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Efficacy of Spinal Manipulative Therapy for Low-back Pain of Less than Three Months’ Duration. Ferreira ML, Ferrera PH, Latimer J, Herbert R, Maher CG. J Manipulative Physiol Ther. 2003 Nov-Dec;26(9):593-601.

Objectives: To review the efficacy of spinal manipulation for low-back pain of less than three months’ duration.

Data sources: Randomized clinical trials on spinal manipulative therapy for low-back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro).

Study Selection: Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy.

Data extraction: Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model.

Data synthesis: Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low-back pain of less than three months’ duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short-wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first four weeks of treatment.

Conclusions: Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short-wave therapy for nonspecific low-back pain of less than three months’ duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first four weeks of treatment.

Comment: The question to be answered now is, does the low incidence of adverse reactions and side effects from SM make it a more plausible therapy than other typical medical care regimens?

Performance Problems of Patients With Chronic Low-Back Pain and the Measurement of Patient-Centered Outcome Study Design Walsh D, Kelly S, Johnson P, Rajkumar S, Bennett K. Spine 2004; 29(1):87-93.

In a prospective interventional study, problems with performance were evaluated in 101 consecutive patients with chronic low-back pain for more than 12 months, before and after participation in an outpatient-based multidisciplinarv pain management program in Mansfield, United Kingdom.

Objectives: To describe problems identified as most important by patients with chronic low-back pain and to evaluate the Canadian Occupational Performance Measure (COPM) as a tool for measuring problem-specific outcomes.

Summary of Background Data: Patients with chronic low-back pain report difficulties with a variety of activities. The COPM permits the identification and measurement of problems of particular concern to the patient.

Materials and Methods: COPM, Likert-modified Roland and Morris Disability Questionnaire, Pain Self-Efficacy Questionnaire, and five-minute walk test were administered at baseline, immediately after, and nine months after intervention. Differences and statistical interactions were determined by nonparametric tests.

Results: Participants identified 60 different types of problem activity, 45 of which were identified by nine or fewer participants. Decreased walking tolerance was the most frequently identified problem (56 percent of participants). Improvements were observed in all outcomes following intervention. Approximately one-third of participants reported improvements with two or more COPM units in overall performance and satisfaction with their performance at nine months. Higher reported performance and satisfaction were associated with greater self-efficacy.

Increased reported walking performance was associated with increased observed five-minute walk distance (R = 0.35, P = 0.02).

Conclusions: Patients with chronic low-back pain report problems with diverse activities. The COPM provides a patient-centered outcome measure that displays good external validity and responsiveness to change when addressing the individual’s goals.

Comment: Normal activities of daily living (ADL) are an important component of a patient’s lifestyle, and the inability to perform ADLs is an important reason why patients visit physicians. The COPM appears to be a valid tool to help patients reach their goals for therapy, and it demonstr

Predictors of Back Pain in a General Population Cohort Kopec J, Sayre E, Esdaile J. Spine 2004;29:70-78.

Study Design: The study used longitudinal data from the first and second cycles (1994-1995 and 1996-1997) of the Canadian National Population Health Survey.

Objective: Our objective was to derive prediction models for back pain in the general male and female household populations.

Summary of Background Data: Little is known about the predictors of back pain in the general population. Most previous studies focused on specific occupational groups and used a cross-sectional or case-control design.

Methods: The study cohort consisted of all respondents aged 18+ years who reported no back problems in the 1994-1995 National Population Health Survey cycle (N = 11,063). Potential predictors of chronic back pain were classified into nine groups and entered into stepwise logistic regression models. Bootstrap methods were used to derive the final models and assess their predictive power.

Results: The overall incidence of back pain was 44.7 per 1,000 person-years and was higher in women (47.0 per 1,000 person-years), compared with men (42.2 per 1,000 person-years). In men, significant predictors of back pain were age (peak effect in 45-64 years), height, self-rated health, usual pattern of activity (especially heavy work), yard work or gardening (negative association), and general chronic stress. In women, significant factors were self-reported restrictions in activity, being diagnosed with arthritis, personal stress, and history of psychological trauma in childhood or adolescence.

Conclusions: Overall health and psychosocial factors are important predictors of back pain in both men and women. Other risk factors differ between the two sexes.

Comment It is interesting to note the differences between the sexes, particularly the incidence of back pain in men who do heavy work and in women who reported restricted activity. This study emphasizes the fact that the etiology and incidence of back pain remain somewhat of an enigma.

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Objective: To describe the applied-kinesiological evaluation of Chapman’s neurolymphatic reflexes in the management of a person with an unusual congenital bowel abnormality and its role in the manifestation of low back pain. The theoretical foundations of these reflexes will be elaborated upon and practical applications discussed.

Clinical features: A 29-year-old male had chronic low back pain. Radiographs of the patient’s lumbar spine and pelvis were normal. Magnetic resonance imaging (MRI) demonstrated a mild protrusion of the fifth lumbar disc. Oral anti-inflammatory agents, cortisone injections, and chiropractic manipulative therapy provided little relief. Though generally in robust health, the patient was aware of a congenital intestinal abnormality, diagnosed when he was a child; it was thought to be of no consequence with regard to his current back condition.

Intervention and outcome: The patient’s history, combined with applied kinesiology examination, indicated a need to direct treatment to the large bowel. The essential diagnostic indicators were the analysis of the Chapman’s neurolymphatic reflexes themselves, coupled with an evaluation of the traditional acupuncture meridians. The primary prescribed therapy was the stimulation of these reflexes by the patient, at home. This intervention resulted in the resolution of the patient’s musculoskeletal symptomatology, as well as improved bowel function.

Conclusion: The rather remarkable outcome from the application of this relatively simple, yet valuable, diagnostic and therapeutic procedure represents a thought-provoking impetus for future study and clinical application.

Objective: To review new and advanced biomechanical assessment techniques for the lumbar spine and illustrate the differences in lumbar function in patients with low back pain and asymtomatic subjects.

Data Sources: The biomedical literature was searched for research and reviews on spinal kinematic differences between low back pain subjects and healthy controls. A data search for articles indexed on MEDLINE until April 2002 was performed.

Results: Kinematic measurements of lumbar function were categorized into three areas where low back patients may differ from normals: 1. End range of motion during simple movements; 2. Higher order kinematics (displacement, velocity and acceleration) during complex movement tasks; and 3. Spinal proprioception. The assessment of higher order kinematics during complex movement tasks is the most highly researched and the most successful in describing differences between the populations. The use of simple end range of motion appears questionable while assessing spinal proprioception is the least researched, yet shows potential in highlighting differences between low back pain sufferers and asymptomatics.

Conclusion: Current kinematic biomechanical assessment techniques are capable of identifying functional differences between low back pain populations and controls. The use and validity of the majority of these techniques as outcome measures is currently unknown yet may be valuable in generating functional diagnoses, evaluating the mechanisms of current therapies and prescribing specific rehabilitation programs.

Key indexing terms: Biomechanics; spine kinematics; chiropractic; low back pain; outcome measures.

The unmeetable deadline, the never-satisfied boss, the you-don’t-deserve-him mother-in-law: We all know how pressure and aggravation make us feel. Not just in terms of emotional stress (that’s a given), but how they tangibly, really feel — the racing heartbeat, the churning gut, the dry mouth. Mental stress has always had its physical component. In fact, that’s what the stress response is: the visceral priming of the body to either fight or run away from a perceived danger. Less well recognized is that even chronic, unpleasant stress, the kind that’s so constant you consider it normal, can cause aches and pains that you might not attribute to emotions.

“Many people who have stress-related pain aren’t even aware of what they’re fearful or angry about,” says Ian Wickramasekera, Ph.D., clinical professor of psychiatry at Stanford University Medical School. By some estimates, half of the patients doctors see for various common body aches are actually expressing psychological distress through physical pain. Stress experts across the country saw evidence of this after the terrorist attacks last September. “In 30 years of specializing in stress-related diseases, I’ve never seen more flare-ups of physical pain, even in people who’d been free of symptoms for years,” Wickramasekera says. (Intrigued Stanford scientists immediately launched a study of the phenomenon.)

The source of stress-related pain lies in the brain, which, when you feel under the gun, triggers the release of cortisol, adrenaline and other hormones that prepare the body for action by, for example, increasing heart rate, blood pressure and respiration. Less noticeably, these hormones also make muscles tense up, which can cause aches and irritate nerves. Here’s a guide to the areas stress hits most often, and simple steps you can take to relieve the pain:

Low-back pain

Back pain can be caused by many different factors, such as poor posture or pressure on the spine from long hours of sitting. But a classic Swedish study of low-back pain in the workplace more than a decade ago showed that women who reported signs of stress such as dissatisfaction, worry and fatigue were more likely to experience low-back pain than those who had physical stressors like doing a lot of lifting. More recently, researchers at Ohio State University found that when volunteers felt stressed (from a snippy lab supervisor criticizing them as they tried lifting an object at a certain rate of speed), they used their back muscles in ways that made them more susceptible to injury. “I expect you’d see this even more in the real world, where stress is experienced over long periods and you care more about your task,” says study coauthor Catherine Heaney, Ph.D., associate professor of public health. To ease the twinge of low-back pain:

* Stand with your heels and shoulders touching a wall. Tilt your pelvis so that the small of your back presses against the wall, relieving back muscles. Hold for 15-30 seconds. Do this exercise regularly to reduce your risk of getting back pain or to relieve existing pain.

* Strengthen your abdominal muscles, which support the spine, by doing crunches three times per week Lie flat on your back on an exercise mat with hands cupped behind your ears. Feet should be together and flat on the floor, with knees bent at about a 45-degree angle. Curl your upper torso up, bringing ribs in toward hips until your shoulder blades clear the floor. Do one set of 15-25 crunches; gradually build to three sets. Also, increase endurance of the muscles along the spine, the spinal erectors, by doing alternate leg and arm raises from an all-fours position, holding each position for eight counts. Initially, do one set of 10 repetitions, building up to three sets.

Neck and shoulder pain

The neck is particularly prone to stress-related pain in part because it’s already bearing the burden of your 10-pound head. Pain may start with bad habits like squeezing the phone between your shoulder and your ear, but tension in neck muscles makes the problem worse, often causing pain to radiate. A recent study in Finland found that in addition to physical factors like working with a hand raised above shoulder level, mental stress is strongly linked to the likelihood of experiencing radiating neck pain. In most cases, getting rid of pain in the neck will benefit the shoulders as well. Here is what you can do:

* Give your neck muscles an all-around stretch one step at a time. First, while sitting erect in a chair, lower your chin to your chest, letting the weight of your head gently stretch tense muscles at the back of the neck. Hold the stretch for 15 seconds.

* Next, gently let your head drop toward one shoulder. Hold for 15 seconds and repeat on the other side.

* Use progressive muscle relaxation, in which you mentally focus on muscles and consciously allow them to relax. ‘First, you have to isolate the muscles by actually tensing them more,’ says Ronald Kanner, M.D., chairman of the department of neurology at Long Island Jewish Medical Center in New Hyde Park, N.Y. To do it, rest your elbows on your desk and press your face against your hands, then release, which will relax the muscles in your neck Mentally note the neck muscles you’re using and, over the course of about 15 seconds, slowly release their tension. Keep focusing on your neck muscles even after you lift your face from your hands, imagining the muscles deeply relaxing.

WHEN gas prices jumped to $3 a gallon this year in Peachtree City, Ga., restaurant owner Duane Stewart parked his gas-guzzling minivan in the driveway and charged up the battery of his four-seater electric golf cart instead.

But his destination was not the golf course. In fact, he rarely plays the game. Stewart was dropping off his children at school and running other errands. “It’s gotten so ridiculously expensive to fill up my minivan, so I drive my golf cart just like I used my car,” says Stewart, his golf cart humming as he drives down a path to the local grocery store. “You don’t have to worry about traffic and the pain at the pump. It’s the way to go until gas prices go down.”

Originally designed for leisure, electric golf carts–about 70 percent cheaper than a new car–are becoming a necessity with higher gas prices for Stewart and other motorists in Peachtree City. This golf cart capital is a community with more than 90 miles of golf cart paths and 9,000 registered golf carts.

Stewart still needs a car to hit the highway because, on most days, he drives 55 miles one way to make business deliveries, and he spends an average of $225 a week on gasoline when he drives his minivan. He recently switched to driving his wife’s smaller car, and that saves him $100 a week on gas.

These steps are among the creative, cost-cutting strategies millions of motorists around the country are using to get relief from higher gas prices. Motorists are making lifestyle and spending changes to cope.

More than two-thirds of consumers reported that they are combining their shopping trips, and 39 percent say they are staying home more often and cutting down on non-essential living expenses to offset the cost of gas, according to a new AC Nielsen survey. Consumers, African-Americans included, are also being squeezed by the ripple effect of gas spikes into the everyday economy as big companies pass on the increased costs for energy, transportation, goods and services. Not only will the pain come from the pump, consumers can expect to see higher heating bills and price increases on everything from toiletries to clothing to pizza, according to the Energy Information Administration.

Black motorists, many like Duane Stewart, are adjusting to the gas price shock in numerous ways. They are carpooling, using mass transit more frequently, scaling back on vacations, riding bicycles, and even walking more often, according to the American Automobile Association. Other motorists are purchasing fuel-efficient hybrid cars or seeking to convert their cars to use fuel alternatives such as ethanol and, oddly enough, vegetable oil. Some motorists who rely on vehicles daily to do their jobs are cutting back on driving to complete errands. Instead, they are using the Internet more to conduct business, and combining trips or relocating to shorten their commutes.

For instance, rather than driving clients to the actual homes for showings, Los Angeles-area Realtor Danita Tabron often refers clients to virtual house tours online before scheduling an appointment. “You can’t get away from the high cost of gas, but it forces you to become a better time manager,” says Tabron, who drives about 190 miles a week for business. The cost to fill up the gas tank of her Mercedes has doubled to $60 over the past year.

On average, she says she spends about $220 a month on gas. “Giving up the car is not an option. It’s part of my business,” Tabron says. “No matter how expensive it gets, I have to pay it.”

Tanya Elzy, a Los Angeles real estate office manager, puts current gas prices in perspective, saying: “Now I would be grateful for those past gas prices as I look around at prices of $3.19 a gallon.”

In New York City, photojournalist Margot Jordan depends on her 1995 Volvo to haul equipment, but with gas prices (at the time) over $3.35 for self-service, regular unleaded, Jordan worries about making ends meet. “Sometimes I have to choose between buying gas or groceries,” she says. “Gas has gone up about 40 percent over last year. Everybody’s feeling the pinch at the pump.”

The current gas pinch forced one Los Angeles photographer to trade in her new utility vehicle for a fuel-efficient hybrid car that gets 36 miles to the gallon. She had been paying nearly $800 a month on gas purchases, while driving an average of 200 miles a week. “I took a gigantic loss trading in the SUV, but my cost in gas purchases has been chopped in half by driving the hybrid,” she says. “I had to have something to get me around, but I didn’t want it to cost me an arm and a leg.”

One observer, the Rev. Jesse Jackson, founder of the Rainbow/PUSH Coalition, says: “African-Americans get gassed. We pay the highest part of our incomes in home heating and cooling bills, and [many of us] live in old buildings with miserable insulation. But we are locked out of [working in well-paying jobs] in the industry.”

Very little is known about the relationship between physical activity and low-back pain (LBP) in general populations. This study was designed to evaluate the relationship between different dimensions of physical activity and LBP among all adults of a defined community.

Methods: A cross-sectional survey addressed all adults aged 22 to 70 of a single town. Inhabitants were asked to complete a self-administered questionnaire regarding physical activities, LBP, and related characteristics. The Beacke Physical Activity Questionnaire evaluated physical activity, and the Modified Roland and Morris Disability Questionnaire, a pain severity scale, and the Pain Symptoms Frequency and Bothersomeness Indices evaluated LBP.

High occupational-activity demands contributed to increased LBP prevalence, and, conversely, high sporting-activity participation contributed to a decline in all LBP measures. Subjects free of LBP and subjects who participate in sporting activities are more likely not to smoke and not to participate in high occupational-activity demands. Type of sporting activity was not associated with LBP prevalence or severity.

Different dimensions of physical activity yield different relationships to LBP. There are several shared characteristics of those participating in sport on a regular basis and those free of LBP. Both groups present a healthier lifestyle. Although LBP was less frequent among those who participate in sporting activities, participating in sporting activities did not contribute independently to a lower prevalence of LBP. Once LBP was established, however, participating in sporting activities contributed indirectly to its severity.

The purpose of this project was to determine if subjects with low-back pain (LBP) exhibit greater side-to-side weight-bearing (WB) asymmetry, compared to healthy control subjects without LBP. This study utilized an observational double-cohort design and consisted of 35 subjects with LBP and 31 healthy control subjects. Side-to-side WB asymmetry was calculated as the average of the absolute value of the difference between the right and left lower extremity from three trials. The percentage of the average side-to-side WB asymmetry relative to the total body weight was calculated to normalize expected differences in magnitude of asymmetry based on a subject’s total body weight. An 11-point numeric pain-rating scale was used to represent the subject’s current level of pain.

Patients with LBP demonstrated significantly greater normalized side-to-side WB asymmetry than healthy control subjects (8.8% vs. 3.6%, respectively, P

In conclusion, patients with LBP exhibited increased side-to-side WB asymmetry, compared with healthy control subjects without LBP. This asymmetry was associated with increased levels of pain. This finding is relevant for planning future studies that will attempt to provide evidence for the construct validity of manipulation by determining if side-to-side WB asymmetry normalizes after a manipulation intervention and if this improvement is associated with improvements in pain and function.