Robert M. Rowell

A Randomized Controlled Trial Comparing 2 Types of Spinal Manipulation and Minimal Conservative Medical Care for Adults 55 Years and Older With Subacute or Chronic Low Back Pain

OBJECTIVE Chiropractic care is used by many older patients for low back pain (LBP), but there are no published results of randomized trials examining spinal manipulation (SM) for older adults. The purpose of this study was to compare the effects of 2 biomechanically distinct forms of SM and minimal conservative medical care (MCMC) for participants at least 55 years old with subacute or chronic nonradicular LBP. METHODS Randomized controlled trial. The primary outcome variable was low back-related disability assessed with the 24-item Roland Morris Disability questionnaire at 3, 6, 12, and 24 weeks. Participants were randomly allocated to 6 weeks of care including 12 visits of either high-velocity, low-amplitude (HVLA)-SM, low-velocity, variable-amplitude (LVVA)-SM, or 3 visits of MCMC. RESULTS Two hundred forty participants (105 women and 135 men) ages 63.1 +/- 6.7 years without significant comorbidities. Adjusted mean Roland Morris Disability change scores (95% confidence intervals) from baseline to the end of active care were 2.9 (2.2, 3.6) and 2.7 (2.0, 3.3) in the LVVA-SM and HVLA-SM groups, respectively, and 1.6 (0.5, 2.8) in the MCMC group. There were no significant differences between LVVA-SM and HVLA-SM at any of the end points. The LVVA-SM group had significant improvements in mean functional status ranging from 1.3 to 2.2 points over the MCMC group. There were no serious adverse events associated with any of the interventions. CONCLUSIONS Biomechanically distinct forms of SM did not lead to different outcomes in older LBP patients and both SM procedures were associated with small yet clinically important changes in functional status by the end of treatment for this relatively healthy older population. Participants who received either form of SM had improvements on average in functional status ranging from 1 to 2.2 over those who received MCMC. From an evidence-based care perspective, patient preference and clinical experience should drive how clinicians and patients make the SM procedure decision for this patient population.

A Pilot Mixed Methods Study of Patient Satisfaction With Chiropractic Care for Back Pain

OBJECTIVE Patient satisfaction is important to payers, clinicians, and patients. The concept of satisfaction is multifactorial and measurement is challenging. Our objective was to explore the use of a mixed-methods design to examine patient satisfaction with chiropractic care for low back pain. METHODS Patients were treated 3 times per week for 3 weeks. Outcomes were collected at week 3 and week 4. Qualitative interviews were conducted by the treating clinician and a nontreating staff member. Outcome measures were the Roland Morris Back Pain Disability Questionnaire, the visual analog scale for pain, and the Patient Satisfaction Scale. Interviews were recorded and transcribed and analyzed for themes and constructs of satisfaction. We compared qualitative interview data with quantitative outcomes, and qualitative data from 2 different interviewers. RESULTS All patients reported high levels of satisfaction. Clinical outcomes were unremarkable with little change noted on visual analog scale and Roland Morris Back Pain Disability Questionnaire scores. We categorized patient comments into the same constructs of satisfaction as those identified for the Patient Satisfaction Scale: Information, Effectiveness, and Caring. An additional construct (Quality of Care) and additional subcategories were identified. Satisfaction with care is not explained by outcome alone. The qualitative data collected from 2 different interviewers had few differences. CONCLUSION The results of this study suggest that it is feasible to use a mixed-methods design to examine patient satisfaction. We were able to refine data collection and analysis procedures for the outcome measures and qualitative interview data. We identified limitations and offer recommendations for the next step: the implementation of a larger study.

Similar Effects of Thrust and Nonthrust Spinal Manipulation Found in Adults With Subacute and Chronic Low Back Pain: A Controlled Trial With Adaptive Allocation.

Study Design. A three-arm controlled trial with adaptive allocation. Objectives. The aim of this study was to compare short-term effects of a side-lying, thrust spinal manipulation (SM) procedure and a nonthrust, flexion-distraction SM procedure in adults with subacute or chronic low back pain (LBP) over 2 weeks. Summary of Background Data. SM has been recommended in recently published clinical guidelines for LBP management. Previous studies suggest that thrust and nonthrust SM procedures, though distinctly different in joint loading characteristics, have similar effects on patients with LBP. Methods. Participants were eligible if they were 21 to 54 years old, had LBP for at least 4 weeks, scored 6 or above on the Roland-Morris disability questionnaire, and met the diagnostic classification of 1, 2, or 3 according to the Quebec Task Force Classification for Spinal Disorders. Participants were allocated in a 3:3:2 ratio to four sessions of thrust or nonthrust SM procedures directed at the lower lumbar and pelvic regions, or to a 2-week wait list control. The primary outcome was LBP-related disability using Roland-Morris Disability Questionnaire and the secondary outcomes were LBP intensity using visual analog scale, Fear-Avoidance Beliefs Questionnaire, and the 36-Item Short Form Health Survey. The study was conducted at the Palmer Center for Chiropractic Research with care provided by experienced doctors of chiropractic. Clinicians and patients were not blinded to treatment group. Results. Of 192 participants enrolled, the mean age was 40 years and 54% were male. Improvement in disability, LBP intensity, Fear-Avoidance Beliefs Questionnaire—work subscale, and 36-Item Short Form Health Survey—physical health summary measure for the two SM groups were significantly greater than the control group. No difference in any outcomes was observed between the two SM groups. Conclusion. Thrust and nonthrust SM procedures with distinctly different joint loading characteristics demonstrated similar effects in short-term LBP improvement and both were superior to a wait list control. Level of Evidence: 2

Three-dimensional chiropractor-patient contact loads during side posture lumbar spinal manipulation: a pilot study

BackgroundPatients with low back pain often seek chiropractic care and more than ninety percent of Chiropractors use lumbar side posture manipulation for the treatment of low back pain. During this procedure chiropractors deliver forces by means of hand contact on the patient in a side lying position. The objective of this pilot study was to report on the three-dimensional forces at the hand contact between the chiropractor and the simulated patient (asymptomatic volunteers) during side posture lumbar high velocity low amplitude adjustments.MethodsIn 2005, two licensed chiropractors delivered spinal manipulations to the lumbar spines of the participants. A three-dimensional force transducer (Model # Mini-45, ATI-Industrial Automation, Apex, North Carolina) was used to measure the three-dimensional loads. The force-time histories were analyzed for preloads, peak loads, duration of thrusts to peak load, duration of thrust for completion, rate of loading, and magnitudes of the three forces and the resultant total force delivered by the chiropractor.ResultsThe two chiropractors delivered a total of 14 thrusts to the five asymptomatic volunteers. Normal force (Fz) is the dominating force, followed by inferior-superior force (Fx). The lateral force (Fy) occurred in both directions.ConclusionsThis study reports on the three dimensional load (three forces and the total resultant force) characteristics of chiropractor-patient hand contact while delivering a chiropractic high velocity low amplitude (HVLA) manipulation in a side lying position.

Low-back pain, leg pain, and chronic idiopathic testicular pain treated with chiropractic care.

OBJECTIVES The purpose of this article is to report the case of a patient who had low-back pain, leg pain, and idiopathic chronic testicular pain and who sought chiropractic care for his low-back and leg pain and received pain relief including his testicular pain. SUBJECT A 36-year-old male patient had low-back pain, right leg pain, and testicular pain that was worsening. All had been present for 5 years. He had been seen by several medical physicians and had lumbar magnetic resonance imaging and x-rays performed. All were read as normal. Examination revealed tenderness of the testicles bilaterally with no masses or other abnormality of the testicles or scrotum. Orthopedic and neurological testing was unremarkable. Tenderness rated 8 out of 10 was noted at the L4 spinous process. INTERVENTION The patient was treated with Cox Technic (flexion-distraction) of the lumbar spine, receiving a total of 19 treatments over an 8-week time period. RESULTS After 4 weeks, the patients low-back pain was decreased and his leg pain was gone. The testicular pain was improved after the first treatment and gone after 3 weeks of care. The patient was followed up by telephone at 3 and 6 months after discharge to find out if the testicle pain had returned, which it had not. CONCLUSIONS This case was one of chronic idiopathic testicular pain. The patient was treated with the Cox Technic, and his low-back pain improved with complete remission of his leg and testicular pain. The testicular pain had not returned 6 months following his discharge from care.

Three-Dimensional Quantification of Multi-Point Contact Loads During Lumbar Spinal Manipulation

The objective of this study was to measure the complete three-dimensional loads at each of the support contacts namely both hand contacts, and the support loads at the rib cage and the pelvis during chiropractic treatments for low back pain. Two small force transducers were used to measure hand contact loads, and a specially instrumented force plate table was used for measuring support loads. A doctor of chiropractic delivered fourteen spinal manipulations to the lumbar spines of five subjects during a period of three weeks. The results showed that there are three dimensional loads at each of the four contact points. The loads at the thrusting hands reached as high as 382N. For the stabilizing hands the maximum loads were 160N. The support loads reached as high as 727N at the pelvic support and 660N at the rib cage support. This study reports for the first time data on the loads at each of the hand contact points and the support locations during chiropractic spinal manipulation.Copyright

Three Dimensional Doctor-Patient Contact Forces During Chiropractic Spinal Treatments

This paper reports on the three-dimensional loads measured during chiropractic treatments delivered during low back spinal procedures. A three dimensional force transducer was placed between the doctors hand and the patient while delivering the treatment. Two doctors have delivered treatments to a total of five subjects on two consecutive days. A laptop computer was used to collect data using labview software and Keithly instruments PCMCIA card. The data was analyzed using Mathcad software to determine the magnitudes of the forces delivered. The results show three-dimensional loads are applied by the doctor at the doctor’s hand-patient interface. The compressive forces reached as high as 450 Newtons, and the shear forces have reached as high as 150 Newtons. The moments have reached as high as 4Nm. This information is valuable in further understanding the effects of these loads on the spine.Copyright