William C. Meeker

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.

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.

Chiropractic and CAM Utilization: A Descriptive Review

ObjectiveTo conduct a descriptive review of the scientific literature examining use rates of modalities and procedures used by CAM clinicians to manage chronic LBP and other conditionsData SourcesA literature of PubMed and MANTIS was performed using the key terms Chiropractic; Low Back Pain; Utilization Rate; Use Rate; Complementary and Alternative Medicine; and Health Services in various combinations.Data SelectionA total of 137 papers were selected, based upon including information about chiropractic utilization, CAM utilization and low back pain and other conditions.Data SynthesisInformation was extracted from each paper addressing use of chiropractic and CAM, and is summarized in tabular form.ResultsThematic analysis of the paper topics indicated that there were 5 functional areas covered by the literature: back pain papers, general chiropractic papers, insurance-related papers, general CAM-related papers; and workers compensation papers.ConclusionStudies looking at chiropractic utilization demonstrate that the rates vary, but generally fall into a range from around 6% to 12% of the population, most of whom seek chiropractic care for low back pain and not for organic disease or visceral dysfunction. CAM is itself used by people suffering from a variety of conditions, though it is often used not as a primary intervention, but rather as an additional form of care. CAM and chiropractic often offer lower costs for comparable results compared to conventional medicine.

Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study.

Study Design. Randomized controlled trial. Objective. To assess changes in pain levels and physical functioning in response to standard medical care (SMC) versus SMC plus chiropractic manipulative therapy (CMT) for the treatment of low back pain (LBP) among 18 to 35-year-old active-duty military personnel. Summary of Background Data. LBP is common, costly, and a significant cause of long-term sick leave and work loss. Many different interventions are available, but there exists no consensus on the best approach. One intervention often used is manipulative therapy. Current evidence from randomized controlled trials demonstrates that manipulative therapy may be as effective as other conservative treatments of LBP, but its appropriate role in the healthcare delivery system has not been established. Methods. Prospective, 2-arm randomized controlled trial pilot study comparing SMC plus CMT with only SMC. The primary outcome measures were changes in back-related pain on the numerical rating scale and physical functioning at 4 weeks on the Roland-Morris Disability Questionnaire and back pain functional scale (BPFS). Results. Mean Roland-Morris Disability Questionnaire scores decreased in both groups during the course of the study, but adjusted mean scores were significantly better in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Mean numerical rating scale pain scores were also significantly better in the group that received CMT. Adjusted mean back pain functional scale scores were significantly higher (improved) in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Conclusion. The results of this trial suggest that CMT in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP.

Health professions education and integrative healthcare.

Over the past three decades, evidence has accumulated that demonstrates that the US healthcare system as currently structured is untenable given the cost of healthcare, poor outcomes associated with this cost, imminent shortages in many categories of health professionals, and underutilization of other health professionals. The system also faces other challenges, such as the lack of access to care and a growing demand by consumers for healthcare that offers choice, quality, convenience, affordability, and personalized care. Workforce analyses estimating needs and anticipated shortages of health professionals are projected on the current healthcare system, which generally does not include integrative healthcare and does not include complementary and alternative medicine (CAM) practitioners. This paper examines the opportunities and implications of going beyond the current paradigm of workforce planning and health professions education and offers recommendations that detail how the health of the public may be served by incorporating an integrative health perspective into health professions education and workforce planning, deployment, and utilization.

Public demand and the integration of complementary and alternative medicine in the US health care system

Public use of complementary and alternative medicine (CAM) grew 25% between 1990 and 1997 and had a number of implications for chiropractic and the US health care system. Recent surveys describe the issues surrounding definitions of CAM; patterns of CAM use and its costs; attitudes of the public, health care providers and business entities; increasing scientific research; and changes in the health care system. Almost one third (192 million) of the 629 million visits to CAM providers in 1997 were to chiropractors. The new US National Center for Complementary and Alternative Medicine have funded chiropractic and other CAM research as a regular part of its scientific portfolio. Health maintenance organizations and other health care business entities have created new markets for CAM services, including chiropractic. profession, chiropractic appears to be positioned somewhere between mainstream practice and CAM, with conflicting opinions held by the public, the health care industry, and chiropractors themselves. The benefits and risks of chiropractic being identified with the CAM movement must be weighed carefully.

Recruitment and Enrollment for the Simultaneous Conduct of 2 Randomized Controlled Trials for Patients with Subacute and Chronic Low Back Pain at a CAM Research Center

OBJECTIVE To describe recruitment and enrollment experiences of 2 low back pain (LBP) randomized controlled trials (RCTs). DESIGN Descriptive report. SETTING Chiropractic research center in the midwest United States that is not a fee-for-service clinic. PARTICIPANTS Both trials enrolled participants with subacute or chronic LBP without neurologic signs who had not received spinal manipulative care during the previous month. For study 1 we screened 1940 potential participants to enroll 192 participants (89 women and 103 men), mean age 40.0 +/- 9.4 years (range, 21-54 years). For study 2 we screened 1849 potential participants to enroll 240 participants (105 women and 135 men) at least 55 years old (mean, 63.1 +/- 6.7 years). INTERVENTIONS Study 1 randomly assigned participants to 2 weeks of 2 different chiropractic techniques or a wait list control group. Study 2 randomly assigned participants to 6 weeks of 2 different chiropractic techniques or medical care consisting of 3 provider visits for medications. OUTCOME MEASURES Recruitment source costs and yield, and baseline characteristics of enrolled versus nonparticipants were recorded. RESULTS We conducted 3789 telephone screens for both trials to enroll 432 (11%) participants, at a cost in excess of

The CAM movement and the integration of quality health care: the case of chiropractic.

156,000 for recruitment efforts. The cost per call for all callers averaged

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

41, ranging from

Improving Our Nation's Health Care System: Inclusion of Chiropractic in Patient-Centered Medical Homes and Accountable Care Organizations

4 to