The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain.

BACKGROUND: Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered. METHODS: We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain. RESULTS: The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate. CONCLUSIONS: This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

Beliefs, perceptions and practices of chiropractors and patients about mitigation strategies for benign adverse events after spinal manipulation therapy.

BACKGROUND: Approximately 50% of patients who receive spinal manipulative therapy (SMT) experience some kind of adverse event (AE), typically benign and transient in nature. Regardless of their severity, mitigating benign AEs is important to improve patient experience and quality of care. The aim of this study was to identify beliefs, perceptions and practices of chiropractors and patients regarding benign AEs post-SMT and potential strategies to mitigate them. METHODS: Clinicians and patients from two chiropractic teaching clinics were invited to respond to an 11-question survey exploring their beliefs, perceptions and practices regarding benign AEs post-SMT and strategies to mitigate them. Responses were analyzed using descriptive statistics. RESULTS: A total of 39 clinicians (67% response rate) and 203 patients (82.9% response rate) completed the survey. Most clinicians (97%) believed benign AEs occur, and 82% reported their own patients have experienced one. For patients, 55% reported experiencing benign AEs post-SMT, with the most common symptoms being pain/soreness, headache and stiffness. While most clinicians (61.5%) reported trying a mitigation strategy with their patients, only 21.2% of patients perceived their clinicians had tried any mitigation strategy. Clinicians perceived that patient education is most likely to mitigate benign AEs, followed by soft tissue therapy and/or icing after SMT. Patients perceived stretching was most likely to mitigate benign AEs, followed by education and/or massage. CONCLUSIONS: This is the first study comparing beliefs, perceptions and practices from clinicians and patients regarding benign AEs post-SMT and strategies to mitigate them. This study provides an important step towards identifying the best strategies to improve patient safety and improve quality of care.

The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects.

BACKGROUND: The mechanisms thorough which spinal manipulative therapy (SMT) exerts clinical effects are not established. A prior study has suggested a dorsal horn modulated effect; however, the role of subject expectation was not considered. The purpose of the current study was to determine the effect of subject expectation on hypoalgesia associated with SMT. METHODS: Sixty healthy subjects agreed to participate and underwent quantitative sensory testing (QST) to their leg and low back. Next, participants were randomly assigned to receive a positive, negative, or neutral expectation instructional set regarding the effects of a specific SMT technique on pain perception. Following the instructional set, all subjects received SMT and underwent repeat QST. RESULTS: No interaction (p = 0.38) between group assignment and pain response was present in the lower extremity following SMT; however, a main effect (p < 0.01) for hypoalgesia was present. A significant interaction was present between change in pain perception and group assignment in the low back (p = 0.01) with participants receiving a negative expectation instructional set demonstrating significant hyperalgesia (p < 0.01). CONCLUSION: The current study replicates prior findings of c- fiber mediated hypoalgesia in the lower extremity following SMT and this occurred regardless of expectation. A significant increase in pain perception occurred following SMT in the low back of participants receiving negative expectation suggesting a potential influence of expectation on SMT induced hypoalgesia in the body area to which the expectation is directed.

Brain Mechanisms of Anticipated Painful Movements and Their Modulation by Manual Therapy in Chronic Low Back Pain.

Heightened anticipation and fear of movement-related pain has been linked to detrimental fear-avoidance behavior in chronic low back pain (cLBP). Spinal manipulative therapy (SMT) has been proposed to work partly by exposing patients to nonharmful but forceful mobilization of the painful joint, thereby disrupting the relationship among pain anticipation, fear, and movement. Here, we investigated the brain processes underpinning pain anticipation and fear of movement in cLBP, and their modulation by SMT, using functional magnetic resonance imaging. Fifteen cLBP patients and 16 healthy control (HC) subjects were scanned while observing and rating video clips depicting back-straining or neutral physical exercises, which they knew they would have to perform at the end of the visit. This task was repeated after a single session of spinal manipulation (cLBP and HC group) or mobilization (cLBP group only), in separate visits. Compared with HC subjects, cLBP patients reported higher expected pain and fear of performing the observed exercises. These ratings, along with clinical pain, were reduced by SMT. Moreover, cLBP, relative to HC subjects, demonstrated higher blood oxygen level-dependent signal in brain circuitry that has previously been implicated in salience, social cognition, and mentalizing, while observing back straining compared with neutral exercises. The engagement of this circuitry was reduced after SMT, and especially the spinal manipulation session, proportionally to the magnitude of SMT-induced reduction in anticipated pain and fear. This study sheds light on the brain processing of anticipated pain and fear of back-straining movement in cLBP, and suggests that SMT may reduce cognitive and affective-motivational aspects of fear-avoidance behavior, along with corresponding brain processes. PERSPECTIVE: This study of cLBP patients investigated how SMT affects clinical pain, expected pain, and fear of physical exercises. The results indicate that one of the mechanisms of SMT may be to reduce pain expectancy, fear of movement, and associated brain responses.

Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials.

BACKGROUND: The most important risk factors for back and neck pain are psychosocial. Nevertheless, systematic reviews of spinal manipulation have concentrated on pain and spine related disability, and ignored psychological outcomes. OBJECTIVE: To assess whether spinal manipulation was effective in improving psychological outcome. DESIGN: Systematic review of randomised controlled trials (RCTs). METHODS: RCTs were identified by searching Medline, CINAHL, Embase, CENTRAL, AMED, PsycINFO until November 2005. Trials reporting psychological outcomes including the mental health components of generic outcomes were extracted, and combined where appropriate in meta-analyses. RESULTS: One hundred and twenty nine RCTs of spinal manipulation were identified; 12 had adequately reported psychological outcomes. Six trials with a verbal intervention comparator were combined in a meta-analysis, and found a mean benefit from spinal manipulation equivalent to 0.34 of the population standard deviation (S.D.) [95% confidence interval (CI) 0.23-0.45] at 1-5 months; 0.27 of the S.D. [95% CI 0.14-0.40] at 6-12 months. Eight trials with a physical treatment comparator were combined in a meta-analysis and found a mean benefit of 0.13 of the S.D. [95% CI 0.01-0.24] in favour of manipulation at 1-5 months; 0.11 of the S.D. [95% CI -0.02 to 0.25] at 6-12 months. CONCLUSIONS: There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.

What do patients value about spinal manipulation and home exercise for back-related leg pain? A qualitative study within a controlled clinical trial.

BACKGROUND: Patient perceptions may influence the effectiveness and utilization of healthcare interventions, particularly for complex health conditions such as sciatica or back-related leg pain (BRLP). OBJECTIVES: To explore BRLP patients' perceptions of spinal manipulative therapy (SMT) and home exercise with advice (HEA). DESIGN: Qualitative study in a controlled clinical trial. METHOD: Semi-structured interviews conducted after 12 weeks of treatment asked participants about satisfaction with care and whether treatment was worthwhile. An interdisciplinary research team conducted content analysis using qualitative data analysis software to identify and summarize themes. RESULTS: Of 192 trial participants, 174 (91%) completed interviews (66% female, age 57.0 ± 11.5 years). Participants identified interactions with providers and staff, perceived treatment effects, and information as key contributors to both their satisfaction and the worthwhile nature of treatment. HEA was liked for its convenience and ability to foster an exercise habit. SMT was liked for specific aspects of the modality (e.g. manipulation, stretching) and provider competency. Most participants reported no dislikes for SMT or HEA, but some noted the dose/time commitment for SMT and discipline of HEA as least liked aspects of the interventions. CONCLUSIONS: The quality of patient-provider interactions, perceived treatment effects, and information sharing influenced BRLP patients' satisfaction with care. Qualitative research describing patients' preferences can facilitate translation of study findings into practice and allow clinicians to tailor treatments to facilitate compliance and satisfaction with care.

Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial.

BACKGROUND: Three different types of manual therapy techniques for patients with neck pain and relationship with psychological factors has not been evaluated. AIM: To compare the effectiveness high velocity and low amplitude (HVLA) manipulation vs. posteroanterior mobilization (PA mob) vs. sustain appophyseal natural glide (SNAG) in the management of patients with neck pain and to evaluate the interaction with psychological factors. STUDY DESING: Randomized clinical trial. SETTING: Primary Health Care Center. POPULATION: Patients with history of chronic neck pain over the last 3 months were recruited. METHODS: Patients were randomly assigned to receive treatment with HVLA (N.=15), with PA mob (N.=16) or with SNAG (N.=17). One session was applied. Pain intensity of neck pain, pressure pain threshold over processus spinosus of C2 (PPT_C2) and cervical range of motion (CROM) were measured pre- and post-intervention. Pain catastrophizing, depression, anxiety and kinesiophobia were assessed in baseline. ANOVAs were performed, with main effects, two-way (treatment x time) and three-way interactions (treatment x psychological variable x time) were examined. RESULTS: Fourthy-eight patients (mean±SD age, 36.5±8.7 years; 87.5% female). A significant interaction treatment x time was observed for VAS-rest in HVLA and AP mob groups (P<0.05). With more pain relief to HVLA and AP mob groups than SNAG groups but all groups improve the same in CROM. Also, a significant three-way treatment x anxiety x time interaction for VAS in Flexion/Extension was identified (P<0.01), and a trend toward significance was observed for the three way treatment x anxiety x time interaction, with respect to CROM in Lateral-Flexion movement (P<0.05). CONCLUSION: The results suggest that an HVLA and PA mob groups relieved pain at rest more than SNAG in patients with Neck pain. Among psychological factors, only trait anxiety seems interact with Manual therapy, mainly high anxiety conditions interact with the Mobilization and SNAG effects but under low anxiety conditions interact with the HVLA effects. Significant mean differences can be observed both in VAS in Flexion/Extension and in CROM in lateral-flexion movement when using mobilization under high anxiety conditions CLINICAL REHABILITATION IMPACT: The findings provide preliminary evidence to support that three different techniques have similar immediate effects over neck pain and while under high anxiety levels a better outcome is expected after mobilization intervention, under low anxiety levels a better prognosis is expected after manipulation and SNAG intervention.