Low Back Disorders – Best Practices Report
The Chiropractic Report March 2009, volume 23, #2

Recommendations were made for best practices for three specific conditions, myofascial trigger point and myofascial pain syndrome, fibromyalgia syndrome and tendinopathy. 

With respect to myofascial trigger points and myofascial pain syndromes, they recommend manual type therapies and some physiologic therapeutic modalities, have acceptable evidence and support in the treatment of these conditions.  They suggested that there is substantial evidence supporting laser therapy for myofascial trigger points and myofascial pain syndrome; and moderately strong evidence for a TENS unit for myofascial trigger points but limited evidence for other forms of electrotherapy including ultrasound.  They found moderate evidence for acupuncture for myofascial trigger points and moderate evidence for the use of magnets for myofascial trigger points and myofascial pain syndrome. 

RE: Fibromyalgia syndrome, they found strong evidence supporting aerobic exercise and cognitive behavioral therapy; moderate evidence supporting massage, muscle strength training, acupuncture and spa therapy; limited evidence supporting spinal manipulation, mobilization, vitamins, herbs, and dietary modification.

With respect to tendinopathy, they note that chronic tendon pathology, a soft tissue condition commonly seen in chiropractic practices are often known as tendinitis. They prefer the term tendinopathy because the condition has not been associated with inflammation.  Their conclusions relative to chiropractic management for tendinopathy notes that there is limited evidence that manipulation and mobilization are beneficial for tendinopathy and more research is needed on the combination of manipulation, mobilization, facilitating stretching or other interventions most commonly used in chiropractic practice. 

____________________________________________________

Low Back Disorders – Best Practices Report
The Chiropractic Report March 2009, volume 23, #2

This report was based upon the contributions of a representative panel of 40 doctors of chiropractic in the USA. 

The panel made recommendations for treatment frequency and duration of chiropractic.  They stated that a therapeutic trial of treatment of care would include new patients with a low back disorder whether acute or chronic, a typical initial therapeutic trial of chiropractic care consisting of 6 to 12 visits over a two to four-week period with the doctor monitoring the patient’s progress with each visit to ensure that acceptable clinical gains are realized. 

They recommended reevaluation/reexamination, including a detailed or focus reevaluation designed to determine the patient’s progress and response to treatment which should be conducted at the end of each trial of treatment.  They stated that the patient’s condition should be monitored for progress with each visit and near the midway point of a trial of care the practitioner should reassess whether the current course of care is continuing to produce satisfactory clinical gains using commonly accepted outcomes assessment methods.  The purpose of the reevaluation at the end of the trial of treatment would be determined a necessity for additional treatment, which should be based on a response to the trial of care and the likelihood that additional gains can be achieved.

With respect to maximum therapeutic effect, they stated that this would be the point where there had been only partial resolution of the patient’s problem, measurable responses ended following all reasonable treatment and diagnostic studies. 

Regarding continuing course of treatments, they stated that this follows the initial trial of care, given where there are substantial measurable functional gains, but remaining functional deficits and the patient is continuing to improve.  Continuing is different from and can be compared with additional care which is subsequent care in cases of exacerbations or flare-up or when withdrawal of care results and substantial measurable decline in function or work status. 

The outcome measurements, for a trial of care to be considered beneficial it must be substantive, meaning that a definite improvement in the patient’s functional capacity has occurred.  They offered examples of acceptable outcome measures and which included: A) Pain scales such as the visual analog scale

and the numeri rating scale.  B) Pain diagrams that allow the patients to demonstrate the location and character of their symptoms.  C) Validated activities of daily living measures such as the Oswestry back disability index and the Roland-Morris back disability index, Rand36, Bournemouth Disability Questionnaire. D) Increase in home and leisure activities, in addition to increase in exercise capacity.  E) Increases in work capacity or decreases in prior work restrictions.   F) Improvement in validated functional capacity testing such as lifting capacity, strength, flexibility, and endurance. 

The committee stated that this would present a clear requirement of objective documentation in contemporary chiropractic practice.  They note that range of motion testing, for the purpose of determining patient response with a single treatment session is not regarded as an overall valuable functional outcome measure.

They stated that the contraindications for the use of high-velocity manipulation includes inadequate manipulative training and skills, certain types of osseous conditions, neurologic conditions, inflammatory conditions, and bleeding disorders. 

AAS/rt

___________________________________________