Spinal manipulation: when is it appropriate?
Explore the source record for details and available documents.
Acute Disease↗
Biomedical subjects
R A Deyo
Publications and source records attributed to R A Deyo.
Imaging studies for acute low back pain. When and when not to order them.
Acute low back pain is generally a self-limited condition, and most patients recover within a few weeks without the need for imaging studies. However, physicians need to be on the lookout for red flags that point to more serious conditions, such as infection or malignancy, which require imaging. In this article, the authors identify these warning signs and discuss the appropriate use of imaging studies for a variety of symptoms and conditions.
Acute Disease↗
A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain.
BACKGROUND AND METHODS: There are few data on the relative effectiveness and costs of treatments for low back pain. We randomly assigned 321 adults with low back pain that persisted for seven days after a primary care visit to the McKenzie method of physical therapy, chiropractic manipulation, or a minimal intervention (provision of an educational booklet). Patients with sciatica were excluded. Physical therapy or chiropractic manipulation was provided for one month (the number of visits was determined by the practitioner but was limited to a maximum of nine); patients were followed for a total of two years. The bothersomeness of symptoms was measured on an 11-point scale, and the level of dysfunction was measured on the 24-point Roland Disability Scale. RESULTS: After adjustment for base-line differences, the chiropractic group had less severe symptoms than the booklet group at four weeks (P=0.02), and there was a trend toward less severe symptoms in the physical therapy group (P=0.06). However, these differences were small and not significant after transformations of the data to adjust for their non-normal distribution. Differences in the extent of dysfunction among the groups were small and approached significance only at one year, with greater dysfunction in the booklet group than in the other two groups (P=0.05). For all outcomes, there were no significant differences between the physical-therapy and chiropractic groups and no significant differences among the groups in the numbers of days of reduced activity or missed work or in recurrences of back pain. About 75 percent of the subjects in the therapy groups rated their care as very good or excellent, as compared with about 30 percent of the subjects in the booklet group (P<0.001). Over a two-year period, the mean costs of care were $437 for the physical-therapy group, $429 for the chiropractic group, and $153 for the booklet group. CONCLUSIONS: For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.
Adult↗
Outcome measures for low back pain research. A proposal for standardized use.
STUDY DESIGN: An international group of back pain researchers considered recommendations for standardized measures in clinical outcomes research in patients with back pain. OBJECTIVES: To promote more standardization of outcome measurement in clinical trials and other types of outcomes research, including meta-analyses, cost-effectiveness analyses, and multicenter studies. SUMMARY OF BACKGROUND DATA: Better standardization of outcome measurement would facilitate comparison of results among studies, and more complete reporting of relevant outcomes. Because back pain is rarely fatal or completely cured, outcome assessment is complex and involves multiple dimensions. These include symptoms, function, general well-being, work disability, and satisfaction with care. METHODS: The panel considered several factors in recommending a standard battery of outcome measures. These included reliability, validity, responsiveness, and practicality of the measures. In addition, compatibility with widely used and promoted batteries such, as the American Academy of Orthopaedic Surgeons Lumbar Cluster were considered to minimize the need for changes when these instruments are used. RESULTS: First, a six-item set was proposed, which is sufficiently brief that it could be used in routine care settings for quality improvement and for research purposes. An expanded outcome set, which would provide more precise measurement for research purposes, includes measures of severity and frequency of symptoms, either the Roland or the Oswestry Disability Scale, either the SF-12 or the EuroQol measure of general health status, a question about satisfaction with symptoms, three types of "disability days," and an optional single item on overall satisfaction with medical care. CONCLUSION: Standardized measurement of outcomes would facilitate scientific advances in clinical care. A short, 6-item questionnaire and a somewhat expanded, more precise battery of questionnaires can be recommended. Although many considerations support such recommendations, more data on responsiveness and the minimally important change in scores are needed for most of the instruments.
Clinical Trials as Topic↗
5-year reoperation rates after different types of lumbar spine surgery.
STUDY DESIGN: Population-based cohort study of Washington State patients who underwent lumbar spine surgery for degenerative conditions in 1988. OBJECTIVES: To compare complications and reoperation rates during the 5-year period after surgery between patients who have undergone lumbar spine fusion surgery and those who have undergone laminectomy or discectomy alone. SUMMARY OF BACKGROUND DATA: Spinal fusion is associated with wider surgical exposure, more extensive dissection, and longer operative times than lumbar surgery without fusion, and previous studies have shown higher complication rates and hospital charges associated with these more complex procedures. In elderly patients, spinal fusion operations were associated with higher mortality rates than laminectomy or discectomy alone, and reoperation rates were not lower. In the current study, reoperations, mortality, and complications following lumbar spine surgery were examined for the general population. METHODS: A statewide hospital discharge database was used to identify all Washington patients who underwent spine surgery in 1988 and to determine the rate of reoperation during the subsequent 5 years. Administrative records also were used to identify complications, mortality, and hospital charges associated with the operations. Unadjusted complication and reoperation rates for the groups were compared using chi-square statistics. Adjusted rates were compared using logistic regression and proportional hazards (Cox) regression after controlling for age, gender, prior spine surgery, diagnosis, comorbidity, type of surgery, and coverage by Workers' Compensation. RESULTS: Of 6376 patients who underwent lumbar surgery for degenerative conditions in Washington in 1988, 1041 (16%) had operations involving spine fusion. Diagnoses of degenerative disc disease or possible instability were more frequent among patients undergoing fusion surgery, whereas herniated discs were more frequent among those undergoing discectomy or laminectomy alone. Complications were recorded in 18% of fusion patients and 7% of nonfusion patients (P < 0.01), but mortality rates did not differ. Unadjusted reoperation rates over the 5-year period were greater for patients who underwent fusion than for patients who underwent nonfusion surgery (18% vs. 15%, respectively), but after adjustment for baseline characteristics, fusion patients had only a slightly greater (and nonsignificant) risk of reoperation (relative risk 1.1, confidence interval .9-1.3). CONCLUSION: As in previous studies, complications in the current study occurred more frequently among patients who underwent lumbar spine fusion than among those who underwent laminectomy or discectomy alone. Reoperations were at least as frequent after fusion, but the authors could not assess treatment efficacy in terms of pain relief or improved function. Although the characteristics of patients undergoing fusion differed from those undergoing a laminectomy or discectomy alone, there appeared to be sufficient overlap in the clinical populations to warrant closer scrutiny of the safety, efficacy, and indications for spinal fusions, preferably in randomized trials.
Adult↗
Medication use for low back pain in primary care.
STUDY DESIGN: A longitudinal observational study of primary care patients with low back pain. OBJECTIVES: 1) To describe medications prescribed for back pain, 2) to identify patient characteristics associated with type of drug therapy, 3) to determine if the prescription of certain drugs is associated with better outcomes, and 4) to compare physician prescribing behavior with national guidelines. SUMMARY OF BACKGROUND DATA: Few previous studies have focused on medication prescribing patterns for back pain in primary care. METHODS: Two-hundred nineteen patients aged 20-69 years who were making a first visit for an episode of back pain were studied. After the visit, patients completed questionnaires regarding sociodemographic characteristics, health status, back pain experience, and use of medications. Symptom severity and dysfunction were assessed by telephone 1 week after the visit. RESULTS: Sixty-nine percent of patients were prescribed nonsteroidal anti-inflammatory drugs, 35% muscle relaxants, 12% narcotics, and 4% acetaminophen. Twenty percent received no medications. Patients were more likely to receive medications if they had a desire for medication, pain below the knee, less than 3 weeks of pain before visit, more severe symptoms, or greater dysfunction. Patients with more severe symptoms were more likely to receive narcotics or muscle relaxants. Patients with greater dysfunction were also more likely to receive narcotics. Type of drug therapy predicted symptom severity but not dysfunction after 1 week. Controlling for other factors, those receiving medications had less severe symptoms after 1 week than patients who received no medication. Patients receiving both muscle relaxants and nonsteroidal anti-inflammatory drugs had the best outcomes. Medication use for back pain in this health maintenance organization was generally concordant with national guidelines. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs, often augmented by muscle relaxants, are a standard medical treatment for back pain in primary care. In this observational study, patients prescribed medications, particularly muscle relaxants, reported less severe symptoms after 1 week than those receiving no medications. However, randomized trials are needed to determine which medication or combinations of medications are most effective.
Adult↗
The importance of radiating leg pain in assessing health outcomes among patients with low back pain. Results from the Veterans Health Study.
STUDY DESIGN: Cross-sectional data were analyzed from the Veterans Health Study, an observational study of patients receiving ambulatory care. OBJECTIVE: To develop a method of stratifying patients with low back pain by combining patient reports of radiating leg pain with the results of straight leg raising tests. SUMMARY AND BACKGROUND DATA: Four hundred thirty-four participants with low back pain were identified through patient reports of ever having had low back pain, of low back pain that began more than 3 months ago, and of a health-care visit for low back pain in the past year. Four hundred twenty-eight patients with low back pain were included in the current analysis. METHODS: Participants were mailed a health-related quality of life questionnaire and had an interview that included a low back pain questionnaire and a straight leg raising test. Patients' reports of radiating leg pain and results of the straight leg raising tests were combined into four hierarchical groups. This stratification was evaluated in relation to responses to the health-related quality of life questionnaire, localized low back pain, disability, and use of medical services. RESULTS: The intensity of localized low back pain and disability increased from Group 1 (low back pain alone) to Group 4 (pain below knee with positive straight leg raising test result), whereas health-related quality of life decreased. Group 4 patients were 5.1 times more likely than were Group 1 patients to use medications for low back pain (95% confidence interval 1.2, 22.9), 6.8 times more likely to have a spinal magnetic resonance study (95% confidence interval, 2.7, 17.2), and 3.9 times more likely to have surgery (95% confidence interval, 1.3, 11.4). CONCLUSIONS: The method of measuring correlation performs well in identifying patients with different levels of localized low back pain intensity, health-related quality of life, and use of services. It may be useful in studies of health outcomes, in clinical trials, and in predicting demands on health care resources.
Aged↗
Trends in hospital use for mechanical neck and back problems in Ontario and the United States: discretionary care in different health care systems.
OBJECTIVE: To describe and compare trends in hospital admission rates for mechanical neck and back problems between 1982 and 1992 in Ontario and the United States. DESIGN: A descriptive analysis of hospital admissions, with data for Ontario extracted from the Canadian Institute for Health Information database and data for the US extracted from the National Hospital Discharge Survey. SETTING: All acute care hospitals in Ontario and a probability sample of acute care hospitals in the US. PATIENTS: Adults aged 20 years or more who were admitted to an acute care hospital for mechanical neck or back problems in 1982, 1987 or 1992. Mechanical neck and back problems were defined using an algorithm developed by the study team. OUTCOME MEASURE: Hospital admission rate per 100,000 adults. RESULTS: Between 1982 and 1992 the hospital admission rate for medically treated cases decreased by 52% in Ontario and by 75% in the US. Over the same period the admission rate for surgically treated cases increased by 14% and by 35% respectively. By 1992 the admission rate for medically treated cases in the US was 23% higher than that in Ontario, whereas the rate for surgically treated cases was 164% higher. CONCLUSIONS: The hospital-based medical or surgical treatment of mechanical neck and back problems provides an example of discretionary care. The higher admission rates for surgery in the US may reflect a larger supply of surgical specialists and imaging units. Further work is needed to confirm these findings for other types of discretionary care and to compare the appropriateness of care and clinical outcomes for discretionary care in these 2 jurisdictions.
Adult↗
Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States.
OBJECTIVE: To provide a single source for the best available estimates of the national prevalence of arthritis in general and of selected musculoskeletal disorders (osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, the spondylarthropathies, systemic lupus erythematosus, scleroderma, polymyalgia rheumatica/giant cell arteritis, gout, fibromyalgia, and low back pain). METHODS: The National Arthritis Data Workgroup reviewed data from available surveys, such as the National Health and Nutrition Examination Survey series. For overall national estimates, we used surveys based on representative samples. Because data based on national population samples are unavailable for most specific musculoskeletal conditions, we derived data from various smaller survey samples from defined populations. Prevalence estimates from these surveys were linked to 1990 US Bureau of the Census population data to calculate national estimates. We also estimated the expected frequency of arthritis in the year 2020. RESULTS: Current national estimates are provided, with important caveats regarding their interpretation, for self-reported arthritis and selected conditions. An estimated 15% (40 million) of Americans had some form of arthritis in 1995. By the year 2020, an estimated 18.2% (59.4 million) will be affected. CONCLUSION: Given the limitations of the data on which they are based, this report provides the best available prevalence estimates for arthritis and other rheumatic conditions overall, and for selected musculoskeletal disorders, in the US population.
Adolescent↗
Health consequences of pregnancy and childbirth as perceived by women and clinicians.
OBJECTIVE: To develop patient-centered outcome measures for clinical research by characterizing the effects of pregnancy and childbirth on functioning. METHODS: Five focus groups of mothers (n = 33) and three focus groups of clinicians (midwives [n = 8], obstetricians [n = 4], and family practitioners [n = 7]) were convened. Discussions were audiotaped and transcribed. Major narrative themes were identified by using two independent readers and were confirmed by participants and additional clinicians. RESULTS: Themes were grouped into four outcome domains: physical, psychologic, sexual, and social. Themes identified included lack of knowledge about postpartum health, emotional lability, sexual satisfaction, depression, parenting skills, body image, fatigue, and incontinence. Lack of knowledge about typical postpartum health was the dominant theme for mothers and clinicians. Mothers felt unprepared for the health consequences of pregnancy and delivery. Clinicians lamented that paucity of data made counseling and treating patients difficult. Decreased functioning months after delivery was reported. Differences between mother and clinician concerns surfaced, particularly in emphasis. Mothers wanted more information about their health; providers emphasized newborn care. Mothers reported inspiration to improve their economic circumstances; clinicians emphasized improving maternal health. Mothers wanted control during labor, whereas clinicians believed control was not always possible. CONCLUSION: Women often felt poorly prepared for the postpartum period in part because functional health consequences are not well understood. This study suggests maternal functional health may be decreased for months after delivery, even among uncomplicated patients. This study identified new maternal outcome measures, which are being incorporated into an outcomes questionnaire.
Adaptation, Psychological↗
Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State.
OBJECTIVE: To examine back and neck hospitalizations in the Province of Ontario and Washington State. Because of their different organization and financing, there has been considerable interest in comparing healthcare systems in Canada and the United States. Features of healthcare systems might be expected to result in greater variations in care for elective than urgent conditions. DATA SOURCE: Automated hospital discharge databases. STUDY DESIGN: Previously developed algorithms were used to identify surgical and nonsurgical hospitalizations for back and neck problems in the administrative databases. We compared overall rates of hospitalization and lengths of hospital stay in Ontario and Washington as well as small area variations within the province and state. PRINCIPAL FINDINGS: Surgical back and neck hospitalizations were three times as common in Washington, but medical hospitalizations were twice as common in Ontario. Provincial lengths of stay were longer for both surgical and nonsurgical hospitalizations. Admission rates varied substantially and significantly among small areas in both Washington and Ontario. Variations in hospital length of stay were greater in Ontario, particularly for nonsurgical back and neck hospitalizations. CONCLUSION: The two jurisdictions had very different patterns of hospital utilization for one of the most common health problems seen by physicians. Our results suggest that the global controls on hospital budgets and access to technology in Ontario were associated with lower rates of surgery, higher rates of hospital-based medical care, and longer lengths of stay. They also indicate that the utilization review process in Washington was associated with lower small area variation rates for medical back care.
Adult↗
The effect of Medicare's payment system for rehabilitation hospitals on length of stay, charges, and total payments.
BACKGROUND: Medicare's system for the payment of rehabilitation hospitals is based on limits derived from a hospital's average allowable charges per patient discharged during a base year. Thereafter, payments are capped but hospitals receive incentive payments if charges per patient are reduced in succeeding years. We hypothesized that per-patient charges would increase during the base year and then decrease in subsequent years. Hospitals would thus have higher reimbursement limits and receive incentive payments for reducing their charges. METHODS: We analyzed Medicare claims data for 190,921 discharges from 69 rehabilitation hospitals from 1987 through 1994. We compared total charges, length of stay, and interim payments before, during, and after each hospital's base year. RESULTS: After we controlled for inflation and temporal and seasonal trends, mean charges per patient discharged increased from $25,131 for patients discharged before the base year to $32,167 for patients discharged in the base year (a 28 percent increase, P<0.001) and the mean length of stay increased from 22.1 to 26.7 days (a 21 percent increase, P<0.001). After the base year, mean charges decreased to $29,307 (a 9 percent decrease) and the mean length of stay decreased to 24.0 days (a 10 percent decrease) (P<0.001 for both comparisons). Analysis of data on patients according to diagnosis -- for example, spinal cord injury, brain injury, stroke, amputations and deformities, hip fracture, and arthritis and joint disorders -- showed similar findings for each, with increases in charges and length of stay in the base year, followed by smaller reductions thereafter. For-profit hospitals had greater increases than nonprofit hospitals in their per-patient charges (mean increase, $7,434 vs. $2,929; P<0.001) and length of stay (mean increase, 4.6 vs. 2.3 days, P<0.001) during the base year. CONCLUSIONS: Although Medicare's reimbursement system for rehabilitation hospitals put an upper limit on total payments, its design was associated with substantial extra costs, including significantly increased payments to hospitals and doctors and increased numbers of hospital days for the average patient.
Aged↗
The messenger under attack -- intimidation of researchers by special-interest groups.
Explore the source record for details and available documents.
Biomedical Research↗
Predicting long-term functional limitations among back pain patients in primary care settings.
To identify predictors of back-related long-term functional limitations, 1213 adult enrollees of a Health Maintenance Organization (HMO) in Washington state were interviewed about a month after a consultation for back pain in a primary care setting in 1989-1990, and followed each year thereafter. Out of 100 factors documented at the one-month assessment, measures of somatization, depression, functional limitations, and pain were the strongest predictors of two-year modified Roland-Morris score among a random subsample of 569 subjects. A multiple regression model containing the Symptom Checklist Depression and Somatization scores, the one-month modified Roland-Morris score and the number of pain days in the past six months explained about 30% of the variance in the outcome. Using recursive partitioning, a very simple model was developed to identify patients at high risk of sustaining long-term significant functional limitations. The regression model and the recursive partitioning model were successfully tested in a fresh sample of patients (n = 644). Clinical application of the recursive partitioning model and methodological aspects of this study are discussed.
Adult↗
Impact of a worker's compensation practice guideline on lumbar spine fusion in Washington State.
OBJECTIVES: In the face of escalating medical costs for injured workers, the Washington State Department of Labor and Industries (L&I), which pays for most workers' compensation costs in the state, established guidelines for elective lumbar fusion as part of its inpatient utilization review program. The guidelines were tied to reimbursement strictures. The authors attempt to assess the effects of these guidelines, which were introduced in November 1988, upon subsequent L&I fusion procedures. METHODS: Discharge data from the Comprehensive Hospital Abstract Reporting System and algorithms using International Classification of Diseases, Version 9, Clinical Modification diagnosis and procedure codes were used to identify lumbar surgical cases. Population estimates were from the 1990 US Census Bureau. RESULTS: During the period of years 1987 through 1992, the lumbar fusion rate for the state showed a 26% decline compared with a 3% decrease for all lumbar operations. After November 1988, when the guidelines went into effect, the state fusion rate declined 33%, whereas rates for nonfusion operations essentially were unchanged. The sharpest decline corresponded in time to implementation of the guidelines. Prior to the initiation of L&I guidelines, the proportion of fusions among L&I patients was higher than among non-L&I patients. The opposite was true by the end of 1992, and the L&I proportion decreased more rapidly than the non-L&I proportion. Time series analysis revealed that both the decline in Washington state lumbar fusion rates and the decline in the proportion of lumbar fusion among L&I patients were statistically significant. CONCLUSIONS: The data suggest that the L&I lumbar fusion surgery criteria and reimbursement standards implemented in 1988 contributed to a decline in rates of performing that procedure. The utilization review aspect of the guidelines as well as the process of involving surgeons in the preparation and dissemination of guidelines also may have been contributory.
Adult↗