leg pain, compared 12 weeks of home exercise and advice with spinal manipulative therapy plus home exercise and advice. Spinal manipulative therapy with home exercise and advice improved self-reported pain and function outcomes more than exercise and advice alone at 12 weeks, but differences between groups were not present at 52 weeks except for some secondary outcomes. Caution The intervention was not blinded. Implication Spinal manipulative therapy combined with home exercise and advice can improve short-term outcomes in patients with back-related leg pain. The Editors Back-related leg pain (BRLP) is an important symptom commonly associated with pervasive low back pain (LBP) conditions and, despite its socioeconomic effect, has been generally understudied. With poorer prognosis and quality of life, persons with BRLP have greater pain severity and incur more work loss, medication use, surgery, and health-related costs than those with uncomplicated LBP (16). Most patients with BRLP are treated with prescription medications and injections, although little to no evidence supports their use (7, 8). Surgical approaches are also commonly applied, although there is only some evidence for short-term effectiveness compared with less invasive treatments (9). Concerns are mounting about the overuse, costs, and safety of these conventional medical treatments (1018), warranting identification of more conservative treatment options. Spinal manipulative therapy (SMT), exercise, and education promoting self-management are increasingly recommended as low-risk strategies for BRLP (19). Although limited, evidence shows that these conservative approaches can be effective (2026). A recent systematic review by our group showed that SMT is superior to sham SMT for acute BRLP in the short and long term; however, the evidence for subacute and chronic BRLP is inconclusive, and high-quality research is needed to inform clinical and health policy decisions (20). The underlying mechanisms of SMT seem to be multifactorial, including improvement in spinal stiffness, muscle recruitment, and synaptic efficacy of central neurons (27, 28). The purpose of this study was to test the hypothesis that the addition of SMT to home exercise and advice (HEA) would be more effective than HEA alone for patients with subacute and chronic BRLP. Methods Design Overview This pragmatic trial used a parallel design with allocation by minimization and has been described previously (29). Patients were recruited between 2007 and 2010, and follow-up was completed in 2011. Institutional review boards approved the study protocol, and all patients provided written consent. The primary outcomes and most secondary outcomes were self-reported; objective measures were obtained by blinded examiners. There were no important changes to methods after trial commencement. Settings and Patients The trial was conducted at institution-affiliated research clinics at Northwestern Health Sciences University (Minneapolis, Minnesota) and Palmer College of Chiropractic (Davenport, Iowa). Patients were recruited through newspaper advertisements, direct mail, and community posters. Interested patients were initially screened by telephone interviews, followed by 2 in-person baseline evaluation visits. Inclusion criteria were age 21 years or older; BRLP based on Quebec Task Force on Spinal Disorders classifications 2, 3, 4, or 6 (radiating pain into the proximal or distal part of the lower extremity, with or without neurologic signs) (30); BRLP severity of 3 or greater (scale of 0 to 10); a current episode of 4 weeks or more; and a stable prescription medication plan in the previous month. Exclusion criteria were Quebec Task Force on Spinal Disorders classifications of 1, 5, 7, 8, 9, 10, and 11 (pain without radiation into the lower extremities, progressive neurologic deficits, the cauda equina syndrome, spinal fracture, spinal stenosis, surgical lumbar spine fusion, several incidents of lumbar spine surgery, chronic pain syndrome, visceral diseases, compression fractures or metastases, blood clotting disorders, severe osteoporosis, and inflammatory or destructive tissue changes of the spine). Patients could not be receiving ongoing treatment of leg pain or LBP; be pregnant or nursing; have current or pending litigation for workers compensation, disability, or personal injury; be unable to read or comprehend English; or have evidence of substance abuse. Allocation A Web-based program assigned patients to treatment after the second baseline visit using a minimization algorithm based on the Taves method (31), balancing on 7 baseline characteristics previously shown to influence outcomes (3234). Baseline characteristics included age, BRLP duration, neurologic signs, distress, positive straight leg raise, time spent driving a vehicle, and pain aggravation with coughing or sneezing. Patients were assigned in a 1:1 ratio, stratified by site. The allocation algorithm was prepared by the study statistician before enrollment, and its administration was concealed from study personnel. Interventions The intervention protocols were developed and tested in previous pilot studies (32, 33). Both interventions were intended to be pragmatic in nature (for example, modified to patient presentation and needs) and were informed by commonly recommended clinical practices, patient preferences, and promising research evidence (19, 3538). Eleven chiropractors with a minimum of 5 years of practice experience delivered SMT in the SMT plus HEA group. Thirteen providers (7 chiropractors, 5 exercise therapists, and 1 personal trainer) delivered the HEA intervention. When possible, patients worked with the same providers during the 12-week course of care; however, to accommodate patient and provider schedules during the intervention period, providers were trained to comanage patients. Treatment fidelity was facilitated through standardized training, manuals of operation, and clinical documentation forms that were monitored weekly by research staff. SMT Plus HEA Group As many as 20 SMT visits were allowed, each lasting 10 to 20 minutes, including a brief history and examination. Patients assigned to SMT plus HEA also attended 4 HEA visits, as described in the HEA Group section. For SMT visits, the primary focus of treatment was on manual techniques (including high-velocity, low amplitude thrust procedures or low-velocity, variable amplitude mobilization maneuvers to the lumbar vertebral or sacroiliac joints). The specific spinal level treated and the number and frequency of SMT visits were determined by the clinician on the basis of patient-reported symptoms, palpation, and pain provocation tests (39). Adjunct therapies to facilitate SMT were used as needed and included light soft-tissue techniques (that is, active and passive muscle stretching and ischemic compression of tender points) and hot or cold packs. To facilitate adherence to HEA, chiropractors asked about patients adherence, reaffirmed main HEA messages, and answered questions as needed. HEA Group Home exercise and advice were delivered in four 1-hour, one-on-one visits during the 12-week intervention. The main program goals were to provide patients with the tools to manage existing pain, prevent pain recurrences, and facilitate engagement in daily activities. Instruction and practice were provided for positioning and stabilization exercises to enhance mobility and increase trunk endurance. These were individualized to patients lifestyles, clinical characteristics (including positional sensitivities), and fitness levels. Positioning exercises included extension and flexion motion cycles (patients were encouraged to perform 25 repetitions 3 times per day in the lying, standing, or seated position) (33, 40). Stabilization exercises included pelvic tilt, quadruped, bridging, abdominal curl-ups, and side bridging with positional variations appropriate to patients tolerance and abilities (41). Patients were instructed to do 8 to 12 repetitions of each stabilization exercise every other day. Patients were also instructed in methods for developing spine posture awareness related to their activities of daily living, such as lifting, pushing and pulling, sitting, and getting out of bed (42). Information about simple pain-management techniques, including cold, heat, and movement, was also provided. Printed materials were distributed to take home and review. They included instructions of exercises with photos and a modification of the Back in Action book (43), emphasizing movement and restoration of normal function and fitness (35, 44). To facilitate adherence to HEA, providers called or e-mailed patients 3 times (at 1, 4, and 9 weeks) to reaffirm main messages and answer exercise-related questions. Outcomes and Measurements Patients demographic and clinical characteristics were collected at their first baseline visit through self-report questionnaires, histories, and physical examinations. Self-reported outcomes were collected at the baseline visit and at 3, 12, 26, and 52 weeks via questionnaires independent of study personnel influence. Patients were queried in each questionnaire about attempts to influence their responses. The primary outcome measure was patient-rated typical level of leg pain during the past week using an 11-point numerical rating scale, a reliable, valid, and important patient-centered outcome (36, 4547). The primary end points were 12 weeks, which was the end of the intervention phase, and the 52-week follow-up. A complete description of all secondary outcome measures is provided elsewhere (29). The measures reported in this article include LBP, disability measured with the modified RolandMorris Disability Questionnaire (4850), physical and

Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain

Context Few studies evaluate the comparative effectiveness of conservative treatments for back-related leg pain. Contribution This randomized trial, involving 192 adults with subacute or chronic back-related leg pain, compared 12 weeks of home exercise and advice with spinal manipulative therapy plus home exercise and advice. Spinal manipulative therapy with home exercise and advice improved self-reported pain and function outcomes more than exercise and advice alone at 12 weeks, but differences between groups were not present at 52 weeks except for some secondary outcomes. Caution The intervention was not blinded. Implication Spinal manipulative therapy combined with home exercise and advice can improve short-term outcomes in patients with back-related leg pain. The Editors Back-related leg pain (BRLP) is an important symptom commonly associated with pervasive low back pain (LBP) conditions and, despite its socioeconomic effect, has been generally understudied. With poorer prognosis and quality of life, persons with BRLP have greater pain severity and incur more work loss, medication use, surgery, and health-related costs than those with uncomplicated LBP (16). Most patients with BRLP are treated with prescription medications and injections, although little to no evidence supports their use (7, 8). Surgical approaches are also commonly applied, although there is only some evidence for short-term effectiveness compared with less invasive treatments (9). Concerns are mounting about the overuse, costs, and safety of these conventional medical treatments (1018), warranting identification of more conservative treatment options. Spinal manipulative therapy (SMT), exercise, and education promoting self-management are increasingly recommended as low-risk strategies for BRLP (19). Although limited, evidence shows that these conservative approaches can be effective (2026). A recent systematic review by our group showed that SMT is superior to sham SMT for acute BRLP in the short and long term; however, the evidence for subacute and chronic BRLP is inconclusive, and high-quality research is needed to inform clinical and health policy decisions (20). The underlying mechanisms of SMT seem to be multifactorial, including improvement in spinal stiffness, muscle recruitment, and synaptic efficacy of central neurons (27, 28). The purpose of this study was to test the hypothesis that the addition of SMT to home exercise and advice (HEA) would be more effective than HEA alone for patients with subacute and chronic BRLP. Methods Design Overview This pragmatic trial used a parallel design with allocation by minimization and has been described previously (29). Patients were recruited between 2007 and 2010, and follow-up was completed in 2011. Institutional review boards approved the study protocol, and all patients provided written consent. The primary outcomes and most secondary outcomes were self-reported; objective measures were obtained by blinded examiners. There were no important changes to methods after trial commencement. Settings and Patients The trial was conducted at institution-affiliated research clinics at Northwestern Health Sciences University (Minneapolis, Minnesota) and Palmer College of Chiropractic (Davenport, Iowa). Patients were recruited through newspaper advertisements, direct mail, and community posters. Interested patients were initially screened by telephone interviews, followed by 2 in-person baseline evaluation visits. Inclusion criteria were age 21 years or older; BRLP based on Quebec Task Force on Spinal Disorders classifications 2, 3, 4, or 6 (radiating pain into the proximal or distal part of the lower extremity, with or without neurologic signs) (30); BRLP severity of 3 or greater (scale of 0 to 10); a current episode of 4 weeks or more; and a stable prescription medication plan in the previous month. Exclusion criteria were Quebec Task Force on Spinal Disorders classifications of 1, 5, 7, 8, 9, 10, and 11 (pain without radiation into the lower extremities, progressive neurologic deficits, the cauda equina syndrome, spinal fracture, spinal stenosis, surgical lumbar spine fusion, several incidents of lumbar spine surgery, chronic pain syndrome, visceral diseases, compression fractures or metastases, blood clotting disorders, severe osteoporosis, and inflammatory or destructive tissue changes of the spine). Patients could not be receiving ongoing treatment of leg pain or LBP; be pregnant or nursing; have current or pending litigation for workers compensation, disability, or personal injury; be unable to read or comprehend English; or have evidence of substance abuse. Allocation A Web-based program assigned patients to treatment after the second baseline visit using a minimization algorithm based on the Taves method (31), balancing on 7 baseline characteristics previously shown to influence outcomes (3234). Baseline characteristics included age, BRLP duration, neurologic signs, distress, positive straight leg raise, time spent driving a vehicle, and pain aggravation with coughing or sneezing. Patients were assigned in a 1:1 ratio, stratified by site. The allocation algorithm was prepared by the study statistician before enrollment, and its administration was concealed from study personnel. Interventions The intervention protocols were developed and tested in previous pilot studies (32, 33). Both interventions were intended to be pragmatic in nature (for example, modified to patient presentation and needs) and were informed by commonly recommended clinical practices, patient preferences, and promising research evidence (19, 3538). Eleven chiropractors with a minimum of 5 years of practice experience delivered SMT in the SMT plus HEA group. Thirteen providers (7 chiropractors, 5 exercise therapists, and 1 personal trainer) delivered the HEA intervention. When possible, patients worked with the same providers during the 12-week course of care; however, to accommodate patient and provider schedules during the intervention period, providers were trained to comanage patients. Treatment fidelity was facilitated through standardized training, manuals of operation, and clinical documentation forms that were monitored weekly by research staff. SMT Plus HEA Group As many as 20 SMT visits were allowed, each lasting 10 to 20 minutes, including a brief history and examination. Patients assigned to SMT plus HEA also attended 4 HEA visits, as described in the HEA Group section. For SMT visits, the primary focus of treatment was on manual techniques (including high-velocity, low amplitude thrust procedures or low-velocity, variable amplitude mobilization maneuvers to the lumbar vertebral or sacroiliac joints). The specific spinal level treated and the number and frequency of SMT visits were determined by the clinician on the basis of patient-reported symptoms, palpation, and pain provocation tests (39). Adjunct therapies to facilitate SMT were used as needed and included light soft-tissue techniques (that is, active and passive muscle stretching and ischemic compression of tender points) and hot or cold packs. To facilitate adherence to HEA, chiropractors asked about patients adherence, reaffirmed main HEA messages, and answered questions as needed. HEA Group Home exercise and advice were delivered in four 1-hour, one-on-one visits during the 12-week intervention. The main program goals were to provide patients with the tools to manage existing pain, prevent pain recurrences, and facilitate engagement in daily activities. Instruction and practice were provided for positioning and stabilization exercises to enhance mobility and increase trunk endurance. These were individualized to patients lifestyles, clinical characteristics (including positional sensitivities), and fitness levels. Positioning exercises included extension and flexion motion cycles (patients were encouraged to perform 25 repetitions 3 times per day in the lying, standing, or seated position) (33, 40). Stabilization exercises included pelvic tilt, quadruped, bridging, abdominal curl-ups, and side bridging with positional variations appropriate to patients tolerance and abilities (41). Patients were instructed to do 8 to 12 repetitions of each stabilization exercise every other day. Patients were also instructed in methods for developing spine posture awareness related to their activities of daily living, such as lifting, pushing and pulling, sitting, and getting out of bed (42). Information about simple pain-management techniques, including cold, heat, and movement, was also provided. Printed materials were distributed to take home and review. They included instructions of exercises with photos and a modification of the Back in Action book (43), emphasizing movement and restoration of normal function and fitness (35, 44). To facilitate adherence to HEA, providers called or e-mailed patients 3 times (at 1, 4, and 9 weeks) to reaffirm main messages and answer exercise-related questions. Outcomes and Measurements Patients demographic and clinical characteristics were collected at their first baseline visit through self-report questionnaires, histories, and physical examinations. Self-reported outcomes were collected at the baseline visit and at 3, 12, 26, and 52 weeks via questionnaires independent of study personnel influence. Patients were queried in each questionnaire about attempts to influence their responses. The primary outcome measure was patient-rated typical level of leg pain during the past week using an 11-point numerical rating scale, a reliable, valid, and important patient-centered outcome (36, 4547). The primary end points were 12 weeks, which was the end of the intervention phase, and the 52-week follow-up. A complete description of all secondary outcome measures is provided elsewhere (29). The measures reported in this article include LBP, disability measured with the modified RolandMorris Disability Questionnaire (4850), physical and

Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints.

Primary pain disorders (formerly “functional pain syndromes”) are common, under-diagnosed and under-treated in children and teenagers. This manuscript reviews key aspects which support understanding the development of pediatric chronic pain, points to the current pediatric chronic pain terminology, addresses effective treatment strategies, and discusses the evidence-based use of pharmacology. Common symptoms of an underlying pain vulnerability present in the three most common chronic pain disorders in pediatrics: primary headaches, centrally mediated abdominal pain syndromes, and/or chronic/recurrent musculoskeletal and joint pain. A significant number of children with repeated acute nociceptive pain episodes develop chronic pain in addition to or as a result of their underlying medical condition “chronic-on-acute pain.” We provide description of the structure and process of our interdisciplinary, rehabilitative pain clinic in Minneapolis, Minnesota, USA with accompanying data in the treatment of chronic pain symptoms that persist beyond the expected time of healing. An interdisciplinary approach combining (1) rehabilitation; (2) integrative medicine/active mind-body techniques; (3) psychology; and (4) normalizing daily school attendance, sports, social life and sleep will be presented. As a result of restored function, pain improves and commonly resolves. Opioids are not indicated for primary pain disorders, and other medications, with few exceptions, are usually not first-line therapy.

Spinal manipulation and exercise for low back pain in adolescents: study protocol for a randomized controlled trial

BackgroundLow back pain is among the most common and costly chronic health care conditions. Recent research has highlighted the common occurrence of non-specific low back pain in adolescents, with prevalence estimates similar to adults. While multiple clinical trials have examined the effectiveness of commonly used therapies for the management of low back pain in adults, few trials have addressed the condition in adolescents. The purpose of this paper is to describe the methodology of a randomized clinical trial examining the effectiveness of exercise with and without spinal manipulative therapy for chronic or recurrent low back pain in adolescents.Methods/designThis study is a randomized controlled trial comparing twelve weeks of exercise therapy combined with spinal manipulation to exercise therapy alone. Beginning in March 2010, a total of 184 participants, ages 12 to 18, with chronic or recurrent low back pain are enrolled across two sites. The primary outcome is self-reported low back pain intensity. Other outcomes include disability, quality of life, improvement, satisfaction, activity level, low back strength, endurance, and motion. Qualitative interviews are conducted to evaluate participants’ perceptions of treatment.DiscussionThis is the first randomized clinical trial assessing the effectiveness of combining spinal manipulative therapy with exercise for adolescents with low back pain. The results of this study will provide important evidence on the role of these conservative treatments for the management of low back pain in adolescents.Trial registration(ClinicalTrials.gov NCT01096628).

Chiropractic and self-care for back-related leg pain: design of a randomized clinical trial.

BackgroundBack-related leg pain (BRLP) is a common variation of low back pain (LBP), with lifetime prevalence estimates as high as 40%. Often disabling, BRLP accounts for greater work loss, recurrences, and higher costs than uncomplicated LBP and more often leads to surgery with a lifetime incidence of 10% for those with severe BRLP, compared to 1-2% for those with LBP.In the US, half of those with back-related conditions seek CAM treatments, the most common of which is chiropractic care. While there is preliminary evidence suggesting chiropractic spinal manipulative therapy is beneficial for patients with BRLP, there is insufficient evidence currently available to assess the effectiveness of this care.Methods/DesignThis study is a two-site, prospective, parallel group, observer-blinded randomized clinical trial (RCT). A total of 192 study patients will be recruited from the Twin Cities, MN (n = 122) and Quad Cities area in Iowa and Illinois (n = 70) to the research clinics at WHCCS and PCCR, respectively.It compares two interventions: chiropractic spinal manipulative therapy (SMT) plus home exercise program (HEP) to HEP alone (minimal intervention comparison) for patients with subacute or chronic back-related leg pain.DiscussionBack-related leg pain (BRLP) is a costly and often disabling variation of the ubiquitous back pain conditions. As health care costs continue to climb, the search for effective treatments with few side-effects is critical. While SMT is the most commonly sought CAM treatment for LBP sufferers, there is only a small, albeit promising, body of research to support its use for patients with BRLP.This study seeks to fill a critical gap in the LBP literature by performing the first full scale RCT assessing chiropractic SMT for patients with sub-acute or chronic BRLP using important patient-oriented and objective biomechanical outcome measures.Trial RegistrationClinicalTrials.gov NCT00494065

Instantaneous helical axis methodology to identify aberrant neck motion

BACKGROUND Neck pain afflicts 30-50% of the U.S. population annually; however we currently have poor diagnostic differentiation techniques to inform individualized treatment. Planar neck kinematics has been shown to be correlated with neck pain, but neck motion is much more complex than pure planar activities. Our objective was to define a methodology for determining aberrant neck kinematics and assess it. METHODS We examined a complex neck kinematic activity of neck circumduction and computed the pathway of motion using the instantaneous helical axis approach in 81 patients with non-specific neck pain and in 20 non-matched symptom free subjects. Neck circumduction, or rolling of the head, represents a complex neck kinematic activity, investigating the innate coupled motion of the cervical spine at the end ranges of motion in all directions. Instance of discontinuities in the helical axis patterns, or folds, were identified and labeled as occurrences of aberrant motion. FINDINGS The instances of aberrant motion, or folds, which are nearly non-existent in the healthy sample group, are present in both the pre- and post-treatment neck pain patients. Following a treatment intervention of the symptomatic patients, pain and neck disability index decreased significantly (P<0.001) concomitant with a decrease in the number of folds (P=0.021). INTERPRETATION The present study highlights a new technique using an instantaneous helical axis approach to detect subtle abnormalities in the pathway of motion of the head about the trunk, during a neck circumduction exercise.

Dose–response of spinal manipulation for cervicogenic headache: study protocol for a randomized controlled trial

BackgroundCervicogenic headache is a prevalent and costly pain condition commonly treated by chiropractors. There is evidence to support the effectiveness for spinal manipulation, but the dose of treatment required to achieve maximal relief remains unknown. The purpose of this paper is to describe the methodology for a randomized controlled trial evaluating the dose–response of spinal manipulation for chronic cervicogenic headache in an adult population.Methods/DesignThis is a mixed-methods, two-site, prospective, parallel groups, observer-blind, randomized controlled trial conducted at university-affiliated research clinics in the Portland, OR and Minneapolis, MN areas. The primary outcome is patient reported headache frequency. Other outcomes include self-reported headache intensity, disability, quality of life, improvement, neck pain intensity and frequency, satisfaction, medication use, outside care, cervical motion, pain pressure thresholds, health care utilization, health care costs, and lost productivity. Qualitative interviews are also conducted to evaluate patients’ expectations of treatment.DiscussionWith growing concerns regarding the costs and side effects of commonly used conventional treatments, greater numbers of headache sufferers are seeking other approaches to care. This is the first full-scale randomized controlled trial assessing the dose–response of spinal manipulation therapy on outcomes for cervicogenic headache. The results of this study will provide important evidence for the management of cervicogenic headache in adults.Trial registrationClinicalTrials.gov (Identifier: NCT01530321)

Accelerometer-Determined Physical Activity and Clinical Low Back Pain Measures in Adolescents With Chronic or Subacute Recurrent Low Back Pain

STUDY DESIGN: Cross‐sectional. BACKGROUND: Although low back pain (LBP) occurs commonly in adolescence, little is known about the relationship between objectively measured physical activity and chronic LBP. OBJECTIVES: To assess the relationship between an objective physical activity measure (accelerometer) and standard clinical measures (pain intensity, disability, and quality of life) in a sample of adolescents with recurrent or chronic LBP. METHODS: The study included a subsample of 143 adolescents, 12 to 18 years of age, from a randomized clinical trial. Pearson correlations (r) and bivariate linear regression were used to assess the relationship between baseline measures of sedentary, light, and moderate‐to‐vigorous physical activity using accelerometers and clinical measures of LBP (pain intensity, disability, and quality of life). RESULTS: Participants spent an average of 610.5 minutes in sedentary activity, 97.6 minutes in light physical activity, and 35.6 minutes in moderate‐to‐vigorous physical activity per day. Physical activity was very weakly associated with clinical measures of LBP (r<0.13). None of the assessed correlations were statistically significant, and bivariate regression models showed that physical activity measures explained very little of the variability for clinical measures of LBP (R2<0.02). CONCLUSION: We found no important relationship between objectively measured physical activity and self‐reported LBP intensity, disability, or quality of life in adolescents with recurrent or chronic LBP. The parent randomized clinical trial was registered at ClinicalTrials. gov (NCT01096628).