| LOWER BACK PAIN
- 80% of people will be disabled
by low back pain during their adult lives.
- It is the third most frequent reason (after respiratory disorder
and headache) that people consult a health practitioner.
- The World Health Organization describes disability from low
back pain as epidemic.
- 50-60% of workers’ compensation cost is from back pain.
The British Medical Research Council Trial by Meade et al, published
in the British Medical Journal in June 1990 with long term follow
up results published in August 1995.
- This was an independent study and subsequently endorsed by
the British Medical Association.
- It is well-designed, large, and compared chiropractic with
medical/physiotherapy hospital out patient practice.
- The study showed excellent short and long-term results for
chiropractic patients, for patients with both acute and chronic
pain, for patients with moderate or severe pain.
- Researchers expressly argued for greater use of and government
funding for chiropractic services because of superior effectiveness
The Effectiveness and Cost-Effectiveness of Chiropractic Management
of Low-back Pain, Manga et al, a government commissioned report
published in 1993 by health economists from the University
of Ottawa. Manga et al looked at all the international evidence,
from hard science to workers’ compensation and other
economic data, and concluded: “In our view, the constellation
of evidence of:
- The effectiveness and cost-effectiveness of chiropractic
management of low-back pain.
- The untested, questionable or harmful nature of many current
- The economic efficiency of chiropractic care for low-back
pain compared with medical care.
- The safety of chiropractic care.
- The higher satisfaction levels expressed by patients of chiropractors.
The U.S. and UK government sponsored multi-disciplinary Guidelines
for management of Low Back Pain, December 1994.
These review the controlled trial evidence and recommend:
- Spinal manipulation and over-the-counter medication (Acetaminophen,
Ibuprofen) for most patients with acute low back pain.
- Patients should be encouraged to remain active and be given
appropriate education in posture and exercises.
- Not to rest or ‘wait and see’.
| NECK PAIN
is a common musculoskeletal complaint and often is the result
of repetitive strain injuries (as found with assembly workers
or computer operators) and motor vehicle accidents (whiplash)
There is now a clear movement in health care towards early
active treatment including spinal manipulation, mobilization,
stretching, exercise and early return to work / activity and
medical and chiropractic specialists warn against passive
management and counsel against extended rest and dependency
on drugs and stress that the primary goal is the recovery
Quebec Task Force Report. Redefining Whiplash and
its Management, May 1995, which is an evidence-based
guideline on management from an international interdisciplinary
panel. The main issues regarding the management of neck pain
- The same principles apply as in the management of low back
- The Report supports the safety and effectiveness of cervical
manipulation in treating neck pain.
- It is the Task Force consensus that the use of short term
spinal manipulation and mobilization by trained persons, the
use of non-steroidal anti-inflammatory (NSAIDs) and analgesics,
and active exercises are the most helpful and appropriate
in treating uncomplicated neck pain.
- The Task Force further recommends that prolonged use of soft
collars, rest or inactivity probably prolong disability.
- The Task Force finds that scientifically unproven therapies
include cervical pillows, postural alignment training, acupuncture,
spray and stretch, electrical stimulation, ultrasound, laser,
short wave diathermy, heat, ice, massage, epidural or intrathecal
Early Mobilization of Acute Whiplash Injuries. Mealy, et al
in the British Medical Journal, 1986. This is a randomized
study, which followed patients with acute soft tissue whiplash
There were two groups:
- Given the standard treatment of rest and initial immobilization
with a soft cervical collar.
- Given “active treatment” of ice in the first 24
hours and then appropriate manipulative techniques and daily
exercises. The researchers found that the patients receiving
the early active treatment (#2) had a statistically significant
increase in cervical spine movement but not those given the
standard treatment (#1) and group #2 had a significant decrease
in pain and they concluded that early active management was
The immediate Effect of Manipulation versus Mobilization on
Pain and Range of Motion in the Cervical Spine: A Randomized
Controlled Trial, Journal of manipulative and Physiological
Therapeutics, Cassidy, Lopes, et al. Shows the spinal manipulation
has better immediate effects than mobilization in terms of
increased ranges of joint motion.
The Appropriateness of Manipulation and Mobilization of the
Cervical Spine, (Research and Development) Corporation of
California, July 1996. Rand is a non-profit private corporation,
which conducts research and development for the US government
and the private sector.
The RAND Report recommends:
- Cervical manipulation and mobilization for neck and headaches.
- Cervical manipulation is far safer than a number of medical
treatments given for the same symptoms (mortality rate for
cervical spine surgery is 6,900 per million, serious gastrointestinal
events from NSAID’s are 1000 per 1 million)
- A comprehensive
US study (1992) estimated that approximately 27 % of females
and 14 % of males suffer from severe headaches and that over
10 million Americans (4%) suffered moderate to severe disability
from various forms of headache.
- A 1993 paper in the journal Headache calculated that headaches
resulted in 74.2 million days of restricted work activity
per annum in the US with an estimated cost of $1.4 billion
dollars in lost productivity.
- A 1992 Canadian study found that 14% of Canadians suffer from
migraine headaches, and that 50% of these have significant
disability – 36% suffer chronic tension headaches with
an 18% disability and 14% suffer from both tension and migraine.
It was calculated that over 7 million workdays per year were
lost because of headaches.
- From the point of view of the patient, given the high incidence
of headaches, the issue is whether medical physicians or chiropractors
should treat headache sufferers. There is a clear role for
Medical leaders acknowledge that there is still grave confusion
in the diagnosis of headaches. It was only in 1988 that the
International Headache Society recognized cervicogenic headache
(headache as the result of pain radiating from the facet joints
of the C2 and the C3 vertebrae) as a distinct entity and thus
common forms of headache include primary types (benign –
the headache pose no danger to the patient other than the
headache itself); migraine, tension, cluster and cerviogenic
and secondary types (those caused by underlying disease and
pose a serious threat to the patient’s health) of which
there are hundred’s of possible causes and include tumor
(space occupying lesion) temporal arthritis, meningitis, acute
glaucoma and subarachnoid hemorrhage.
There is a good body of research studying the cervical spine
and headaches. Some studies include:
A Controlled Trial of Cervical Manipulation for Migraine,
Australian, New Zealand journal of Medicine, Parker et al,
1978. One of the first clinical trials ever conducted on spinal
manipulation and migraines.
- Compared chiropractic manipulation, medical manipulation
and mobilization by physical therapists. All groups of patients
benefited from treatment, chiropractic patients benefited
most on all measures (complete cure, frequency of attack,
mean duration, mean disability, mean intensity of pain)- a
follow-up study showed that the patients who improved maintained
this benefit after 20 months.
The Efficacy of Cervical Adjustments (Toggle Recoil) for Chronic
Headaches with Upper Cervical Subluxation, Whittingham, 1995.
- Results after treatment and at 6 months follow-up, measured
subjectively (Neck Disability Index, Sickness Impact Profile,
pain drawings and daily headache diaries) and objectively
(cervical range of motion, pressure algometry) showed a statistically
significant improvement (decrease in chronic headache) in
the patients treated with spinal manipulation but not in the
control group patients.
Spinal Manipulation vs. Amitriptyline for the treatment
of Chronic Tension-Type Headaches. JMPT, Boline,
DC, Kassam, PhD et al, 1995.
Compared the effectiveness of spinal manipulation and medication
(Amitriptyline) for the treatment of tension headaches.
Found that the patients in the spinal manipulation group showed
a reduction of 42% in headache frequency, 32% in headache
intensity and a 30% decrease in usage of over the counter
medication and a 16% improvement in functional health status
while the medication group showed an improvement of only 6%
or less in all the outcome measures.