|Hospital-Based Standardized Spine Care Pathway (Including Chiropractic) Yields Excellent Results
Paskowski I, Schneider M, Stevans J, Ventura JM, Justice BD. A hospital-based standardized spine care pathway: report of a multidisciplinary, evidence-based process. Journal of Manipulative and Physiological Therapeutics. Feb 2011;34(2):98-106.
OBJECTIVE: A health care facility (Jordan Hospital) implemented a multidimensional spine care pathway (SCP) using the National Center for Quality Assurance (NCQA) Back Pain Recognition Program (BPRP) as its foundation. The purpose of this report is to describe the implementation and results of a multidisciplinary, evidence-based, standardized process to improve clinical outcomes and reduce costs associated with treatment and diagnostic testing. METHODS: A standardized SCP was developed to improve the quality of back pain care. The NCQA BPRP provided the framework for the SCP to determine the standard of quality care delivered. Patients were triaged, and suitable patients were categorized into 1 of 5 classifications based upon history and examination, directional exercise flexion or “extension biases,” spinal manipulation, traction, or spinal stabilization exercises. RESULTS: The findings for 518 consecutive patients were included. One hundred sixteen patients were seen once and triaged to specialty care; 7% of patients received magnetic resonance imagings. Four hundred thirty-two patients (83%) were classified and treated by doctors of chiropractic and/or physical therapists. Results for the patients treated by doctors of chiropractic were mean of 5.2 visits, mean cost per case of $302, mean intake pain rating score of 6.2 of 10, and mean discharge score of 1.9 of 10; 95% of patients rated their care as “excellent.” CONCLUSIONS: By adopting the NCQA BPRP as an SCP, training physicians in this SCP, and using a back pain classification, Jordan Hospital Spine Care demonstrated the quality and value of care rendered to a population of patients. This was accomplished with a relatively low cost and with high patient satisfaction.
Both Exercise and Spinal Manipulation are
Chronic Low Back Pain
Bronfort G, Maiers MJ, Evans RL, et al. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. The Spine Journal: official journal of the North American Spine Society. May 27 2011.
BACKGROUND CONTEXT: Several conservative therapies have been shown to be beneficial in the treatment of chronic low back pain (CLBP), including different forms of exercise and spinal manipulative therapy (SMT). The efficacy of less time-consuming and less costly self-care interventions, for example, home exercise, remains inconclusive in CLBP populations. PURPOSE: The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP. STUDY DESIGN/SETTING: An observer-blinded and mixed-method randomized clinical trial conducted in a university research clinic in Bloomington, MN, USA. PATIENT SAMPLE: Individuals, 18 to 65 years of age, who had a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain to the lower extremity were included in this trial. OUTCOME MEASURES: Patient-rated outcomes were pain, disability, general health status, medication use, global improvement, and satisfaction. Trunk muscle endurance and strength were assessed by blinded examiners, and qualitative interviews were performed at the end of the 12-week treatment phase. METHODS: This prospective randomized clinical trial examined the short- (12 weeks) and long-term (52 weeks) relative efficacy of high-dose, supervised low-tech trunk exercise, chiropractic SMT, and a short course of home exercise and self-care advice for the treatment of LBP of at least 6-week duration. The study was approved by local institutional review boards. RESULTS: A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term. CONCLUSIONS: For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favored the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.
Worksite Chair Massage Eases Musculoskeletal
Improves Range of Motion
Sisko PK, Videmsek M, Karpljuk D. The effect of a corporate chair massage program on musculoskeletal discomfort and joint range of motion in office workers. J Altern Complement Med. Jul 2011;17(7):617-622.
Objectives: The aim of this study was to determine the effects of workplace manual technique interventions for female participants on the degree of joint range of motion and on the level of musculoskeletal ache, pain, or discomfort experienced when performing workplace responsibilities. Design: Nineteen (19) female volunteers were given chair massages on-site twice per week for 1 month. Settings/location: Participants included individuals in administration and management from a company in Ljubljana, Slovenia. Subjects: A total of 19 female volunteers 40-54 years of age enrolled for this study. Fifteen (15) of them completed all measurements. Interventions: The Cornell Musculoskeletal Discomfort Questionnaire was used, and range-of-motion measurements in degrees were taken. Outcome measures: Subjects completed a series of self-report questionnaires that asked for information concerning musculoskeletal discomfort for the neck, upper back, and lower back in the form of a body diagram. A range-of-motion test (to compare the change in joint angles) was performed with a goniometer to assess cervical lateral flexion, cervical flexion, cervical extension, lumbar flexion, and lumbar extension. Results: Between the first and the last measurements, a significant difference (p<0.05) was found in increased range of motion for cervical lateral flexion (28.8%). Wilcoxon signed rank test showed a significant increase (p<0.05) in range of motion for cervical lateral flexion (42.4+/-6.3 to 48.3+/-7.3), cervical extension (63.2+/-12.4 to 67.2+/-12.3), and a significant decrease (p<0.05) in the Cornell Musculoskeletal Discomfort Questionnaire values for the neck (2.7+/-0.8 to 1.9+/-0.6) and the upper back (2.7+/-0.7 to 2.2+/-0.8) from the phase 2 to 3. Significant reductions were also shown in the Cornell Musculoskeletal Discomfort Questionnaire values for the neck (2.8+/-0.8 to 1.9+/-0.6) and the upper back (2.7+/-0.8 to 2.2+/-0.8) from the phase 1 to 3. Conclusions: On-site massage sessions twice per week for 1 month are the most effective interventions (compared to one session or no massage intervention) for decreasing the duration of musculoskeletal ache, pain, or discomfort and for increasing range of motion.
Massage Therapy Helps Chronic Lower Back Pain
Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Annals of Internal Medicine. Jul 5 2011;155(1):1-9.
Background: Few studies have evaluated the effectiveness of massage for chronic low back pain. Objective: To compare the effectiveness of 2 types of massage and usual care for chronic back pain. Design: Parallel-group randomized, controlled trial. Randomization was computer-generated, with centralized allocation concealment. Participants were blinded to massage type but not to assignment to massage versus usual care. Massage therapists were unblinded. The study personnel who assessed outcomes were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00371384) Setting: An integrated health care delivery system in the Seattle area. Patients: 401 persons 20 to 65 years of age with nonspecific chronic low back pain. Intervention: Structural massage (n = 132), relaxation massage (n = 136), or usual care (n = 133). Measurements: Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores at 10 weeks (primary outcome) and at 26 and 52 weeks (secondary outcomes). Mean group differences of at least 2 points on the RDQ and at least 1.5 points on the symptom bothersomeness scale were considered clinically meaningful. Results: The massage groups had similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural massage group than in the usual care group, and adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were small. Limitation: Participants were not blinded to treatment. Conclusion: Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms. Primary Funding Source: National Center for Complementary and Alternative Medicine.
Further Explanation: Relaxation massage, which is intended to induce a generalized sense of relaxation, comprised effleurage, petrissage, circular friction, vibration, rocking and jostling, and holding. Therapists could provide a compact disk of a 2.5-minute relaxation exercise to be done at home to enhance and prolong treatment benefits. Structural massage, which is intended to identify and alleviate musculoskeletal contributors to back pain, comprised myofascial, neuromuscular, and other soft-tissue techniques.