Applying the findings of new studies to clinical practice in order to improve patient outcomes is an ever-evolving process. In the past few years, a profusion of research makes it abundantly clear that in many cases, spinal adjustments should not be done in isolation, but in conjunction with exercise training.
Such an active chiropractic care plan empowers patients, increases their confidence, helps restore their function and expands their activity tolerance, giving them the gift of a greatly improved quality of life.
This paper examines some of the recent research to clarify the current basis for integrating spinal adjustments and exercise training into an active chiropractic management plan. First, let's briefly review the natural history of back and neck problems to better understand the role of active chiropractic care.
The predominant model of the 1990s, which described back and neck problems as self-limited conditions with a very good natural history, was both simplistic and mistaken. The state of the science a decade ago concluded 80 percent of patients return to work within one month and 90 percent within two months. Only short-term care was necessary.1 Care beyond six weeks was not considered usual or customary. This model remains a frequent source of denial of care for many chiropractic claims today.
In 2000, there was a marked change in paradigm, based on emerging research, that made it increasingly clear the actual course of back and neck problems was more complicated and prolonged. Two-thirds of the people who have experience back pain in the past can be expected to have some symptoms every year.2 The once-clear dichotomy between acute vs. chronic pain was being replaced by an understanding that the natural history of these problems, even if appropriately treated, was more typically a recurrent or intermittent syndrome that erupts periodically over the course of a lifetime.3 In other words, low back pain is a chronic problem with intermittent exacerbations analogous to asthma, rather than an acute disease that can be cured.4
Similarly, it was found that of the 54 percent of adults who reported suffering neck pain in the previous six months, only 36.6 percent reported their neck pain had resolved at one-year follow-up.5 The authors concluded that neck and back pain run similar courses, characterized by periods of remissions and exacerbations. Both neck and back pain represent important chronic health conditions. These neuromusculoskeletal problems are recurrent and might well encompass a patient's life history. Therefore, seen from the perspective of the sufferer's lifetime, the logic of self-management is overwhelming.6
This summary of important papers captures the basis for the radical paradigm shift away from thinking about low back pain as a biomedical injury to viewing it as a multifactorial biopsychosocial pain syndrome.7 One major transition has been away from pain relief as the primary goal of care and toward reactivation and restoration of function.
Clinicians should strive to get patients to become active in their own self-care program, to shift them from being pain avoiders to pain managers.8 Unless persistent fear of pain is specifically recognized and treated, it leads to pain avoidance, disuse and passive coping. A goal for managing fearful patients is to increase their confidence in normal activities and exercises. Liebenson emphasizes that how well patients do depends more on what they do rather than what is done to them.8
Other researchers echo this call to enlist patients as active participants in their recovery and maintenance of function. In fact, a study in 2005 concluded that a passive coping style associated with fear-avoidance beliefs, inactivity and bed rest was a strong, independent risk factor for disabling neck and/or low back pain.9 Those with moderate to high levels of passive coping strategies were at a greater-than-fivefold increased risk of developing disabling neck pain and/or back pain.
For chiropractors, translating this information into a practical, active patient-care program is critical in order to achieve maximal short- and long-term benefits. Current review articles consistently conclude that a best-evidence synthesis suggests treatments involving manual therapy (manipulation and/or mobilization) and exercise are more effective than alternative strategies for patients with neck pain.10 A 2006 CCGPP chiropractic best-practices review concluded the use of exercise in conjunction with manipulation is likely to speed and improve outcomes, as well as minimize episodic recurrence.11 A major longitudinal study in 2006 concluded manipulation, mobilization and spinal-stabilization exercise training are effective in pain reduction, but manual therapy fails to show any consistent improvement in disability or impairment.12 The results suggest manipulation and mobilization should not be used in isolation.
Another major review stated spinal manipulation and/or mobilization plus exercise demonstrates long-term benefit for pain relief, functional improvement and global perceived effect for subacute/chronic mechanical neck disorders with or without headache.13 However, the authors noted evidence did not favor spinal manipulation or mobilization done alone or in combination with various physical modalities.
A series of recent studies have found spinal manipulation provides additional benefit to "best care" in general practice. In a major longitudinal study of more than 1,300 patients with low back pain, the authors conclude both spinal manipulation alone and spinal manipulation followed by exercise provide cost-effective additions in "best care" general practice.14 Another benchmark study from Norway found that patients on sick leave for more than eight weeks but less than six months for low back problems demonstrated significantly better outcomes in terms of pain reduction, disability and return-to-work rates if they received spinal manipulation and mobilization in addition to general and stabilizing exercises.15 In fact, there was 48 percent less pain, 47 percent less disability and an incredible 82 percent better return-to-work rate at six months follow-up in those receiving the combination of care.
In total, the articles reviewed in this paper point clearly and indisputably toward an integrated method of care that successfully combines spinal manipulation and exercise training in order to produce large and enduring changes in patients' health status, pain, function and quality of life. Patients need to play an active role in their care. Reactivation, a renewed sense of self-reliance and an ability to perform activities of daily living without undue fear or risk of injury are primary goals. An understanding of the issues discussed above allows the chiropractor to offer with confidence an effective means to greatly reduce patients' pain and improve their quality of life.
References
- Waddell, et al. Clinical Guidelines for the Management of Acute Low Back Pain. Royal College of General Practitioners 1996:2.6
- McGorry, et al. The relation between pain intensity, disability, and the episodic nature of chronic and recurrent low back pain. Spine, 2000;25(7):834-41.
- Borkan, et al. Advances in the field of low back pain in primary care. A report from the Fourth International Forum. Spine, 2002;27(5):E128-32.
- Deyo, Weinstein. Low back pain. NEJM, 2001;344(5):363-9.
- Cote, et al. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain, 2004;112(3):267-73.
- McKenzie. "The Myth of Short-Term Acute Low Back Pain." New Zealand Family Practitioner, 2005;32(2):125-6.
- Borkan, et al. Advances in the field of low back pain in primary care. A report from the Fourth International Forum. Spine, 2002;27(5):E128-32.
- Liebenson C. Active Self-Care: Functional Reactivation for Spine Pain Patients. In: Rehabilitation of the Spine, 2nd Edition. Baltimore: Lippincott Williams & Wilkins, 2007:295-329.
- Mercado, et al. Passive coping is a risk factor for disabling neck or low back pain. Pain, 2005;117:51-7.
- Cassidy, et al. "What Do We Know About Diagnosis, Relative Risks & Benefits of Nonsurgical Management of Patients With Neck Pain?" The Bone & Joint Decade Task Force on Neck Pain and Its Associated Disorders, 2007.
- Chiropractic Best Practices: A Systematic Review by the Research Commission of the Council on Chiropractic Guidelines and Practice Parameters. Draft document, 2006.
- Goldby, et al. A randomized controlled trial investigating the efficiency of musculoskeletal physiotherapy on chronic low back disorder. Spine, 2006;31:1083-93.
- Gross, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine, 2004;29(14):1541-8.
- U.K. BEAM (Back, Exercise and Manipulation) Trial Team. United Kingdom Back Pain Exercise and Manipulation randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ, Dec. 11, 2004;329:1381.
- Aure, Vasseljen. Manual and exercise therapy in CLBP patients. Spine, 2003;28(6):525-31.
