Marc S. Micozzi

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.

OBJECTIVES The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP). METHODS A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. RESULTS A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies. CONCLUSIONS As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

The Person of the Teacher

It’s a very old story, told all around the world. A stranger comes to a little community that’s been under great stress, where food is scarce, and where people have drawn away from each other and are looking out for themselves. The stranger manages to borrow a cooking pot and starts making soup. He begins with a “magic” ingredient, a stone, maybe a button, or even a nail. The community members become interested in what he’s doing, and each secretly comes for a look at the pot. The stranger stirs and tastes. “Ah, it’s coming along nicely,” he says. “But it would be really wonderful if it had just a little something extra, like a potato, maybe…,” he says to one visitor in just the way she needs to hear it. She goes off inspired to find something to offer. “…like a carrot,” he says in his just-right way to another. Later, “… a cabbage,” and then “…some beans.” And soon there’s a shy parade of community folks bringing ingredients and standing around a pot that’s now aswim with good things — enough for everyone. They share a meal. There’s even a little music. Someone sings; another finds his fiddle; there’s dancing into the night. And the stranger has already gone, picking up a new “magic” stone on his way to the next community.

The Skills of the Teacher

In teaching mindfulness as a professional, the teacher works from her or his own unique authenticity, authority, and friendship. That means, of course, that all individual teachers are different, with singular ways of integrating and embodying mindfulness. In fact, for this purpose, integrating and embodying are the same thing. Teachers know what they know, and can do what they do, based on the fruits of their practice and on the skills they have developed along the paths of their own professional and personal development. As a result, the skills each teacher possesses may be a melange of ideas, which is not so much integrated theoretically in the thinking, but, rather, more directly in the body of the teacher. Even at the Center for Mindfulness at the University of Massachusetts, the programs of teacher training comprise such a melange. Pragmatic and eclectic, these trainings make use of a wide range of insights and practices from medicine, psychotherapy, education, anthropology-sociology, and world wisdom traditions. Again, the integration of all of this substance is not in theory but in the body of each teacher. Yet, at the same time, we also believe that there are general skills that teachers share; that is, we believe each teacher uses comparable skills to work with participants in her own inimitable way.

Practices for the Classroom

This practice can be used to bring participants’ attention to the sense of connection that is created within the group as the course progresses. Class 6 of MBSR is an appropriate moment for it, as the interrelationships of the class have been developing and the curriculum is focused for the session on interpersonal communication.

Practices for Teacher Development

Confirmation bias refers to the tendency to seek and find confirmatory evidence in support of already existing beliefs and ignore or reinterpret disconfirming evidence and is a major barrier to evidenced-based practice (Lilienfeld et al., 2013). Confirmation bias is a universal human tendency that applies to everyone, so what distinguishes the mindful person from an unmindful one is not the presence or absence of the bias, but rather the willingness to acknowledge and challenge the bias in the service of “seeing clearly.” The following is an exercise for investigating the sources of our own confirmation biases.

Practice Scripts and Descriptions

This chapter presents scripts for a range of practices, including the core practices of mindfulness-based stress reduction (MBSR), and practices that approach the teaching intentions from different perspectives. They are specific embodiments of the “emptied” motions or gestures of the teaching intentions, drawn from our own authenticity, authority, and friendship. If Chapter 7 characterized the water marks or tide lines of the intentions, perhaps the practices in this chapter are objects found at those lines — a piece of driftwood, a pretty shell, a polished piece of broken glass. They are that concrete, and that unique. Perhaps their usefulness is found in the way that driftwood might be used by an artist: taken home, looked at reflectively, and then abstracted into a new creation. Take these for inspiration, not imitation. Feel the gestures called out in the margins, don’t follow them.

A History Exercise to Locate “Mindfulness” Now

The practice of mindfulness is an experience that from a certain perspective is inexpressible. You gain a tacit knowledge of it that is yours alone; you “know more than [you] can tell,” as Michael Polanyi (1966) phrases it. Yet, from a different perspective, the practice is also a product of all the communications that you have around your experience. Your explicit knowledge, what you can tell, is co-created in relationship with all of those with whom you share your experience now or in the future, from your mindfulness teachers and fellow students, to your colleagues and supervisors in working with mindfulness-based interventions, to the clients or patients that you teach. This co-creation takes place most obviously in verbal language. You learn from a talk or a book by a teacher, a conversation with a colleague, or a dialog with a client. But the nonverbal dimensions are also important. There is much to be learned from a teacher’s posture, gestures, tone of voice, and rate of speech, or from the way a colleague meets your eyes, or from the quality of the pause before a supervisor responds in a tense moment. So, within such relationships, within your own small community, there is an evolving discourse, through which you learn to better understand and, thereby, better express your tacit knowledge of mindfulness practice. Further, it is within such a community and its discourse that you are learning, or will learn, to teach mindfulness as a professional.

Getting Grounded (In Our Own Instability)

The applications and use of mindfulness-based interventions (MBIs) in medicine and mental healthcare have been expanding as rapidly as the empirical evidence base that is validating and recommending them. This growth has created a powerful demand for professionals who can effectively deliver these interventions and for training new professionals who can enter the fold.

Defining Mindfulness for the Moment

In the preceding chapters, we have described both the broader discourse of the meditative and contemplative traditions and the specific discourse of the mindfulness-based interventions (MBIs). In the long journey from the nineteenth century Romantic and Transcendentalist discoveries of Asian religious texts and practices to the current flowering of the empirically supported MBIs, a variety of streams of this discourse have been active. At times, one stream has predominated; at other times another has drawn the most attention and found the most utility.

Fulfilling the Intentions of Teaching

In teaching mindfulness as a professional, using your authenticity, authority, and friendship, each session is fresh and different, like a new wave breaking on the shore. Each progress through a course is unique. Participants and teacher find other ways of saying, demonstrating, learning, understanding — together. Participants and teacher are never the same, course to course, or even session to session, again like the river flowing past the shore. Never the same people again, as they are changing in each moment. There will never be these same sufferings, these same questions, these same jokes or joys — each a challenge to the teacher and the others. And so, there will never be these same responses. Holding this. Exploring that. Sitting with the terrible, the unanswerable, the riotous, and the oh-so-sweet.