Long-term trajectories of patients with neck pain and low back pain presenting to chiropractic care: A latent class growth analysis.

BACKGROUND: Information on the course of neck pain (NP) and low back pain (LBP) typically relies on data collected at few time intervals during a period of up to 1 year. METHODS: In this prospective, multicentre practice-based cohort study, patients consulting a chiropractor responded weekly for 52 weeks to text messages on their cell phones. Data from 448 patients (153 NP, 295 LBP) who had returned at least one set of answers in the first 26 weeks were used. Outcome measures were pain intensity (VAS) and functional outcome, assessed using four different questions: pain intensity, limitation in activities of daily living (ADL), number of days with pain in the previous week and number of days limited in ADL. Distinct patterns of pain were analysed with quadratic latent class growth analysis. RESULTS: The final model was a 4-class model for NP and LBP. The 'recovering from mild baseline pain' is most common (76.3% of NP patients/58.3% of LBP patients) followed by the 'recovering from severe baseline pain' class (16.3% NP/29.8% LBP). They follow similar trajectories when considered over a period of 6 months. Pain at baseline, duration of complaints, functional status, limitations in ADL and the score on psychosocial scales were the variables that most contributed to distinguish between groups. CONCLUSIONS: Most patients with NP or LBP presenting in chiropractic care show a trajectory of symptoms characterized by persistent or fluctuating pain of low or medium intensity. Only a minority either experience a rapid complete recovery or develop chronic severe pain. SIGNIFICANCE: Ninety percentage of patients with neck pain or low back pain presenting to chiropractors have a 30% improvement within 6 weeks and then show a trajectory of symptoms characterized by persistent or fluctuating pain of low or medium intensity. Only a minority either experience a rapid complete recovery or develop chronic severe pain.

Cost-effectiveness of manual therapy versus physiotherapy in patients with sub-acute and chronic neck pain: a randomised controlled trial.

PURPOSE: To evaluate the cost-effectiveness of manual therapy according to the Utrecht School (MTU) in comparison with physiotherapy (PT) in sub-acute and chronic non-specific neck pain patients from a societal perspective. METHODS: An economic evaluation was conducted alongside a 52-week randomized controlled trial, in which 90 patients were randomized to the MTU group and 91 to the PT group. Clinical outcomes included perceived recovery (yes/no), functional status (continuous and yes/no), and quality-adjusted life-years (QALYs). Costs were measured from a societal perspective using self-reported questionnaires. Missing data were imputed using multiple imputation. To estimate statistical uncertainty, bootstrapping techniques were used. RESULTS: After 52 weeks, there were no significant between-group differences in clinical outcomes. During follow-up, intervention costs (ß:€-32; 95 %CI: -54 to -10) and healthcare costs (ß:€-126; 95 %CI: -235 to -32) were significantly lower in the MTU group than in the PT group, whereas unpaid productivity costs were significantly higher (ß:€186; 95 %CI:19-557). Societal costs did not significantly differ between groups (ß:€-96; 95 %CI:-1975-2022). For QALYs and functional status (yes/no), the maximum probability of MTU being cost-effective in comparison with PT was low (≤0.54). For perceived recovery (yes/no) and functional status (continuous), a large amount of money must be paid per additional unit of effect to reach a reasonable probability of cost-effectiveness. CONCLUSIONS: From a societal perspective, MTU was not cost-effective in comparison with PT in patients with sub-acute and chronic non-specific neck pain for perceived recovery, functional status, and QALYs. As no clear total societal cost and effect differences were found between MTU and PT, the decision about what intervention to administer, reimburse, and/or implement can be based on the preferences of the patient and the decision-maker at hand. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00713843.

Somatization is associated with worse outcome in a chiropractic patient population with neck pain and low back pain.

AIM: To determine if psychosocial factors are associated with outcome in patients with neck pain or low back pain. METHODS: In a prospective, multi-center chiropractic practice-based cohort study in Belgium and The Netherlands, 917 patients, of which 326 with neck pain and 591 with low back pain, completed self-administered questionnaires at baseline, following the second visit, and at 1, 3, 6 and 12 months. Psychosocial factors assessed at baseline were: distress, depression, anxiety and somatization via the Four Dimensional Symptom Questionnaire, patient's beliefs regarding the effect of physical activity and work on their complaint via the Fear Avoidance Beliefs Questionnaire, and social support via the Feij social support scale. Primary outcome measures were perceived recovery, pain intensity, and functional status which was measured with the Neck Disability Index and Oswestry Disability Index. A univariable regression analysis to estimate the relation between each psychological variable and outcome was followed by a multivariable multilevel regression analysis. RESULTS: There were no differences in baseline patient characteristics between the patient population from Belgium and the Netherlands. Somatization scores are consistently associated with perceived recovery, functional status and pain for both neck pain and low-back pain. Depression was associated with poorer functioning in patients with LBP. There was a small association between fear and function and pain for patients with neck pain or low-back pain. CONCLUSION: Somatization was the only variable consistently found to be associated with diminished perceived recovery, higher degree of neck or low back disability, and increased neck or low back pain.

Cervical manipulation to a patient with a history of traumatically induced dissection of the internal carotid artery: a case report and review of the literature on recurrent dissections.

OBJECTIVE: To describe the use of rotational cervical manipulation in treating a patient who had undergone a traumatically induced dissection of the internal carotid artery and to review the literature on recurrent cervical artery dissections. CLINICAL FEATURES: A 21-year-old woman with hemiparesis from an internal carotid artery dissection that occurred as the result of a motor vehicle accident had neck pain and headaches. Moderate range of motion restrictions in the neck were present along with articular restrictions to movement palpation. INTERVENTION AND OUTCOME: After a year of soft-tissue treatment, we obtained detailed, informed consent from the patient to attempt diversified manipulation to the neck. The patient described greater and more immediate relief and longer pain-free periods than could be achieved by soft-tissue treatment alone. CONCLUSION: Patients with previous cervical artery dissections may present with unrelated neck pain and headaches and request treatment. In selected cases, with complete informed consent, manipulation of the neck may relieve these symptoms. A review of published case reports on recurrent dissections suggests that trauma is not a significant factor in the second dissection. Care must be taken in extrapolating the results from this case to any other patient with a history of cervical artery dissection.

Chiropractic patients in the Netherlands: a descriptive study.

BACKGROUND: Despite the worldwide popularity of chiropractic, there is still relatively little known about the patients who visit chiropractors in the Netherlands and other European countries. OBJECTIVE: To describe in-depth the patient population of new patients to chiropractors in the Netherlands. DESIGN: Study population consisted of 10 consecutive new patients per participating chiropractor. A retrospective-type questionnaire was used. SETTING: Private practice. OUTCOME MEASURES: Mode of referral, area, and nature of the complaints; related to the chief complaint: previous treatments, examinations, type of referral, days lost at work, level of pain, and treatment expectations. RESULTS: Of the 130 chiropractors registered with the Netherlands Chiropractors'Association, 94 chiropractors(78%) participated. Eight hundred thirty-three patients (89%) returned questionnaires. By far, the greatest reason that patients visit chiropractors in the Netherlands is for neuromusculoskeletal (NMS) complaints. At the time of examination, 86% of the patients had spinal-related complaints, of which 12% involved multiple areas of the spine. Non-NMS complaints are minimal (<2%). Seventy-seven percent of patients with NMS complaints have chronic complaints (>12 weeks). Three-quarters of these patients have undergone previous conservative therapy for their complaint, which includes physical and manual therapy, postural correction, and exercise therapy. Despite the chronic nature of their complaints, patients have high expectations that their treatment will be effective. CONCLUSIONS: Most patients who see chiropractors in the Netherlands have chronic NMS-related complaints. Chiropractors are not a part of the normal referral system in this country, with the result that the patients have rather long histories, including previous evaluations by medical specialists and other previous forms of (conservative) care.

The precipitation or aggravation of musculoskeletal pain in patients receiving spinal manipulative therapy.

Complications of chiropractic adjustments or manipulations can be considered either benign or catastrophic. Although there are a number of papers on the more severe complications, the precipitation of benign and often reversible symptoms following chiropractic care has been largely ignored in the literature. This article discusses six cases where pain symptomatology was either aggravated or precipitated at a location other than the presenting complaints. Two potential causes of these complications are discussed: a) the use of long levers, which can exert force on nonsymptomatic joints in the extremities, and b) the manipulation of biomechanically dysfunctional but asymptomatic joints.

Cauda equina syndrome in patients undergoing manipulation of the lumbar spine.

Cauda equina syndrome has been implicated as a potential complication of spinal manipulation. A review of the literature from 1911 to 1989 revealed ten reported cases of cauda equina syndrome in patients undergoing manipulation without anesthesia. This article presents three new cases where a temporal association was found between the onset of cauda equina symptoms and lumbar manipulation. The type of manipulation administered and the relationship between the treatment and symptoms is reviewed. In each of these cases both the chiropractic practitioner and the emergency room physician failed to comprehend the nature of the problem and take appropriate action. As a consequence, the patients went untreated for several days. This may have led to residual symptomatology. It is concluded that patients who present with bowel or bladder disturbances, leg weakness, or rectal and genital sensory changes after manipulation, be recognized as experiencing a cauda equina syndrome.

Compression fractures in patients undergoing spinal manipulative therapy.

Increasing numbers of elderly patients are currently seeking chiropractic care. One condition commonly seen in the elderly is osteoporosis of the spine, which carries with it the risk of compression fractures. We present four cases in which patients were noted to have compression fractures following chiropractic adjustments. In each of these cases, serious questions are raised concerning the relationship between the adjustment and the occurrence of fracture. What is clear is that failure to diagnose a compression fracture, together with the application of adjustment into the area of fracture, can increase symptoms and prolong disability. It is recommended that patients with osteoporosis who have suffered a fall or injury be X rayed before treatment is given. In addition, special care should be exercised in elderly patients with osteoporosis.

PET scan investigations of Huntington's disease: cerebral metabolic correlates of neurological features and functional decline.

Fifteen drug-free patients with early to midstage Huntington's disease were evaluated with quantitative neurological examinations, scales for functional capacity, computed tomographic (CT) scans, and positron emission tomographic (PET) scans of 18F-2-fluoro-2-deoxyglucose (18F-FDG) uptake. All patients had abnormal indices of caudate metabolism on PET scanning, whereas in patients with early disease indices of putamen metabolism and CT measures of caudate atrophy were normal. Indices of caudate metabolism correlated highly with the patients' overall functional capacity (r = 0.906; p less than 0.001) and bradykinesia/rigidity (r = -0.692; p less than 0.01). Indices of putamen metabolism correlated highly with motor functions: chorea (r = -0.841; p less than 0.01), oculomotor abnormalities (r = -0.849; p less than 0.01), and fine motor coordination (r = -0.866; p less than 0.01). Indices of thalamic metabolism correlated positively with dystonia (r = 0.559; p less than 0.05). The data suggest that PET scanning with 18F-FDG is a sensitive measure of brain dysfunction in Huntington's disease and that basal ganglia metabolism is highly correlated with the overall functional capacity of individual patients and with the degree of their motor abnormalities.