Neck Pain

Neck pain affects a significant number of individuals. Recent studies have found more than 10% of Americans suffer from neck pain at any given time.

The reason is that the neck region contains many delicate, pain sensitive structures commonly exposed to abuse and abnormal stresses. Incomplete rehabilitation of past injuries, poor posture, prolonged sitting, and lack of periodic spinal alignments are some of the more common factors in the development of neck problems.

Fortunately, most individuals suffering from neck problems will find chiropractic care extremely beneficial. Unlike prescription drugs, most chiropractic procedures address the cause of the majority of neck problems, not simply the symptoms. Best of all, chiropractic care is safe, natural, and noninvasive... no side effects allowed!

Neck Pain Related Articles and Research

• Spinal manipulation vs. Acetaminophen for chronic neck pain
• Manual Mobilization for Neck Pain Patients Superior to Massage and Physical Therapies
• Manipulation of the Cervical Spine - A Pilot Study
• Pressure Pain Threshold Evaluation of the Effect of Spinal Manipulation in the Treatment of Chronic Neck Pain: A Pilot Study
• The Immediate Effect of Manipulation vs. Mobilization on Pain and Range of Motion in the Cervical Spine: A Randomized Controlled Trial
• Early Mobilization of Acute Whiplash Injuries
• 3 Studies Evaluating the Effectiveness of Manual Therapy (Manipulation), Physiotherapy, and Treatment by the General Medical Practitioner for Nonspecific Back and Neck Complaints

Spinal Manipulation vs. Acetaminophen for Chronic Neck Pain

In this University of Colorado study, researchers compared chiropractic spinal manipulation with Acetaminophen for the treatment of chronic neck pain. On average, patients had been suffering from neck pain on and off for approximately 10 years. Patients were split into 2 groups, receiving either:

• i. 12 chiropractic spinal adjustments over a 6 week period, or
• ii. Acetaminophen 4X/day plus 12 visits with a nurse over a 6 week period.

Both groups were also instructed to exercise and use a heating pad. At the end of the 6 weeks, patients who received the chiropractic spinal manipulation reported a significant improvement in neck pain and function, showing increased range of motion and strength. Patients receiving medication and nurse care showed no significant changes or improvements. Researchers are currently performing a long-term follow-up.

1. Baker B. Family Practice News 1996; June 1:14.

Manual Mobilization for Neck Pain Patients is Superior to Massage and Physical Therapies

Editors Summary

Cervical mobilization in comparison to other therapies has not been reported, but several researchers have found positive effects of mobilization. The purpose of this study is to address two problems:

• i. Do patients with restricted mobility and pain in cervical mobile segments benefit from mobilizing manual therapy?
• ii. Is there any relationship between reduction of pain and increase of the total cervical spine mobility?

Subjects were patients with restricted movement in the pain-producing segment. The patients were examined and randomized into three groups:

• Group 1 - Patients were told that they should try a new type of drug known to reduce pain most efficiently; they received salicylate daily for 3 weeks.
• Group 2 - Patients had the same information as those in group 1, and in addition were told that they would have some special information to help ease their pain, and also treatment by a skilled physiotherapist; they received salicylate, and their manual (mock) therapy consisted of superficial massage, electrical stimulation, and slight relaxing traction given three times a week for three weeks.
• Group 3 - Patients had the same information as those in group 2; they received salicylate, and their specific therapy consisted of relaxation techniques such as superficial heat, soft tissue treatment and slight traction, and specific manual mobilization of the actual mobile segments in the cervical spine; three treatments were given each week for three weeks.

(The special information given to groups 2 and 3 included anatomy and pathophysiology of the cervical spine as well as biomechanical problems and practical problems such as lifting, carrying and relaxation).

Each patient estimated their pain and reported the actual level each week. Total cervical mobility in the coronal, sagittal and transverse planes was recorded before and after therapy each week and even one week after the therapy finished by a physiotherapist. In addition, social conditions were recorded by a social worker, and Eysenck personality inventory tests were used by assistants.

Results showed that the initial pain level was about the same in all three groups. Before the treatment, tender spots with increased consistency in the muscle were frequent in 80-90% of the patients in all three groups. Manual examination revealed the same distribution of hypo mobile segments, C7-T2, in the three groups. The effect on pain was evaluated by the pain level and the decrease of pain. Group 3 showed a significant difference in pain level after treatment from the other groups. Group 3 also showed a significant difference in decrease of pain one week after the treatment and at the conclusion of the treatment. Mobility increased significantly at the final treatment for group three compared to the other groups.

This study concludes that cervical pain patients can be improved by simple manual technique as a first step towards complete treatment.

1. H. Brodin, Manuelle Medizin 1982; 20:90-94. From the Institution of Physical Medicine, Karolinska, Sjukhuset, Sweden.

Manipulation of the Cervical Spine

Authors Abstract

A randomized controlled trial of manipulation of the cervical spine was carried out on 52 patients in general practice, and the results were assessed symptomatically and goniometrically for three weeks. Manipulation produced a significant immediate improvement in symptoms in those with pain or stiffness in the neck, and pain/paresthesia in the shoulder, and a nearly significant improvement in those with pain/paresthesia in the arm/hand. Manipulation also produced a significant increase in measured rotation that was maintained for three weeks and an immediate improvement in lateral flexion that was not maintained.

Editors Summary

Pain and/or stiffness in the neck or pain referred to the head, shoulder, arm or hand are presentations of common neck disorders. The pathology of these conditions is uncertain and some probable causes are: minor subluxations of intervertebral facet joints, derangements of intervertebral discs with secondary osteoarthritis of the interarticular joints, or meniscoid entrapment in the upper cervical apophyseal joints straining the joint capsule. Manipulation for these conditions is controversial, and this study tries to assess its effectiveness.

Subjects were selected, were assessed by doctors A and B, and were divided into either the treatment or control group. The treatment group was treated by manipulation and/or injection (if the neck was too painful) and was asked to return for further treatment at Dr. A's discretion. Both groups were treated with axapropazone. They were all instructed not to tell Dr. B whether they had been manipulated or not. Patients then returned to Dr. B who again recorded their symptoms and measured their neck movements via a goniometer.

Results showed that among patients initially affected with a symptom, the proportion showing immediate improvement after manipulation was greater than the corresponding proportion in controls; the difference reached significance for neck pain and neck stiffness and shoulder pain/paresthesia. Manipulation also produced a highly significant immediate improvement in rotation and lateral flexion. The improved rotation was maintained at one and three weeks, but the lateral flexion improvement did not last. However, more than half the control group experienced improved symptoms despite no measured improvement in movement, confirming clinical impression.

1. Journal of the Royal College of General Practitioners 1983; 33:574-579.

Pressure Pain Threshold Evaluation of the Effect of Spinal Manipulation in the Treatment of Chronic Neck Pain

Authors Abstract

Nine subjects with chronic mechanical neck pain syndromes were evaluated for pressure pain threshold (PPT) over standardized tender points in the paraspinal area surrounding a manipulable spinal lesion. The subjects were then allocated randomly to an intervention consisting of either an oscillatory mobilization of the cervical spine (n=4), which was designated as the control procedure, or a rotational manipulation of the cervical spine (n=5). An assessor-blinded re-evaluation of the pressure pain threshold levels was conducted after 5 minutes. In the group receiving a manipulation the mean increases in pressure pain threshold ranged from 40-56% with an average of 45%. In the control group no change in any of the pressure pain thresholds was found. These results were analyzed using ANOVA and were found to be statistically significant (p < 0.0001). This study confirms that manipulation can increase local paraspinal pain threshold levels. The use of the pressure pain threshold meter allows for the determination of such a beneficial effect in the deeper tissues.

Editors Summary

Very few clinical trials have been produced to provide evidence that manipulative treatment by chiropractors is beneficial to patients with neck pain. The senior author of this study, Howard T. Vernon, conducted clinical analog studies in which the results of a single manipulation were compared to control procedures. In the first study, a single thoracic manipulation produced a significantly higher rise in cutaneous pain tolerance levels than the sham manipulation group. In the second study, a single manipulation of the cervical spine produced a modest increase in plasma beta-endorphin levels while control and sham procedures dropped. These studies support the idea that pain relief occurs subsequent to manipulation, and to the theory that this pain relief is a result of reflex mechanisms activated by the thrust. The reflex mechanisms can be described as afferent bombardment from the articular and myofascial receptors which produces pre synaptic inhibition of segmental pain pathways and possibly activation of the endogenous opiate system. The purpose of this study is to extend this earlier work to prove that a single manipulation would produce a significantly higher rise in pressure pain threshold levels in the paraspinal area surrounding a spinal fixation as compared to a control procedure. In this study, a more accurate device is used, the pressure threshold meter. The advantages are that this device can objectively measure pressure pain threshold over tender points in muscles as well as measure functional changes in the deeper tissues around a joint. Subjects were chiropractic patients diagnosed with chronic mechanical neck pain for an average duration of less than 3 months. The research treating physician assessed for joint dysfunction of the cervical spine, and marked the "fixated" or hypo mobile segment. The treater left the room and the assessor entered to conduct a PPT assessment of four tender points above and below, and on each side of the fixated level. The points were consistently measured as:

• i. ipsilateral to the clinically painful side, slightly below the fixation;
• ii. ipsilateral, above;
• iii. contralateral, above;
• iv. contralateral, below.

Two measurements were taken at each point and the assessor left the room. The treater entered and applied the appropriate treatment of either a rotational mobilization with gentle oscillations into the elastic barrier, or a rotational manipulation (high velocity, low amplitude thrust). All subjects were asked if they felt pain and if they believed that they had received a "real" treatment. Finally, the blinded assessor re measured the tender points twice after 5 minutes.

Results revealed a statistically significant rise in pressure pain threshold ranging from 40-55% in all four points around the fixation level in the manipulation group compared to virtually no change in the mobilization group. All subjects that were manipulated reported no pain and regarded the manipulation as a "real" treatment. Of the four mobilized subjects, three reported no pain and none regarded the mobilization as "real". These findings are behavioral as related to the subject's perception of pain, but the underlying mechanism of spinal reflexes causing pain threshold changes is still supported especially since no subject felt pain from the manipulation.

In conclusion, the pressure pain threshold meter has proven to be useful in objectifying the effect of manipulation versus mobilization in the cervical spine of subjects suffering from chronic mechanical neck pain, and these findings support the theoretical mechanisms proposed to explain the effects of spinal manipulation on spinal pain.

1. Journal of Manipulative and Physiological Therapeutics 1990; 13:13-16. From the Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.

The Immediate Effect of Manipulation vs. Mobilization on Pain and Range of Motion in the Cervical Spine

Authors Abstract

Objective - The main objective of this study is to compare the immediate results of manipulation to mobilization in neck pain patients.

Design - The patients were compared in a randomized controlled trial without long-term follow-up.

Setting - The study was conducted at an outpatient teaching clinic on primary and referred patients.

Patients - One hundred consecutive outpatients suffering from unilateral neck pain with referral into the trapezius muscle were studied. Fifty-two subjects were manipulated and 48 subjects were mobilized. The mean (SD) age was 34.5 (13.0) yr for the manipulated group and 37.7 (12.5) for the mobilized group. Sixteen subjects had neck pain for less than 1 week, 34 subjects had pain for between 1 wk and 6 mo and 50 subjects had pain for more than 6 mo. Seventy-eight subjects had a past history of neck pain. Thirty-one subjects had been involved in an injurious motor vehicle accident and 28 subjects had other types of minor trauma to the neck. There were no significant differences between the two treatment groups with respect to history of neck pain or level of disability as measured by the Pain Disability Index.

Intervention - The patients received either a single rotational manipulation (high-velocity, low-amplitude thrust) or mobilization in the form of muscle energy technique.

Main Outcome Measures - Prior to and immediately after the treatments, cervical spine range of motion was recorded in three planes, and pain intensity was rated on the 101-point numerical rating scale (NRS-101). Both pre- and post-test measurements were conducted in a blinded fashion.

Results - The results show that both treatments increase range of motion, but manipulation has a significantly greater effect on pain intensity. 85% of the manipulated patients and 69% of the mobilized patients reported pain improvement immediately after treatment. However, the decrease in pain intensity was more than 1.5 times greater in the manipulated group (p=.05).

Conclusion - This study demonstrates that a single manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain. Both treatments increase range of motion in the neck to a similar degree. Further studies are required to determine any long-term benefits of manipulation for mechanical neck pain.

Editors Summary

Neck pain with decreased mobility is a common condition that improves, for most cases, with time, but may persist in others as moderate or severe pain for several years after the initial onset. Many different treatments have been used to handle mechanical neck pain, but few clinical trials have been performed to establish their effectiveness. The purpose of this study is to compare the immediate results of manipulation and mobilization on pain and ROM in patients with unilateral mechanical neck pain. Subjects were patients suffering from unilateral, mechanical neck pain with radiation into the trapezius, and local cervical paraspinal tenderness. After the initial exam and before the treatment, patients rated their pain intensity on the NRS-101. Cervical ROM was measured next by a goniometer after which patients were randomized into two groups: Group 1- Cervical Manipulation- involved contacting the pillar on the painful side of the neck at the level of tenderness, passively rotating the neck away from the painful side as far as possible, and applying a high-velocity, low-amplitude thrust in the same direction. Group 2- Cervical Mobilization- involved application of muscle energy technique (active resisted isometric contraction held for 5 seconds and repeated four times with increasing rotation or lateral flexion of the neck; aims to improve mobility and pain via post-isometric relaxation) to hypertonic muscles responsible for restricting joint movement. All treatments were given once and were applied to the symptomatic side. Patients rated their pain intensity again within five minutes after the treatment, and the ROM exam was also repeated.

Results show that both manipulation and mobilization have the immediate effect of decreasing pain and increasing cervical ROM. Improvements were slightly higher in the manipulation group, and the overall pain improvement on the NRS-101 was 1.5 times greater than the mobilized group. The question is which treatment would give better results when considering long-term follow up and risk/benefit (manipulation may cause a cerebrovascular accident whereas mobilization will not, but mobilization may be of little therapeutic value).

In conclusion, this study proves that manipulation is more effective than mobilization in decreasing pain in patients with mechanical neck pain, but both treatments increase cervical ROM to the same degree. Further studies should examine the long-term benefits of manipulation for mechanical neck pain.

1. Journal of Manipulative and Physiological Therapeutics 1992; 15:570-575. From the Department of Orthopedic Surgery, Royal University Hospital, Saskatoon, Saskatchewan, Canada.

Early Mobilization of Acute Whiplash Injuries

Authors Abstract

Acute whiplash injuries are a common cause of soft tissue trauma for which the standard treatment is rest and initial immobilization with a soft cervical collar. Because the efficacy of this treatment is unknown a randomized study in 61 patients was carried out comparing the standard treatment with an alternative regimen of early active mobilization. Results showed that eight weeks after the accident the degree of improvement seen in the actively treated group compared with the group given standard treatment was significantly greater for both cervical movement (p<0.05) and intensity of pain (p<0.0125).

The results of this study indicate that early mobility of the neck following whiplash accident compared with a cervical collar and instructions to rest results in significantly less pain and stiffness.

Editors Summary

Whiplash injuries are due to sudden flexion and hyperextension of the spine with hyperextension as the main cause of damage. Standard treatment consists of a period of immobility using a soft cervical collar and simple analgesia before gradual mobilization. The purpose of this study is to evaluate the efficacy of this standard treatment compared with an alternative treatment of daily neck exercises and mobilization using the Maitland technique.

Subjects were patients with acute whiplash injuries who had not suffered a cervical fracture. Intensity of pain was assessed and cervical mobility was measured via a goniometer from which the total cervical movement was calculated. Patients were then randomized into two groups:

Group 1 - Standard treatment- soft cervical collar and instruction to rest for two weeks before beginning gradual mobilization; analgesia was given as required.

Group 2 - Active treatment- application of ice in the first 24 hours and then neck mobilization using the Maitland technique (repetitive and passive movements within the patients' tolerance with tiny movements and movements with a restricted amplitude for pain and spasm, and movements with larger amplitude for stiffness) and daily exercises of the cervical spine within pain limits every hour at home; application of local heat after each treatment; no analgesia was required.

Both groups were assessed for residual pain and cervical movement at four and eight weeks after the accident.

Results proved that patients who are treated actively show significantly greater improvement in both cervical movement and intensity of pain compared with patients treated the standard way. At four weeks, a significant increase in cervical movement occurred in the patients given active treatment but not in those given standard treatment. At eight weeks, the same findings were yielded indicating that the increase in cervical mobility occurred earlier and to a significantly greater degree with active treatment. In terms of pain, the improvement was greater at both four and eight weeks in the group given active treatment compared with those given standard treatment.

These results confirm the expectations that initial immobility (lack of movement) after whiplash injuries gives rise to persistent pain and stiffness whereas a more rapid improvement can occur by early active management without any consequent increase in discomfort.

1. British Medical Journal 1986; 292:656-657. From the Department of Orthopedics, St. James's Hospital, Dublin 8, Ireland.

Effectiveness of Manual Therapy (Manipulation), Physiotherapy and Treatment by the General Medical Practitioner for Nonspecific Back and Neck Complaints

The following 3 studies come from the Netherlands and compare the effectiveness of manual therapy (manipulation), physiotherapy and treatment by general medical practitioners for nonspecific back and neck complaints.

• The Effectiveness of Manual Therapy, Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints
• Randomized Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up
• Randomized Clinical Trial of Manual Therapy and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis and Relationship Between Outcome Measures

The Effectiveness of Manual Therapy (Manipulation), Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints

Authors Abstract

In a randomized trial, the effectiveness of manual therapy (manipulative techniques), physiotherapy, continued treatment by the general practitioner, and placebo therapy (detuned ultrasound and detuned short-wave diathermy) were compared for patients (n=256) with nonspecific back and neck complaints lasting for at least 6 weeks. The principle outcome measures were severity of the main complaint, global perceived effect, pain, and functional status. These are presented for 3, 6 and 12 weeks follow-up. Both physiotherapy and manual therapy (manipulation) decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner.

1. Spine 1992; 17:28-35. From the University of Limburg, Maastricht, the Netherlands.

Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up

Editors Summary

The third trial of the series evaluating the effectiveness of manual therapy (manipulation) and physiotherapy utilized the same treatments and outcome measures as the prior studies, but chose changes in severity of the main complaint, limitation of physical functioning, and global perceived effect as the main outcome measures.

Results for this trial revealed an interesting factor: many patients in the GP (general medical practitioner treatment group) and placebo groups changed from their assigned treatment to another treatment during the one year follow-up. This clearly indicates the superiority of manual therapy (manipulation) and physiotherapy over the other two treatments, and the willingness of patients to turn to other treatments when their assigned treatment is not effective enough.

In terms of the change of the main complaint, the manual therapy (manipulation) group showed the largest improvement after 12 months follow up. Manual therapy also gave larger improvements in physical functioning than the physiotherapy group at all follow up measurements.

The global perceived effect after 6 and 12 months follow up was similar for both treatments. Thus, it can be concluded that manual therapy (manipulation) and physiotherapy are superior to GP and placebo treatment, and manual therapy (manipulation) is slightly better than physiotherapy after 12 months.

1. British Medical Journal 1992; 304:601-605. From the University of Limburg, Maastricht, the Netherlands.

Randomized Clinical Trial of Manual Therapy (Manipulation) and Physiotherapy for Persistent Back and Neck Complaints: Subgroup Analysis and Relationship Between Outcome Measures

Editors Summary

This final trial utilized the same treatments as well as the same three outcome measures as the third study, but also assessed the relationship between the outcome measures via a subgroup analysis. The subgroup analysis was confined to manual therapy (manipulation) and physiotherapy only, focusing on specific subgroups that showed benefit, particularly from a certain therapy. The analysis was further confined to subgroups based on six predefined baseline characteristics only:

• i. duration of the present episode (<1, >1 or =1 yr);
• ii. age (younger than 40 yr, 40 yr old and older than 40 yr);
• iii. localization of the complaints (back only, neck only, back and neck);
• iv. recruitment status (GP, advertisement);
• v. severity of complaint (severity < 7 pts, severity 7 or >);
• vi. appropriateness of allocated treatment according to treating therapist (suitable/not suitable)

Results showed a greater improvement in the main complaint with manual therapy (manipulation) than with physiotherapy for patients with chronic conditions (duration complaint of 1 yr or more). Improvement in the main complaint was also larger with manual therapy (manipulation) than with physiotherapy for patients younger than 40 years (both were measured after 12 months follow up). Labeling of patients as "suitable" or "not suitable" for treatment with manual therapy (manipulation) did not predict differences in outcomes. There was a moderate to strong correlation between the three outcome measures, although a considerable number of patients gave a relatively low score for perceived effect while the research assistant gave a high improvement score for the main complaint and physical functioning. This finding indicates that the outcome measures represent different features of progress in back and neck patients, and that if research interest lies in the opinion of the patient and the observer, it will not suffice to measure just one of the outcome measures.

In conclusion, the subgroup analysis suggests better results of manual therapy (manipulation) compared to physiotherapy in chronic patients and in patients younger than 40 years. Future research must investigate the explorative findings of these subgroup analyses. Of particular interest may be the strong relationship between improvement of physical functioning and improvement of main complaint which can also indicate that the severity of the main complaint of a patient concurs with the patient's limitation in physical functioning.

1. Journal of Manipulative and Physiological Therapeutics 1993; 16:211-219. From the Institute for Research in Extra mural Medicine, Free University, Amsterdam, the Netherlands.

Mid Back Pain

The fast-paced lifestyles of today have taken their toll on the backs of America. Currently, back pain is the number one cause of disability in those aged 19-45 and is the second leading cause of missed work days. Total annual costs for back pain in the US alone are estimated to be in excess of $60 billion.

A number of factors contributing to these statistics, including:

• overall increases in work demands
• overall decreases in physical activity
• increases in prolonged sitting (at the desk, in the car, in front of the television)
• lack of periodic spinal checkups and preventative care
• failure to seek immediate care following injury
• failure to receive adequate treatment for back injuries (i.e. medications only without proper rehabilitation of tissues)
• poor postural habits and lifting techniques

Our treatments primarily focus on the cause of your problems, which not only results in rapid and effective pain-relief, but most importantly, minimizes the chance of future back problems.

To learn more about mid back anatomy, causes of mid back pain, treatments for mid back pain and related articles, choose from the menu links.

Causes of Mid Back Pain

Mid back pain is most commonly caused by irritation or injury to the muscles and ligaments of the thoracic spine. The high incidence of poor postural habits, lack of adequate exercise and muscle conditioning, as well as the ever more popular "seated" lifestyles of Americans are all major contributors.

Chiropractors work hard to identify the exact problems of mid back pain so that only the safest and most effective treatments can be provided. Since the majority of mid back pain cases are caused by soft tissue problems or have a significant soft tissue component, hands on chiropractic treatments are extremely beneficial and have been shown to be superior to other forms of "back" care.

Common events leading or contributing to the development of mid back pain include:

• incomplete rehabilitation of past injuries
• lack of proper and periodic thoracic spinal alignments
• presence of thoracic spine subluxations
• improper lifting techniques
• auto accidents
• improper workstation setup
• poor posture
• prolonged sitting
• prolonged use of non-ergonomically designed equipment
• excessive repetitive torsal motions
• scoliosis (lateral deviation of the spine)
• physical inactivity
• poor diet and nutritional practices
• smoking

Structures which are often the source of mid back pain include:

• thoracic facet joints and capsules
• thoracic paraspinal muscles and ligaments
• costovertebral joints (joints between the thoracic vertebrae and ribs)
• thoracic intervertebral discs
• thoracic spinal nerves

Low Back Pain

If you're suffering from lower back pain you're not alone. More than 80% of North Americans will at some time in their life suffer from the disabling confines of lower back pain.

According to experts, lower back pain is the number one disability culprit in workers' compensation claims and accounts for more than $50 billion annually in the US through medical care and lost production. In addition, the latest research shows most lower back problems which cause low back pain do not fully resolve without extensive treatment and proper rehabilitation, contrary to previous beliefs.

The chiropractic doctor is unique in the health care field in that much of the training in chiropractic colleges is specifically aimed at identifying and successfully treating and managing lower back conditions. General medical practitioners generally lack adequate training in this area and have not learned the skills necessary to most effectively identify and treat most back conditions.

Causes of Low Back Pain

Many tissues can generate low back pain. Unfortunately, research shows that the exact tissues causing low back pain cannot be specifically identified in up to 80% of individuals. In other words, we cannot single out the tissue(s) responsible for the pain. These patients are said to suffer from "nonspecific low back pain"; the specific cause of the pain cannot be determined.

Although the specific tissues causing low back pain are difficult to identify, chiropractic doctors have found a number of factors consistently present in low back pain patients. These factors include vertebral subluxations, faulty spinal biomechanics, deconditioned spinal musculature and the practice of poor postural habits and techniques. By addressing these factors - the actual causes of the tissue injury - chiropractic doctors are able to obtain extraordinary results in low back pain sufferers.

Common events leading or contributing to the development of lower back pain include:

• incomplete rehabilitation of past injuries
• lack of proper and periodic lumbar spinal alignments
• presence of lumbar spine subluxations
• improper lifting techniques
• auto accidents
• improper workstation setup
• poor posture
• prolonged sitting
• prolonged use of non-ergonomically designed equipment
• excessive repetitive torsal motions
• exposure to vibratory forces (truck drivers, jack hammer operators)
• scoliosis (lateral deviation of the spine)
• fallen foot arches and other foot abnormalities
• physical inactivity
• poor diet and nutritional practices
• smoking

Structures which are often the source of lower back pain include:

• lumbar intervertebral discs
• lumbar facet joints and joint capsules
• lumbar and pelvic muscles and ligaments
• lumbar and sacral spinal nerves
• sacroiliac joints

Treatments for Back Pain

Doctors of chiropractic are the health care leaders in the treatment of back pain as well as other spinal conditions. Treatments are gentle, safe, natural, noninvasive and highly effective. Also, the treatments are designed to correct the root cause of your problem and not simply cover up the symptoms you experience. In fact, a Canadian government commissioned study on the effectiveness and cost effectiveness of chiropractic management of low back pain concluded,

"Chiropractic manipulation is safer than medical management of low back pain. Chiropractic management is greatly superior to medical management in terms of scientific validity, safety, cost-effectiveness and patient satisfaction."

- The Manga Report

• Identifying the Cause
• The Treatment
• Proper Habits and Techniques
• Other Therapies
• How to Maintain a Healthy Lower Back

Identifying the Cause

The first step in treating back pain is to determine what has and is causing the back pain. Once the causes and contributing factors are identified, a successful treatment plan can be structured to eliminate the pain and achieve the goals of the patient.

Most individuals experiencing low back pain have a combination of:

i. vertebral subluxations

ii. faulty spinal biomechanics

iii. deconditioned and weak spinal musculature

iv. improper firing patterns of spinal musculature

v. poor postural habits

vi. poor diet and nutritional practices

vii. a history of activities (work or play) generating high levels of spinal stress

The Treatment

Chiropractic doctors have successfully treated back pain for over 100 years. Through the use of natural and safe procedures, chiropractors correct the underlying problems which cause and contribute to the majority of back pain cases.

The main treatment employed by the chiropractor is the chiropractic spinal adjustment. This noninvasive therapy consists of a gentle, manually or mechanically applied force into the segments of the spinal column. Spinal adjustments have been shown to decrease pain, increase spinal range of motion, decrease muscle spasm, reduce inflammation, optimize spinal biomechanics, and reduce the recurrence of old injuries.

Clinical practice guidelines for the management of acute low back pain released by the US Department of Health and Human Services (AHCPR) stated:

i. Conservative treatment such as spinal manipulation should be pursued in most cases before considering surgical intervention;

ii. Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.

iii. The risk of serious complications from lumbar spinal manipulation is rare

1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (1994) - U.S. Department of Health and Human Services.

According to researcher Pran Manga, PhD,

"Spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate."

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

Proper Habits and Techniques

Another key ingredient to a successful back pain treatment plan includes the learning of proper postural habits and other techniques. Proper posture is a significant factor in the health of the back and proper posture should always be practiced. Techniques common to daily living and work also play a major role in the development or lack of development of low back pain. This includes proper lifting techniques, avoidance of repetitive motions, avoidance of prolonged sitting, and much more. We can teach you correct habits and techniques which will protect your back from discomfort and injury.

Other Therapies

Other manual therapies such as massage, trigger point therapy, proprioceptive neuromuscular facilitation, and acupressure therapy may be utilized to assist in the relaxation of lumbar muscles and increase lumbar spine mobility.

Low back stabilization exercises are commonly prescribed to patients suffering from low back pain. These exercises are designed to teach the patient a "neutral spine" position as well as subconsciously enhance the muscles ability to stabilize and protect the spine from injury. Exercises and stretches are unique in that they can be performed outside the office without the assistance of the doctor.

Physical therapies may also be employed and include hot and cold applications, muscle stimulation, interferential therapy, therapeutic ultrasound, and diathermy.

Diet and nutrition also play a key role in the health of the spine. Without the proper nutrients, the lumbar spine and rest of the body are less able to remain healthy and heal once injured. If your diet and nutritional status is poor, we can help get you on track.

How to Maintain a Healthy Back

Regular spinal checkups. Maintaining proper alignment and functioning of the mid and lower back through periodic spinal adjustments minimizes the stresses to structures of the back. Also, keeping the nervous system free from interference ensures proper communication between the various structures of the lower back.

Proper lifting and ergonomics. Practicing proper lifting techniques and ergonomics are key in preventing back injury at work and preventing future recurrences of old injuries.

Regular exercise. Routine physical activity keeps the heart healthy and keeps the spine and the rest of the body strong and healthy. A minimum of 4 times per week for 40 minutes should be your goal. Involve friends and family, mix up the activities, keep it fun and stay consistent!

Proper diet and nutrition. Providing your body with the proper fuel increases performance, reduces the likelihood of injury and sickness, speeds recovery after injury, and keeps you feeling good. If, like the rest of us, you're finding it difficult to get all the nutrients your body needs, it's probably time to supplement.

If you're suffering from back pain, join the millions of other individuals who have benefited from gentle, safe and natural chiropractic care. Our treatments provide fast, effective relief which not only eliminates pain, but can help increase the performance and health of the entire body.

Back Pain Related Articles and Research

• Canadian government's findings on the effectiveness and cost effectiveness of chiropractic care in the treatment of low back pain (The Manga Report)
• Guidelines for the Treatment of Acute Low Back Pain - released by the Agency of Health Care Policy and Research, US Department of Health and Human Services
• Randomized comparison of chiropractic and hospital outpatient management for low back pain
• 90% of individuals with low back pain still suffer 1 year later under regular medical care
• Heavy lifting damages spinal discs
• Back exercises help back injuries

The Manga Report

As the largest existing analysis of scientific literature on low back pain, the 1993 Ontario Ministry of Health commissioned study drew international attention when it recommended the management of low back pain be moved from medical doctors to chiropractic doctors.

Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

The researchers also stated that studies on the prevalence and incidence of low back pain suggest that it is the leading cause of disability and morbidity in middle-aged persons, and is by far the most expensive source of workers' compensation costs North America.

The Canadian Government report concluded with the following findings:

• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by non-chiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;

In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:

• the effectiveness and cost effectiveness of chiropractic management of low back pain
• the untested, questionable or harmful nature of many current medical therapies
• the economic efficiency of chiropractic care for low back pain compared with medical care
• the safety of chiropractic care
• the higher satisfaction levels expressed by patients of chiropractors.

The following recommendations were also included in the report:

• There should be a shift in policy to encourage and prefer chiropractic services for most patients with low back pain;
• Chiropractic services should be fully insured under the Ontario Health Insurance Plan;
• Chiropractic services should be fully integrated into the health care system;
• Chiropractors should be employed by tertiary hospitals in Ontario;
• Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs;
• Chiropractic should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients;
• Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with low back injuries;
• A very good case can be made for making chiropractors the gatekeepers for management of low back pain in the workers' compensation system in Ontario;
• The government should make the requisite research funds and resources available for further clinical evaluations of chiropractic management of low back pain, and for further socioeconomic and policy research concerning the management of low back pain generally;
• Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public finding;
• Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

The Agency of Health Care Policy and Research Study

On December 8, 1994, the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services released Clinical Practice Guidelines for the management of acute low back pain. Their guidelines were developed after extensive study of diagnostic and treatment methods for acute low back pain.

The guidelines were created by the AHCPR panel to provide primary care clinicians with information and recommended strategies for the assessment and treatment of acute low back problems. The AHCPR panel was made up of 23 members consisting of medical doctors, chiropractic doctors, nurses, experts in spinal research, physical therapists, an occupational therapist, a psychologist, and a consumer representative.

The following conclusions were made in this landmark study:

• Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
• Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.

Other interesting finds included:

• The risk of serious complications from lumbar spinal manipulation is rare;
• There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
• The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.

1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (1994) - U.S. Department of Health and Human Services.

Chiropractic vs. Hospital Outpatient Management for Low Back Pain

Study Abstract

Objective - To compare the effectiveness over three years of chiropractic and hospital outpatient management for low back pain.

Design - Randomised allocation of patients to chiropractic or hospital outpatient management.

Setting - Chiropractic clinics and hospital outpatient departments within reasonable traveling distance of each other in 11 centres.

Subjects - 741 men and women aged 18-64 years with low back pain in whom manipulation was not contraindicated.

Outcome Measures - Change in total Oswestry questionnaire score and in score for pain and patient satisfaction with allocated treatment.

Results - According to total Oswestry scores improvement in all patients at three years was about 29% more in those treated by chiropractors than in those treated by the hospitals. The beneficial effect of chiropractic on pain was particularly clear. Those treated by chiropractors had more further treatments for back pain after the completion of trial treatment. Among both those initially referred from chiropractors and from hospitals more rated chiropractic helpful at three years than hospital management.

Conclusions - At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.

1. British Medical Journal. August 05, 1995.

90% Under Regular Medical Care Still Suffer Low Back Pain 1 Year Later

Study Overview

i. It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month

ii. In a large population based study we examined the outcome of episodes of low back pain in general practice with respect to both consultation behavior and self-reported pain and disability

iii. While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability

iv. Only 25% of the patients who consulted about low back pain had fully recovered 12 months later

v. Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact

Study Abstract

Objectives - To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month.

Design - Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation.

Setting - Two general practices in south Manchester.

Subjects - 490 subjects (203 men, 287 women) aged 18-75 years.

Main Outcome Measures - Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months.

Results - Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability.

Conclusions - The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.

1. British Medical Journal. 1998; 316:1356-9

Heavy Lifting Dries Out Vertebral Discs

Heavy lifting may trigger a range of physiological changes that can hasten damage to the discs that cushion the bones of the spine, eventually leading to back pain and disability, according to a study presented by California researchers at a meeting in Belgium on Friday. The study findings may lead to better treatments for back pain and new ways to prevent back injuries.

The report helps shed light on the changes that lead to disc degeneration, a condition in which the spongy cushions separating the vertebral bones in the back become dehydrated and damaged. A common condition, disc degeneration can be painful and debilitating.

"The findings should lead to improved treatments for one cause of low back pain, disc degeneration," noted lead author, Dr. Jeffrey Lotz, of the University of California at San Francisco. The findings should also help researchers determine how much weight people can lift safely.

Lotz and colleagues examined the way compression affects the discs in the tails of mice. A mouse's tail is an extension of its spine, and includes discs similar to those in the human back.

The researchers attached a device that exerted varying degrees of pressure on the discs in each mouse's tail. They found that chronic compression triggered an array of changes in both the structure and biological activity of the discs.

Among other things, chronic compression killed cells in the discs. The greater the pressure, the greater the number of cells killed. Widespread cell death eventually limited the surviving cells' ability to maintain and repair the discs, the authors found. Over time, this caused water loss inside the discs, leaving them dehydrated. Once dehydrated, the discs were less able to withstand pressure, and bulged outward.

Dehydration of the discs triggered other changes, including the release of chemicals that appeared to irritate surrounding nerves, the researchers found. The release of these chemicals, and the pressure that bulging discs might exert on nearby nerves, may cause the pain associated with disc degeneration, the researchers report.

In light of these findings, it may be possible to treat degeneration by injecting damaged discs with growth factors that stimulate cell repair, note the researchers, who are now testing this procedure. If the technique is successful, it could be an alternative to back surgery, the current treatment for disc degeneration.

1. Reuters. June 12, 1998.

Back Exercises Help Back Injuries

According to a new study, specific back stabilizing exercises are essential for preventing the recurrence of back injuries.

Following back injuries, the smaller stabilizing muscles of the back, such as the multifidus muscles, undergo atrophy. Because these smaller muscles play an important "stabilizing" role in the back, failing to rehabilitate them back to normal almost always results in reinjury.

In this study, researchers found that in patients who sustained back injuries, 29% experienced reinjury within one year if they had received treatment which included back stabilizing exercises. In the group of individuals who did not receive these exercises, an astonishing 80% experienced reinjury within 1 year.

This not only marks the importance of fully rehabilitating the spine following a back injury, but also shows the recurrent nature of back injuries in general. Therefore, individuals suffering from back injuries should seek treatment which addresses the health of their spine and involves the full rehabilitation of the spinal components. Treatments dealing with symptomatic relief only are highly ineffective and short-lived.

1. Reuters. June 03, 1998.

Interesting Facts and Statistics

• The popularity of chiropractic is at an all-time high, 80% of Americans will suffer from back pain at some point in their lives.
• Back symptoms are the most common cause of disability for individuals under the age of 45.
• 20% of all American military medical discharges are due to low back pain.
• More than 20 million Americans will seek chiropractic care this year.
• Chiropractic has been around for more than 100 years.
• Today there are approximately 50,000 chiropractors in the United States; 10,000 in Japan; 5,000 in Canada; 2,500 in Australia; 1,000 in the U.K.; and, 100-500 in each of: Belgium, Denmark, France, Italy, Norway, Sweden, Switzerland, New Zealand, South Africa, The Netherlands.
• In the western world 85% of people will be disabled by back pain at some point in their lives. Spine 12(3):264-268.
• 1992 costs associated with low back pain in the U.S. were estimated to be $60 billion. The Manga Report - 1993.
• Nearly 30% of the U.S. population aged 18 and older have used chiropractic. The Gallup Organization - 1991.
• WCB studies indicate a 45-55% saving in overall costs when treatments are provided by a chiropractors instead of a medical doctors. California, 1972 - Wisconsin, 1978 - Florida, 1988 - Utah, 1991 - State of Victoria, Australia, 1992.
• 9 out of 10 chiropractic users feel their treatment is effective. The Gallup Organization - 1991.
• 58% of those using chiropractic considered it an essential part of their health insurance package. The Gallup Organization - 1991.
• "Chiropractic patients were 3 times more satisfied with their care than patients of family practice physicians." Western Journal of Medicine - 1989.
• "Chiropractors are now accepted as a legitimate healing profession by the public and by an increasing number of physicians." The Manga Report - 1993.
• "Chiropractic is a growing component of the health care sector, and it is widely used by the population." The College of William and Mary, Williamsburg, Virginia, and Medical College of Virginia, Richmond, Virginia, January 1992.
• 94% of all spinal manipulations are performed by chiropractors. RAND Corporation.

Comparison Studies

Chiropractic Care versus...

• "Chiropractic Care, Second To None"
• Standard Medical Care
• Outpatient Hospital Care
• Physiotherapy
• Physiotherapy + Corset + Analgesics
• Mobilization
• Massage
• Exercise + Deep Heat
• Bed Rest
• Codeine
• Back School + Corset + Traction
• Deep Heat

Do You Know That Chiropractic Care Is Second To None?

According to a study conducted by Ontario's Ministry of Health, "...for the management of low-back pain, chiropractic care is the most effective treatment, and it should be fully integrated into the government's health care system." The same study also found, "...injured workers ... diagnosed with low-back pain returned to work much sooner when treated by chiropractors than by physicians."

According to the British Medical Research Council Study, spinal manipulation performed by chiropractors was found more effective than alternative treatments for low-back pain.

According to medical researcher TW Meade, M.D. "...chiropractic is a very effective treatment, more effective than conventional hospital outpatient treatment for low-back pain, particularly in patients who had back pain in the past and who got severe problems".

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

2. Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment. Meade, TW et al British Medical Journal - 1990;300:1431-1437.

Chiropractic Treatment vs. Standard Medical Care

Patient Evaluations	Chiro Care	Family M.D.
Mean number of days incapacitated after first visit	11 days	40 days
Restricted for greater than one week	17%	48%
Perception of doctor's confidence in diagnosing and treating back pain	60%	23%
Satisfied With Their Treatment	66%	22%

1. Patient Evaluations of Care from Family Physicians and Chiropractors. ACA Journal of Chiropractic - 1989.

Chiropractic Treatment vs. Outpatient Hospital Treatment by P.T.'s and M.D.'s

In this study, British medical researchers found chiropractic treatment significantly more effective than hospital outpatient treatment, especially in patients with chronic and severe back pain. Significantly fewer patients needed to return for further treatments at the end of the first and second year in those who received chiropractic care (17% compared with 24%). In addition, "two and three years after patients with back pain were treated by chiropractors, they experienced far less pain than those who were treated by medical doctors."

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

Chiropractic Treatment vs. Physiotherapy

Spinal manipulation provided greater improvement of symptoms in those suffering from persistent back and neck complaints compared with physiotherapy. The patients receiving spinal manipulation also had greater improvements of physical functioning in fewer visits.

1. Randomized Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up. Koes, B.W. et al. British Medical Journal - 1992;304:601-605.

Chiropractic Treatment vs. Physiotherapy + Corset + Analgesics

Statistical benefit for spinal manipulation at 3 weeks.

1. Manipulation in the Treatment of Low-back Pain: A Multicentre Study. Doran D and Newell DJ. British Medical Journal - 1975;2:161-164.

Chiropractic Treatment vs. Mobilization

Those receiving spinal manipulation achieved a 50% reduction in their pain levels more rapidly than those receiving mobilization (therapy commonly used by Physical Therapists).

1. A Benefit of Spinal Manipulation as Adjunctive Therapy for Acute Low-back pain: A Stratified Controlled Trial. Hadler NM et al. Spine - 1987;12:703-706.

Chiropractic Treatment (spinal manipulation) vs. Massage

In a group of patients, those receiving spinal manipulation obtained pain relief in a shorter period of time compared with massage. Also, significantly more subjects were able to return to work 6 months after treatment in the chiropractic treatment group compared with the massage therapy group (60% vs. 36%).

A Canadian study found spinal manipulation resulted in significantly greater back mobility compared with massage at 2 weeks (30% vs 15%).

1. The Efficacy of Manual Treatment in Low-back Pain: A Clinical Trial. Arkuszewski Z. Manual Medicine - 1986;2;68-71.

2. A Randomized Trial of Manipulation for Low-back Pain in a Medical Setting. Godfrey CM et al. Spine - 1984;9:301-304.

Chiropractic Treatment vs. Exercise Combined With Deep Heat Applications

Those receiving spinal manipulation experienced pain relief in a shorter period of time (3.5 vs. 5.8 treatments).

1. Acute Low-back Pain: Comparison of Two Conservative Treatment Approaches. Farrell JP and Twomey LT. Med J Aust - 1982;1:160-164.

Chiropractic Treatment vs. Bed Rest

50% of the individuals in the spinal manipulation group were pain free in 1 week compared with only 27% of those receiving bed rest only.

1. Low-back pain Treated by Manipulation. Coyer AB and Curwin I. British Medical Journal - 1955;1:705-707.

Chiropractic Treatment vs. Codeine

Spinal manipulation provided significant improvement in the subjects overall pain score compared with the commonly prescribed pain medication, codeine.

1. Lumbar Spinal Manipulation on Trial: Part 1 - Clinical Assessment. Evans DP et al. Rheumatology and Rehabilitation - 1978;17:46-53.

Chiropractic Treatment vs. Back School + Corset + Traction

Researchers found a statistically significant benefit with spinal manipulation at 4 weeks.

1. Multicentre Trial of Physiotherapy in the Management of Sciatic Symptoms. Coxhead CE et al. Lancet - 1981;1:1065-1068.

Chiropractic Treatment vs. Deep Heat Applications

Patients receiving spinal manipulation experienced a significantly shorter time to pain relief than those receiving deep heat applications.

Distinct benefit for spinal manipulation vs diathermy (deep heat application used by P.T.'s) in return to light work at one month.

Another study found spinal manipulation provided better pain relief for those with less than 1 week of pain and in patients with their first attack of back pain.

1. Relative Therapeutic Efficacy of Vertebral Manipulation and Conventional Treatment in Back Pain Management. Nwuga VC. American Journal of Physical Medicine - 1982;61:273-278.

2. Manipulation in the Treatment of Low-back Pain - A Randomized Clinical Trial. Rasmussen GG. Manuelle Medizin - 1979;1:8-10.

3. Back Pain: A Randomized Clinical Trial of Rotational Manipulation of the Trunk. Glover JL et al. British Journal of Industrial Medicine - 1974;31:59-64.

Cost Effectiveness Studies

It was estimated that 1992 low back pain costs in the US were a staggering $60 billion when production lost was taken into consideration. Research has indicated that low back pain disability is growing 14 times faster than the population. It's the leading cause of disability and morbidity in middle-aged persons, and is the most expensive source of workers' compensation costs in North America. In the 30-50 age group, low back pain is the single most expensive health care problem.

The escalating costs associated with low back pain have prompted legislators, policy makers and insurance companies to investigate cost-containment strategies. As you will see in the following studies, chiropractic care has been consistently identified as one of the most effective and cost effective treatments for the management of many low back conditions, in addition to a number of other neuromusculoskeletal disorders. Moreover, the volume of scientific evidence now being compiled makes a compelling case for the use of chiropractic as a means of controlling the escalating costs of our overburdened health care system.

1. Prevalence of Selected Impairments. United States - 1971. National Center for Health Statistics, Hyattsville, Maryland - 1975, DHHS Publication No. (PHS) 75-1526 (Series 10, No. 9) and 1981 DHHS Publication No. (PHS) 87-1587 (Series 10, No. 159)

2. Back Injuries in Industry: A Retrospective Study Part I Overview and Cost Analysis. Spengler et al. Spine, 1986 - 11(3):241-245.

• The Manga Report
• The Utah Study
• The Oakland University Study
• The Virginia Research Study
• The Florida Study
• The Av-Med Study
• The Australian Study

The Manga Report

The following excerpts from the Canadian government commissioned study clearly indicates the cost effectiveness of chiropractic treatment over standard medical treatment:

"The overwhelming body of evidence shows that chiropractic management of low-back pain is more cost effective than medical management, and that many medical therapies are of questionable validity or are clearly inadequate ... Chiropractic manipulation is safer than medical management of low-back pain."

"There would be highly significant cost savings if more management of low-back pain was transferred from physicians to chiropractors... Users of chiropractic care have substantially lower health care costs, especially inpatient costs, than those who use medical care only."

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

The Utah Study

In 1988 a Utah Workers' Compensation Board study found the total treatment costs for back-related injuries cost an average of $775.30 per case when treated by a doctor of chiropractic. When injured workers received standard medical treatment as opposed to chiropractic treatment, the average cost per case was $1,665.43.

They also found the mean compensation cost paid out by the Utah Worker's Compensation Board for patients treated by medical doctors was $668.39, while the mean compensation cost paid for patients treated by chiropractic doctors was only $68.38.

1. Cost per Case Analysis of Utah Industrial Back Injury Claims: Chiropractic Management vs. Medical Management for Diagnostically Equivalent Conditions. D.C. Tracts - 1989.

2. Cost per Case Comparison of Back Injury Claims of Chiropractic versus medical Management for Conditions with Identical Diagnostic Codes. Jarvis KB, et al. Journal of Occupational Medicine - 1991;33:847-852.

The Oakland University Study

After reviewing the health insurance claims for 395,641 chiropractic and medical care patients, Miron Stano, Ph.D., lead researcher, concluded:

Those patients who receive chiropractic care, either solely or in conjunction with medical care, experienced "significantly lower health care costs... on the order of $1,000 each over the two-year period" compared with those who received only medical care. Specifically, total insurance payments were $1,138 (30% higher) for those who elected medical care only. The lower costs for chiropractic patients were attributable both to lower inpatient and outpatient costs and indicated that "chiropractic treatment substitutes for other forms of outpatient care."

1. Stano/Medstat Research. Miron Stano, Ph.D. Oakland University.

The Virginia Research Study

An economic analysis conducted in Richmond, Virginia in 1992 found chiropractic care to be a lower cost option for back-related ailments. The researchers concluded that if chiropractic care was insured to the extent of other medical specialties, it would likely emerge as a first option for many patients with certain medical conditions. They also believed this could result in a decrease in the overall treatment costs for these conditions.

Additional research conducted by The College of William and Mary and the Medical College of Virginia in 1992 on mandated health insurance coverage and the economic impact of chiropractic coverage revealed:

• The low cost of chiropractic is due not to its low rate of use, but to its apparently offsetting impacts on costs in the face of high rates of utilization. Chiropractic is a growing component of the health care sector, and it is widely used by the population.
• Formal studies of the cost, effectiveness, or both of chiropractic, usually measured against other forms of treatment, show it to compare favorably with them.
• By every test of cost and effectiveness, the general weight of evidence shows chiropractic to provide important therapeutic benefits, at economical costs. Additionally, these benefits are achieved with apparently minimal, even negligible, impacts on the costs of health insurance.
• The conclusion of this analysis is that chiropractic mandates help make available health care that is widely used by the American public and has proven to be cost-effective.
• A Comparison of the Costs of Chiropractors versus Alternative Medical Practitioners. Dean DH, Schmidt RM. University of Richmond, Richmond, Virginia - January 13, 1992.

1. Mandated Health Insurance Coverage for Chiropractic Treatment: An Economic Assessment, with Implications for the Commonwealth of Virginia. Schifrin LG. The College of William and Mary, Williamsburg, Virginia, and Medical College of Virginia, Richmond, Virginia - January 1992.

The Florida Study

This large State of Florida study examined 10,652 patients who sustained back-related injuries on the job. Their findings revealed that individuals who received chiropractic care compared with standard medical care for similar diagnoses experienced had a,

i. 51.3 percent shorter temporary total disability duration

ii. lower treatment cost by 58.8 percent ($558 vs. $1,100 per case)

iii. 20.3 percent hospitalization rate in the chiropractic care group vs. 52.2 percent rate in the medical care group.

1. An Analysis of Florida Workers' Compensation Medical Claims for Back Related Injuries. Wolk S. Foundation for Chiropractic Education and Research, Arlington, VA. - 1988.

The Av-Med Study

In this study, 80 patients who previously received medical treatment were subsequently referred to the Silverman Chiropractic Center. Of the 80 patients, 21 percent had just been diagnosed with spinal disc problems, 12 percent had been diagnosed as requiring surgery and 5 percent had received emergency room treatment. Following chiropractic treatment, none of the patients were required to have surgery, 86 percent of the patients needed no further care, and the estimated health care savings in the group of 80 was estimated to be $250,000.

1. The Av-Med Study - 1993.

The Australian Study

In this Australian study, 1,996 workers' compensation cases were evaluated in patients who experienced work-related mechanical low back pain. It was found that those individuals who received chiropractic care for their back pain returned to work 4 times faster (6.26 days vs. 25.56 days) and had treatment that cost 4 times less ($392 vs. $1,569) than those who received treatments from medical doctors. Also, in those patients who received chiropractic care there was a significantly lower incidence of progression to a chronic low back pain status.

1. Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic Management Within the Victorian Work Care Scheme. Ebrall, PS. Chiropractic Journal of Australia - 1992;22:47-53.

Effectiveness Studies

• The Agency on Health Care Policy and Research Study
• The Rand Corporation Study
• The Manga Report
• The Av-Med Study
• The Midwest Research Institute Study
• The Annals of Internal Medicine Study

The Agency on Health Care Policy and Research Study

On December 8, 1994, the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services released Clinical Practice Guidelines for the management of acute low back pain. Their guidelines were developed after extensive study of diagnostic and treatment methods for acute low back pain.

The guidelines were created by the AHCPR panel to provide primary care clinicians with information and recommended strategies for the assessment and treatment of acute low back problems. The AHCPR panel was made up of 23 members consisting of medical doctors, chiropractic doctors, nurses, experts in spinal research, physical therapists, an occupational therapist, a psychologist, and a consumer representative.

The following conclusions were made in this landmark study:

• Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
• Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.

Other interesting finds included:

• The risk of serious complications from lumbar spinal manipulation is rare;
• There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
• The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.

1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (U.S. Department of Health and Human Services) -1994.

The Rand Corporation Study

Members of the Medical Community Recognize Chiropractic's Effectiveness.

This study, conducted by the prestigious RAND Corporation, marks the first time representatives of the U.S. medical community have gone on record stating that chiropractic is an appropriate treatment for certain low back pain conditions. A second, all-chiropractic panel's ratings show agreement with the multidisciplinary panel that spinal manipulation is appropriate for specific kinds of low back pain. A utilization study examining chiropractic patients' charts in multiple geographical locations in the United States is now underway. This will allow investigators to examine actual clinical cases and learn how prevalent each condition is in practice.

The RAND Corporation ("Research and Development") is a nonprofit private corporation in Santa Monica, California. They conduct research and development for the U.S. government and private sector, commanding international respect. It's research programs include classified defense research for the military, applied economics, education, sociology, civil justice and health sciences.

1. The Appropriateness of Spinal Manipulation for Lower Back Pain. Shekelle PG, et al. RAND Corporation, Santa Monica, California - 1992.

The Manga Report

As the largest existing analysis of scientific literature on low back pain, the 1993 Ontario Ministry of Health commissioned study drew international attention when it recommended the management of low back pain be moved from medical doctors to chiropractic doctors.

Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

The researchers also stated that studies on the prevalence and incidence of low back pain suggest that it is the leading cause of disability and morbidity in middle-aged persons, and is by far the most expensive source of workers' compensation costs North America.

The Canadian Government report concluded with the following findings:

• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by non-chiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;
• In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:
• the effectiveness and cost effectiveness of chiropractic management of low back pain
• the untested, questionable or harmful nature of many current medical therapies
• the economic efficiency of chiropractic care for low back pain compared with medical care
• the safety of chiropractic care
• the higher satisfaction levels expressed by patients of chiropractors.

The following recommendations were also included in the report:

• There should be a shift in policy to encourage and prefer chiropractic services for most patients with low back pain;
• Chiropractic services should be fully insured under the Ontario Health Insurance Plan;
• Chiropractic services should be fully integrated into the health care system;
• Chiropractors should be employed by tertiary hospitals in Ontario;
• Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs;
• Chiropractic should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients;
• Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with low back injuries;
• A very good case can be made for making chiropractors the gatekeepers for management of low back pain in the workers' compensation system in Ontario;
• The government should make the requisite research funds and resources available for further clinical evaluations of chiropractic management of low back pain, and for further socioeconomic and policy research concerning the management of low back pain generally;
• Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public finding;
• Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain. Pran Manga and Associates. University of Ottawa, Canada - 1993.

The Av-Med Study

In this study, 80 patients who previously received medical treatment were subsequently referred to the Silverman Chiropractic Center. Of the 80 patients, 21 percent had just been diagnosed with spinal disc problems, 12 percent had been diagnosed as requiring surgery and 5 percent had received emergency room treatment. Following chiropractic treatment, none of the patients were required to have surgery, 86 percent of the patients needed no further care, and the estimated health care savings in the group of 80 was estimated to be $250,000.

1. The Av-Med Study - 1993.

The Midwest Research Institute Study

This study examined clinical trials published in the professional literature between 1930 and 1981.

The researchers concluded that:

• manual therapy was superior to placebos,
• there was greater mobility following manipulation,
• the duration of treatment was shorter for the manipulated groups,
• there was improved lateral flexion and rotation after manipulation,
• the numerous case studies throughout the literature report the satisfaction of chiropractic patients with the outcome of treatments.

1. Chiropractic Evaluation Study Task III Report of the Relevant Literature. MRI Project No. 8533-D. MacDonald MJ, Morton L. For Department of Defense, OCHAMPUS, Aurora, Colorado - 1986.

The Annals of Internal Medicine Study

The Third Most Widely Read Medical Journal Finds Chiropractic A Winner In Low Back Pain.

The use, complications, and efficacy of spinal manipulation for low back pain was reviewed in the Annals of Internal Medicine, the third most widely read medical journal. The article concluded that spinal manipulation clearly helps patients with uncomplicated, acute low back pain.

1. Spinal Manipulation for Low Back Pain. Shekelle P, et al. Annals of Internal Medicine - 1992;117:590-598.

Government Studies on Chiropractic

There have been a number of large investigations conducted on chiropractic by the American, Canadian, New Zealand, Swedish and Australian governments over the last few decades. In all cases, their findings have supported the effectiveness and efficacy of Chiropractic.

Canada's 1993 Manga Report strongly recommended chiropractic care over medical care for the treatment and management of most low-back conditions. The 1994 AHCPR Study from the U.S. Department of Health and Human Services suggested that chiropractic spinal manipulation was a conservative and safe treatment for many low-back conditions and should be utilized prior to any surgical interventions in most cases.

Doctors of Chiropractic have now become integral to the development of governmental guidelines for the treatment of back conditions in Canada and the U.S. In addition, many hospitals are extending privileges to chiropractors and referrals between medical doctors and chiropractors are becoming increasingly common.

• US - "The Agency on Health Care Policy and Research Study"
• CANADA - "The Manga Report"
• NEW ZEALAND - "The New Zealand Commission Report"
• SWEDEN - "The Sweden Report"
• AUSTRALIA - "The Australian Report"

US - The Agency on Health Care Policy and Research Study

On December 8, 1994, the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services released Clinical Practice Guidelines for the management of acute low back pain. Their guidelines were developed after extensive study of diagnostic and treatment methods for acute low back pain.

The guidelines were created by the AHCPR panel to provide primary care clinicians with information and recommended strategies for the assessment and treatment of acute low back problems. The AHCPR panel was made up of 23 members consisting of medical doctors, chiropractic doctors, nurses, experts in spinal research, physical therapists, an occupational therapist, a psychologist, and a consumer representative.

The following conclusions were made in this landmark study:

• Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
• Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.

Other interesting finds included:

• The risk of serious complications from lumbar spinal manipulation is rare;
• There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
• The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.

1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (1994) - U.S. Department of Health and Human Services.

CANADA - The Manga Report

As the largest existing analysis of scientific literature on low back pain, the 1993 Ontario Ministry of Health commissioned study drew international attention when it recommended the management of low back pain be moved from medical doctors to chiropractic doctors.

Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

The researchers also stated that studies on the prevalence and incidence of low back pain suggest that it is the leading cause of disability and morbidity in middle-aged persons, and is by far the most expensive source of workers' compensation costs North America.

The Canadian Government report concluded with the following findings:

• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by nonchiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;
• In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:
  • the effectiveness and cost effectiveness of chiropractic management of low back pain
  • the untested, questionable or harmful nature of many current medical therapies
  • the economic efficiency of chiropractic care for low back pain compared with medical care
  • the safety of chiropractic care
  • the higher satisfaction levels expressed by patients of chiropractors.

The following recommendations were also included in the report:

• There should be a shift in policy to encourage and prefer chiropractic services for most patients with low back pain;
• Chiropractic services should be fully insured under the Ontario Health Insurance Plan;
• Chiropractic services should be fully integrated into the health care system;
• Chiropractors should be employed by tertiary hospitals in Ontario;
• Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs;
• Chiropractic should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients;
• Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with low back injuries;
• A very good case can be made for making chiropractors the gatekeepers for management of low back pain in the workers' compensation system in Ontario;
• The government should make the requisite research funds and resources available for further clinical evaluations of chiropractic management of low back pain, and for further socioeconomic and policy research concerning the management of low back pain generally;
• Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public finding;
• Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

NEW ZEALAND - The New Zealand Commission Report

This 377 page report, Chiropractic In New Zealand, was the most comprehensive and detailed independent examination of chiropractic ever undertaken at that time. The report withstood judicial hearings and extensive investigations by the Commission in New Zealand, the United States, Canada, England and Australia.

According to the researchers,

"We entered into our inquiry in early 1978. We had no clear idea what might emerge. We knew little about chiropractors. None of us had undergone any personal experience of chiropractic treatment. If we had any general impression of chiropractic it was probably that shared by many in the community: that chiropractic was an unscientific cult, not to be compared with orthodox medical or paramedical services. We might well have thought that chiropractors were people with perhaps a strong urge for healing, who had for some reason not been able to get into a field recognized by orthodox medicine and who had found an outlet outside the fringes of orthodoxy."

"But as we prepared ourselves for this inquiry it became apparent that much lay beneath the surface of these apparently simple terms of reference. In the first place it transpired that for many years chiropractors had been making strenuous efforts to gain recognition and acceptance as members of the established health care team. Secondly, it was clear that organized medicine in New Zealand was adamantly opposed to this on a variety of grounds which appeared logical and responsible. Thirdly, however, it became only too plain that the argument had been going on ever since chiropractic was developed as an individual discipline in the late 1800's, and that in the years between then and now the debate had generated considerable more heat than light."

"By the end of the inquiry we found ourselves irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is a soundly based and valuable branch of the health care in a specialized area..."

Their report includes the following findings:

• Chiropractic is a branch of the healing arts specializing in the correction by spinal manual therapy of what chiropractors identify as biomechanical disorders of the spinal column - they carry out spinal diagnosis and therapy at a sophisticated and refined level;
• Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy;
• General medical practitioners and physiotherapists have no adequate training in spinal manual therapy;
• Spinal manual therapy in the hands of a registered chiropractor is safe;
• The education and training of a registered chiropractor are sufficient to enable him/her to determine whether there are contraindications to spinal manual therapy in a particular case, and whether the patient should have medical care instead of or as well as chiropractic care;
• Spinal manual therapy can be effective in relieving musculoskeletal symptoms, such as back pain and other symptoms known to respond to such therapy, such as migraine;
• In a limited number of cases where there are organic and/or visceral symptoms, chiropractic treatment may provide relief, but this is unpredictable, and in such cases the patient should be under concurrent medical care if that is practicable;
• In the public interest and in the interests of patients, there must be no impediment to full professional cooperation between chiropractors and medical practitioners;
• It is wrong that the present law, or any medical ethical rules, should have the effect that a patient can receive spinal manual therapy which is subsidized by a health benefit only from those health professionals least qualified to deliver it;
• The responsibility for spinal manual therapy training, because of its specialized nature, should lie with the chiropractic profession and part-time or vacation courses in spinal manual therapy for other health professionals should not be encouraged.

1. New Zealand Report. Hasselberg PD. Government Printer, Wellington - 1979.

SWEDEN - The Sweden Report

Up until the late 1980's, Sweden had no legislation regulating the practice of chiropractic, although there were approximately 100 chiropractors in Sweden educated in accredited chiropractic colleges. In 1987, a commission on Alternative Medicine in Sweden conducted a detailed investigation of chiropractic education. They had the scientific literature assessed by university medical faculty and additionally commissioned a demographic survey by Statistics Sweden. Subsequent to the report, the Swedish government passed legislation recognizing and regulating the chiropractic profession in Sweden. Then, together with the governments from Denmark, Finland and Norway, it established a school of chiropractic at the University of Odense in Denmark to provide a regional chiropractic college for students from those countries.

The report's findings included:

• Doctors of chiropractic should become registered practitioners and be brought within the national insurance system in Sweden;
• Training for Doctors of Chiropractic follows a 4-5 year course of university level training and was found to be the equivalent to Swedish medical training - chiropractors have "competence in differential diagnosis" and should be regulated on a primary care basis";
• "Measures to improve cooperation between chiropractors, registered medical practitioners and physiotherapists are vital" in the public interest.

1. Ref 11 Supra.

AUSTRALIA - "The Australian Report"

In July of 1984 the Australian Federal Minister for Health asked their Medicare Benefits Review Committee to "consider requests for extending the scope of Medicare (government-funded health care) arrangements to provide benefits for certain paramedical services" - which included chiropractic services.

The Committee recommended funding for chiropractic in hospitals and other public institutions, and stated:

"We are aware of the very considerable organizational and professional obstacles... orthodox practitioners and, indeed, some chiropractors may initially find the experience an uneasy one, but we consider the differences that currently exist to be unreasonable and efforts should be made to bridge the gap."

"... the continuing schism between the two professions does little to help improve the health of the many Australians who might benefit from a joint chiropractic/medical approach to their problems."

1. Second Report Medicare Benefits Review Committee. Thompson CJ. Commonwealth Government Printer, Canberra, Australia, Chapter 10 (Chiropractic) - June 1986.

Workers' Compensation & Return to Work Studies

A number of workers' compensation studies have shown chiropractic care to be superior to medical care in the treatment of on the job back injuries. Chiropractors have been able to get their patients out of pain and back to work faster and with lower treatment costs.

• The Utah Study - fewer costs and days lost
• The Florida Study - shorter disability/lower costs/lower hospitalization rates
• The California Study - chiropractic patients get back to work sooner
• The Oregon Study - chiropractic gets individuals back to work, and fast!
• The Australian Study - cost & pain-relief effective with a lower chronicity rate
• The Manga Report - back to work, and fast

The Utah Study - fewer costs and days lost

This 1988 Utah workers' compensation board study found a tenfold savings for mean compensation costs in back-related injuries treated by chiropractors as compared with medical doctors ($68.38 vs. $668.39). To ensure accurate and true results, only those back-related injuries with the same diagnostic codes were compared between the two treatment groups. Also, the medical treatments assessed were limited to nonsurgical medical treatments only.

1. Cost per Case Comparison of Back Injury Claims of Chiropractic versus medical Management for Conditions with Identical Diagnostic Codes. Jarvis KB, et al. Journal of Occupational Medicine - 1991;33:847-52.

The Florida Study - shorter disability/lower costs/lower hospitalization rates

This large State of Florida study examined 10,652 patients who sustained back-related injuries on the job. Their findings revealed that individuals who received chiropractic care compared with standard medical care for similar diagnoses experienced had a:

i. 51.3 percent shorter temporary total disability duration

ii. lower treatment cost by 58.8 percent ($558 vs. $1,100 per case)

iii. 20.3 percent hospitalization rate in the chiropractic care group vs. 52.2 percent rate in the medical care group.

1. An Analysis of Florida Workers' Compensation Medical Claims for Back Related Injuries. Wolk S. Foundation for Chiropractic Education and Research, Arlington, VA. - 1988.

The California Study - chiropractic patients get back to work sooner

In this study, Richard Wolf, M.D. followed 500 individuals sent for chiropractic treatments and 500 individuals sent to medical doctors for treatment. Those who received chiropractic treatments returned to work in an average of 15.6 days vs. 32 days in those who received treatments from medical doctors.

1. Industrial Back Injury. Wolf CR. International Review of Chiropractic - 1974;26:6-7.

The Oregon Study - chiropractic gets individuals back to work, and fast!

This Oregon study found that individuals with workers' compensation claims returned to work significantly faster under chiropractic care compared with medical care. In fact, under chiropractic care 82% were able to return to work after one week compared with only 41% in those who received medical care.

1. A Study of Time Loss Back Claims. Portland, OR. Workers' Compensation Board, State of Oregon, March 1971.

The Australian Study - cost & pain-relief effective with a lower chronicity rate

In this Australian study, 1,996 workers' compensation cases were evaluated in patients who experienced work-related mechanical low back pain. It was found that those individuals who received chiropractic care for their back pain returned to work 4 times faster (6.26 days vs. 25.56 days) and had treatment that cost 4 times less ($392 vs. $1,569) than those who received treatments from medical doctors. Also, in those patients who received chiropractic care there was a significantly lower incidence of progression to a chronic low back pain status.

1. Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic Management Within the Victorian Work Care Scheme. Ebrall, PS. Chiropractic Journal of Australia - 1992;22:47-53.

The Manga Report - back to work, and fast

According to this Canadian government commissioned study,

"...injured workers ... diagnosed with low-back pain returned to work much sooner when treated by chiropractors than by physicians."

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

Patient Satisfaction Studies

Patient satisfaction studies have consistently shown that patients are extremely satisfied with the care they receive from chiropractors and far less satisfied with the care they receive from medical practitioners.

• The Gallup Study
• The Harris Poll
• Patient Evaluations of Care from Family Physicians and Chiropractors
• The Manga Report

The Gallup Study

In 1991 the Gallup Organization performed a nationwide demographic study to determine the attitudes, opinions, and behaviors of both users and nonusers of chiropractic services.

Their findings...

Overall, 90% felt that chiropractic health care was effective: more than 80% were satisfied with the treatment they received; nearly 75% felt that most of their expectations were met during the last visit or series of visits; 68% said they would likely see a doctor of chiropractic again for treatment of a similar condition, and 50% would likely be willing to see a doctor of chiropractic for some other problem chiropractors treat. Nearly 80% of the chiropractic users felt that the cost of chiropractic treatment was reasonable.

1. Demographic Characteristics of Users of Chiropractic Services. The Gallup Organization, Princeton, New Jersey - 1991.

The Harris Poll

According to this 1994 Harris Poll, patients were more satisfied with chiropractic care than care from medical doctors and other health care professionals.

Those who sought care from a chiropractor were more likely to be very satisfied with their care than those who visited any other practitioner. (Choices were between Chiropractic Doctors, Medical Doctors, Physical Therapists, or Osteopathic Doctors) Of those who have seen both types of practitioner, the majority were more likely to be satisfied with the care of the chiropractor than with that of the medical doctor.

1. 1994 Harris Poll.

Patient Evaluations of Care from Family Physicians and Chiropractors

Findings from this study indicate that patients under chiropractic care had 3 times the satisfaction rate as did patients under the care of Family Physicians. In addition, the patient's perception of the doctor's confidence in diagnosing and treating low back pain was almost 3 times higher in patients receiving chiropractic care compared with those receiving care from family physicians.

1. Patient Evaluations of Care from Family Physicians and Chiropractors. Cherkin, D., MacCornack, F. Western Journal of Medicine - 1989;150:351-355.

The Manga Report

As the largest existing analysis of scientific literature on low back pain, the 1993 Ontario Ministry of Health commissioned study drew international attention when it recommended the management of low back pain be moved from medical doctors to chiropractic doctors.

Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

According to lead investigator Pran Manga, Ph.D.,

"There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management."

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain. Pran Manga and Associates. University of Ottawa, Canada - 1993.