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PubMedDate not supplied

Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial.

BACKGROUND CONTEXT: The process through which new scientific developments are incorporated into clinical practice is referred to as "knowledge transfer" and is currently the subject of great interest in many areas of clinical medicine. Family physicians managing patients with acute low back pain have been shown to have a poor overall rate of concordance with clinical practice guideline-recommended treatments. New methods need to be developed to help physicians bridge the guideline implementation gap. PURPOSE: To determine the efficacy of a knowledge transfer method that communicates clinical practice guidelines to family physicians and their patients using patient-specific, physician-to-physician communications. STUDY DESIGN: A prospective randomized controlled study. PATIENT SAMPLE: 428 patients with acute mechanical low back pain and accepted Workers' Compensation Board claims were studied. OUTCOME MEASURES: Concordance with specific clinical practice guideline-derived history taking items, physical examination procedures and treatment recommendations was determined. METHODS: Patients with acute mechanical back pain of less than 4 weeks duration and accepted Workers' Compensation Board claims were randomly assigned to one of three groups. In Group 1 (control group) neither the patients nor their family physicians received any information concerning the guidelines. In Group 2, family physicians alone or as well as their patients (Group 3) received a summary of clinical practice guidelines at approximately 2 weeks postinjury. In addition, both Groups 2 and 3 received reminders summarizing the recommended guidelines for patients at three specific stages of their clinical course. All guideline correspondence was addressed to a specific family physician or patient, signed by the study physician-investigators, and specified the patient by name. RESULTS: Family physicians in the control and intervention groups demonstrated a high degree of concordance with the guideline-recommended history taking and physical examination procedures, but were generally highly discordant with guideline-recommended treatments. Significant improvement in guideline-concordant treatments was seen only with diminished recommendations of prolonged bed rest and passive therapies and an increase in recommended aerobic exercise. Concordance with guideline recommendations relating to the use of spinal manipulative therapy was poor in all study groups. CONCLUSIONS: A knowledge transfer method that involved patient-specific, physician-to-physician communication to family physicians or their patients at three stages of the patient's clinical course was largely unsuccessful in improving concordance with guideline treatment recommendations.

Acute Disease↗

PubMed1995

Randomized controlled trials in industrial low back pain relating to return to work. Part 1. Acute interventions.

Employers and insurers are interested in being able to use cost-effective interventions for returning injured workers to the workplace. Unfortunately, truly objective information is lacking. The purpose of this and two subsequent review articles was to perform thorough scrutiny and methodologic comparison among all obtainable, published randomized and controlled studies on low back pain (LBP) interventions leading to return to work. The study was confined to English language articles published from 1975 through 1993. Of more than 4,000 LBP citations, more than 500 were chosen for review. Of that number, 35 articles met the selection criteria of randomization, reasonable controls, and work return comparisons. This paper focuses on the 10 articles relating to interventions for acute (less than 4 weeks) LBP, and considers bed rest, exercise, spinal manipulation, back school, and case management. A 26-point quality system was used to compare the methodologic rigor of each article. This literature survey demonstrated the meager scientific foundations on which our industrial rehabilitation programs are based.

Bed Rest↗

PubMed2006

Specific stabilisation exercise for spinal and pelvic pain: a systematic review.

The aim of this study was to conduct a systematic review of the efficacy of specific stabilisation exercise for spinal and pelvic pain. Randomised clinical trials evaluating specific stabilisation exercise were identified and retrieved. Outcomes were disability, pain, return to work, number of episodes, global perceived effect, or health-related quality of life. A single trial reported that specific stabilisation exercise was more effective than no treatment but not more effective than spinal manipulative therapy for the management of cervicogenic headache and associated neck pain. Single trials reported that specific stabilisation exercise was effective for pelvic pain and for prevention of recurrence after an acute episode of low back pain but not to reduce pain or disability associated with acute low back pain. Pooled analyses revealed that, for chronic low back pain, specific stabilisation exercise was superior to usual medical care and education but not to manipulative therapy, and no additional effect was found when specific stabilisation exercise was added to a conventional physiotherapy program. A single trial reported that specific stabilisation exercise and a surgical procedure to reduce pain and disability in chronic low back pain were equally effective. The available evidence suggests that specific stabilisation exercise is effective in reducing pain and disability in chronic but not acute low back pain. Single trials indicate that specific stabilisation exercise can be helpful in the treatment of cervicogenic headache and associated neck pain, pelvic pain, and in reducing recurrence after acute low back pain.

Acute Disease↗

PubMed2004

Effective physical treatment for chronic low back pain.

It is now feasible to adopt an evidence-based approach when providing physical treatment for patients with chronic LBP. A summary of the efficacy of a range of physical treatments is provided in Table 1. The evidence-based primary care options are exercise, laser, massage, and spinal manipulation; however, the latter three have small or transient effects that limit their value as therapies for chronic LBP. In contrast, exercise produces large reductions in pain and disability, a feature that suggests that exercise should play a major role in the management of chronic LBP. Physical treatments, such as acupuncture, backschool, hydrotherapy, lumbar supports, magnets, TENS, traction, ultrasound, Pilates therapy, Feldenkrais therapy, Alexander technique, and craniosacral therapy are either of unknown value or ineffective and so should not be considered. Outside of primary care, multidisciplinary treatment or functional restoration is effective; however, the high cost probably means that these programs should be reserved for patients who do not respond to cheaper treatment options for chronic LBP. Although there are now effective treatment options for chronic LBP, it needs to be acknowledged that the problem of chronic LBP is far from solved. Though treatments can provide marked improvements in the patient's condition, the available evidence suggests that the typical chronic LBP patient is left with some residual pain and disability. Developing new, more powerful treatments and refining the current group of known effective treatments is the challenge for the future.

Acupuncture Therapy↗

PubMed1985

Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain.

The effectiveness of spinal manipulation carried out by a non-medical qualified osteopath was compared with that of short-wave diathermy (SWD) and a placebo (detuned SWD) in 109 patients with low back pain. More than half the subjects in each of the 3 treatment groups benefited immediately from therapy. Significant improvements were observed in the 3 groups at the end of 2 weeks' treatment, and these were still apparent at 12 weeks. The outcome of treatment was unrelated to the initial severity or duration of pain or to the trend of pain towards deterioration or improvement. It is, therefore, unlikely that the results simply reflect the natural history of low back pain. Benefits obtained with osteopathy and SWD in this study may have been achieved through a placebo effect.

Adult↗

PubMed1987

A new approach to the treatment of chronic low back pain.

81 patients with chronic low back pain (average duration 10 years) were randomised to two treatment groups. 40 received an empirically devised regimen of forceful spinal manipulation and injections of a dextrose-glycerine-phenol ("proliferant") solution into soft-tissue structures, as part of a programme to decrease pain and disability. The other 41 patients received parallel treatment in which the main differences were less extensive initial local anaesthesia and manipulation, and substitution of saline for proliferant. Neither patients nor assessors knew which treatment had been given. When assessed by disability scores the experimental group had greater improvement than the control group at one (p less than 0.001), three (p less than 0.004), and six (p less than 0.001) months from the end of treatment; at six months an improvement of more than 50% was recorded in 35 of the experimental group versus 16 of the control group and the numbers free from disability were 15 and 4, respectively (p less than 0.003). Visual analogue pain scores and pain diagrams likewise showed significant advantages for the experimental regimen.

Adult↗

PubMed2003

Chiropractic management of Ehlers-Danlos syndrome: a report of two cases.

OBJECTIVE: To discuss 2 patients with Ehlers-Danlos syndrome seeking chiropractic evaluation and management of their disabling musculoskeletal pain and associated disorders. CLINICAL FEATURES: Two disabled patients diagnosed with Ehlers-Danlos syndrome had spinal pain, including neck and back pain, headache, and extremity pain. Commonalities among these 2 cases included abnormal spinal curvatures (kyphosis and scoliosis), joint hypermobility, and tissue fragility. One patient had postsurgical thoracolumbar spinal fusion (T11-sacrum) for scoliosis and osteoporosis. The other patient had moderate anterior head translation. INTERVENTION AND OUTCOME: Both patients were treated with mechanical force and manually assisted spinal adjustments delivered to various spinal segments and extremities utilizing an Activator II Adjusting Instrument and Activator Methods Chiropractic Technique. Patients were also given postural advice, stabilization exercises, and postural corrective exercises, as indicated in Chiropractic BioPhysics Technique protocols. Both patients were able to reduce pain and anti-inflammatory medication usage in association with chiropractic care. Significant improvement in self-reported pain and disability as measured by visual analog score, Oswestry Low-Back Disability Index, and Neck Pain Disability Index were reported, and objective improvements in physical examination and spinal alignment were also observed following chiropractic care. Despite these improvements, work disability status remained unchanged in both patients. CONCLUSION: Chiropractic care may be of benefit to some patients with connective tissue disorders, including Ehlers-Danlos syndrome. Low-force chiropractic adjusting techniques may be a preferred technique of choice in patients with tissue fragility, offering clinicians a viable alternative to traditional chiropractic care in attempting to minimize risks and/or side effects associated with spinal manipulation. Psychosocial issues, including patient desire to return to work, were important factors in work disability status and perceived outcome.

Adult↗

PubMed1999

Spinal pain syndromes: nociceptive, neuropathic, and psychologic mechanisms.

BACKGROUND: Pain continues to be the main symptom reported by patients. Frequently, clinicians incorrectly diagnose patients and resulting treatments are ineffective, which may promote the development of chronic pain. This situation may arise as a result of a lack of clarity in the literature regarding pain syndromes. OBJECTIVE: To discuss the differences between nociceptive, neuropathic, and psychologic induction of pain and provide important clinical correlates to aid in diagnosis and treatment. DATA SOURCES: The data were accumulated over a period of years by reviewing contemporary articles and books and subsequently retrieving relevant papers. Articles also were selected from MEDLINE searches and from manual library searches. DATA SYNTHESIS: Nociceptive pain syndromes are responsible for the majority of pain complaints in clinical practice. Care must be taken to avoid the common mistake of the diagnosis of neuropathic pain, which can lead to inappropriate treatments. CONCLUSION: Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.

Acute Disease↗

PubMedDate not supplied

A review of biomechanics of the central nervous system--Part III: spinal cord stresses from postural loads and their neurologic effects.

OBJECTIVE: To review literature pertaining to neurologic disorders stemming from abnormal postures of the spine. DATA COLLECTION: A hand search of available reference texts and a computer search of literature from Index Medicus sources was performed, with special emphasis placed on spinal cord stresses and strains caused by various postural rotations and translations of the skull, thorax, and pelvis. RESULTS: Spinal postures will often deform the neural elements within the spinal canal. Spinal postures can be broken down into four types of loading: axial, pure bending, torsion, and transverse, which cause normal and shear stresses and strains in the neural tissues and blood vessels. Prolonged stresses and strains in the neural elements cause a multitude of disease processes. CONCLUSION: Four types of postural loads create a variety of stresses and strains in the neural tissue, depending on the exact magnitude and direction of the forces. Transverse loading is the most complex load. The stresses and strains in the neural elements and vascular supply are directly related to the function of the sensory, motor, and autonomic nervous systems. The literature indicates that prolonged loading of the neural tissue may lead to a wide variety of degenerative disorders or symptoms. The most offensive postural loading of the central nervous system and related structures occurs in any procedure or position requiring spinal flexion. Thus flexion traction, rehabilitation positions, exercises, spinal manipulation, and surgical fusions in any position other than lordosis for the cervical and lumbar spines should be questioned.

Biomechanical Phenomena↗

PubMed2000

Complementary and alternative medicine in rheumatology.

Complementary and alternative medicine (CAM) has become an important subject for rheumatologists. This article is an attempt to provide an introduction to this subject. It will provide definitions of, and define the prevalence of, CAM. The emphasis of the article is on evaluating the efficacy of CAM treatment modalities. This is achieved by referring to systematic reviews of clinical trials of acupuncture for low back pain, osteo-arthritis, fibromyalgia, inflammatory rheumatoid disease and neck pain. Further areas addressed in this way are herbal remedies, fish oil and glucosamine. Moreover, massage therapy and spinal manipulation for back pain are discussed. The final sections of this review deal with the safety and cost of CAM. It is concluded that, in view of the popularity of CAM with rheumatological patients, rigorous research into CAM is the best way forward.

Complementary Therapies↗

PubMed1996

To compare the effects of different rates of application of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects.

SUMMARY. The aim of this study was to compare the effects of different rates of application of a commonly used physiotherapeutic spinal manipulative therapy technique on sympathetic function in normal pain-free volunteers. A randomized, repeated measures, double blind, controlled study design was used to investigate the effects of two different rates of a C5 grade III central postero-anterior mobilization technique on skin conductance (SC) and skin temperature (ST) in the distal C6 dermatome of asymptomatic subjects. Sixteen asymptomatic male volunteers participated in the study. Application of a C5 central postero-anterior grade III mobilization at the rate of 2Hz produced significantly greater increases in SC values than that at the rate of 0.5 Hz and control.The results of this study suggest that mobilization with the rate which is commonly used clinically causes a greater increase in sympathetic efferent activity in the upper limb of normal pain-free volunteers than a slower rate. These results may also provide a basis for further investigation into the physiological effects of different rates of mobilization and in particular exploration of the relationship between changes in sympathetic function following mobilization and manipulation-induced analgesia. Copyright 1996 Harcourt Publishers Ltd.

Journal Article↗

PubMed1997

Influence of a cervical mobilization technique on respiratory and cardiovascular function.

SUMMARY. Spinal manipulative therapy techniques are frequently applied by physiotherapists to relieve pain of musculo-skeletal origin and to improve the quality of joint movement in a variety of musculo-skeletal conditions. However, there has been little research into the physiological effects of these techniques, or the mechanisms responsible for these effects. The aim of this study was to establish whether a grade III posteroanterior mobilization technique applied centrally to the cervical spine would affect respiratory and cardiovascular indicators of sympathetic nervous system function in pain-free, normal volunteers. A significant increase in respiratory rate, heart rate, systolic and diastolic blood pressure occurred during application of the technique to C5/6, when compared to the control and placebo conditions. There was little change in any of the measured variables during the placebo condition. This study provides objective evidence that application of this mobilization technique elicits changes in sympathetic nervous system activity distinct from placebo in pain-free individuals. These results provide a basis for further research into the physiological effects of manipulative procedures, and in particular, exploration of the mechanisms responsible for analgesia produced by this method. Copyright 1997 Harcourt Publishers Ltd.

Journal Article↗

PubMed2001

Thoracic disk herniation: a case report.

OBJECTIVE: Thoracic disk herniations are relatively rare events that often mimic other, more serious disorders. This article discusses the case of a patient with thoracic disk herniation who required unusual treatment to aid resolution of her condition. CLINICAL FEATURES: The patient, who had a complicated history of prior lumbar disk surgery, sustained a fall onto her buttocks and developed low back and bilateral leg pain. Initial suspicion was of reinjury of the L5 disk. INTERVENTION AND OUTCOME: Light force spinal manipulation, physical therapies, and eventual cosmetic surgery were able to resolve the condition successfully. CONCLUSIONS: A clinical situation often may require thinking "outside the box" in order for the patient's condition to be resolved. The failure of symptoms to correspond to the suspected condition should increase the suspicion that another problem may be present.

Adult↗

PubMed2001

Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians.

BACKGROUND: Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. OBJECTIVES: To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. METHODS: A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians' practice activities; and low back complaint status at 1 year. RESULTS: Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. CONCLUSIONS: Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.

Adult↗

PubMed1990

Chiropractors for and against vaccines.

The publications of philosophically conservative chiropractors document their allegiance to a posture of hostile opposition to health prevention based upon immunization procedures. The challenge to medical anthropology is to make sense of what seems scientifically senseless. This paper attempts to come to an understanding of this position by tracing professional attitudes which are derived from a history of political and economic conflict with the American medical establishment, which emanate from an explanatory model of disease causation that preserves a nineteenth century monocausal theory, and which reflect a process of cultural schizmogenesis. In preserving these heretical medical beliefs, conservative chiropractors, who are trained in the basic medical sciences, defend themselves by basing their opposition to immunization upon imperfections in vaccines that relate to the efficacy, safety and necessity of immunizations. Further, they persist in a belief that chiropractic spinal manipulation provides an alternative method for achieving immune status. This belief has not been subjected to testing in clinical trials or laboratory experiments, and thus becomes a matter of belief rather than of scientific verity. A refusal to advocate or submit to vaccines serves conservative chiropractors as an understandable cultural symbol, but it is a symbol with sinister health costs to those who translate it into non-immune status in a world otherwise still hostage to disease-producing organisms.

Attitude of Health Personnel↗

PubMed1997

Use of acupuncture by American physicians.

OBJECTIVES: Little is known about the characteristics of American physicians who currently practice acupuncture. We asked: (1) Do the demographics of physicians practicing acupuncture differ from the general physician population? (2) Do these physicians use or endorse other alternative therapies? (3) For which conditions is acupuncture most commonly used? (4) For which conditions is acupuncture perceived to be most efficacious? DESIGN: Mailed survey of physicians who incorporate acupuncture into their practice. PARTICIPANTS: Membership of the American Academy of Medical Acupuncture (AAMA). OUTCOME MEASURES: Demographic information regarding physicians and practice characteristics; specific illnesses treated, and perceived efficacy; use of other complementary modalities; personal reasons for practicing acupuncture. RESULTS: Compared with national data, respondents were more likely to be nonspecialists, in private practice, and age 35 to 54. There was an equal proportion of men and women. Most had been doing acupuncture for < 5 years; most use it on < 25% of their patients. Endorsement or use of other complementary methods (spinal manipulation, herbal medicine, supplements, homeopathy) was common. Acupuncture was more commonly used for pain conditions than general medical problems or addiction management. Reasons for use included: efficacy of the technique, an alternative in cases of inadequacy of standard medical approach, and a multidimensional approach to health care. CONCLUSIONS: Physicians surveyed in this study who incorporate acupuncture into their practice do so mainly to treat pain problems. They are more likely to be in the 35 to 54 age group, nonspecialists, and in private practice when compared with national averages. These physicians are also more likely to use or endorse other complementary modalities.

Acupuncture Therapy↗

PubMed1996

The use of a circumferential cathode improves amplitude of intraoperative electrical transcranial myogenic motor evoked responses.

Measurement of motor evoked responses to transcranial electrical stimulation (tc-MER) is a technique for intraoperative monitoring of motor pathways. Since most anesthetics significantly reduce motoneuronal excitability, optimal stimulation paradigms should be sought. We compared the efficiency of stimulus delivery using two different configurations of the cathode component of the stimulating electrode pair (circumferential: Fz, F3, F4, A1, and A2 versus a single cathode at Fz). The anode was positioned at Cz with both cathode configurations. Fourteen neurologically normal patients undergoing spinal surgery were anesthetized with sufentanil-N2O-ketamine. Partial neuromuscular blockade (single twitch height 25%) was maintained with vecuronium. Compound action potentials to transcranial stimulation with both cathode configurations were recorded from the tibialis anterior muscle. All recordings were completed before spinal manipulation. The median amplitude response using the Fz cathode configuration was 256 microV (10th-90th percentiles: 50-641 microV). With the circumferential cathode configuration, tc-MER amplitude increased to 281 (87-1479) microV (P < 0.01). There was no significant difference in onset latency between electrode configurations. The observed tc-MER amplitude augmentation with the use of a circumferential cathode might allow tc-MER monitoring in those patients who do not have sufficiently reproducible responses when a single cathode is used. A possible explanation is that the circumferential cathode alters the direction of the electrical currents in the cortex, resulting in more efficient depolarization of cortical motor neurons.

Action Potentials↗

PubMed1994

Epidemiology, etiology, diagnostic evaluation, and therapy of low back pain.

New data concerning the epidemiology, etiology, diagnostic evaluation, and treatment of low back pain have been reported over the past year. Patients who have a longer period of pain during the initial episode of pain are at greatest risk of recurrence of pain. Abnormalities of fibrinolytic activity may have predictive value in identifying patients who are at risk for a poor outcome from surgery. Scheuermann's kyphosis is a slowly progressive illness that rarely requires surgical stabilization of the spine. Contrast-enhanced magnetic resonance imaging may be able to identify symptomatic spinal nerve roots. Radiculopathy associated with disk herniations resolves frequently without surgical intervention. Large disk herniations may resolve spontaneously and do not require surgery. Spinal manipulation may be helpful on a short-term basis to decrease back pain but may be associated with occasional serious complications including cauda equina compression.

Humans↗