Education/Exercise and Chiropractic for Chronic Back Pain
|Low Back Pain||Behavioral: Education & Exercise Procedure: Chiropractic treatment (plus Education & Exercise)|
|Study Design:||Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
|Official Title:||Education/Exercise and Chiropractic for Chronic Back Pain|
- Participant Adherence With Education + Exercise Visits [ Time Frame: 12 weeks ]Number of participants completing at least 3 of 4 education + exercise visits
- Participant Adherence With Chiropractic Visits [ Time Frame: 12 weeks ]Number of participants who completed at least 12 chiropractic visits.
- Participant Adherence With "Time and Attention" Visits [ Time Frame: 12 weeks ]Number of participants who completed at least 8 of 10 "time and attention" visits. Note that only arm 1 (nonchiropractic arm) receives "time and attention" visits.
- Participant Adherence With Prescribed Home Exercise [ Time Frame: 12 weeks ]Number of participants who completed at least 20 hours of home exercise
- Participant Adherence With Week 6 Follow-up Questionnaire [ Time Frame: 6 weeks ]Number of participants who completed their week 6 follow-up questionnaire
- Participant Adherence With Week 12 Follow-up Questionnaire [ Time Frame: 12 weeks ]Number of participants who completed their week 12 follow-up questionnaire
- Participant Adherence With Week 26 Follow-up Questionnaire [ Time Frame: 26 weeks ]Number of participants who completed week 26 follow-up questionnaire
|Study Start Date:||April 2008|
|Study Completion Date:||July 2009|
|Primary Completion Date:||July 2009 (Final data collection date for primary outcome measure)|
Active Comparator: Education + exercise
Education was provided in four, 1-hour sessions to improve patients' understanding of their back problem, reduce unwarranted concern about serious outcomes, & empower them to maintain normal activities & reduce risk of future back problems. Patients were taught that recovery depends on moving & restoring normal function & fitness. Patients were shown stretching & strengthening exercises to perform daily at home to enhance mobility & increase trunk endurance while minimizing spinal load. At follow-up, therapists reviewed exercise form & adherence. Participants allocated to no chiropractic care also were scheduled for 10 weekly 10-15 minute sessions to equalize provider attention vs. the group also receiving chiropractic care & not to provide education, exercise instruction, or therapy.
Behavioral: Education & Exercise
Education & Exercise
Experimental: Education + exercise + chiropractic
In addition to education & exercise, all participants in this arm will be assigned chiropractic treatment. A minimum of 4 & up to 12 treatments will be provided over 6 weeks, based on patient response (i.e. treatments stopped if symptoms resolve). Each treatment visit will last 10-20 minutes. After 6 weeks, if the treating chiropractor determined that the patient's LBP was continuing to improve but hadn't reached therapy goals defined at baseline, the patient could receive up to 12 additional treatments over the next 6 weeks. Chiropractic treatment was delivered following standardized protocols. Treatment consisted of manual therapies, including SMT and mobilization techniques, with the assistance of light soft tissue techniques as indicated to facilitate the SMT.
Behavioral: Education & Exercise
Education & ExerciseProcedure: Chiropractic treatment (plus Education & Exercise)
Chiropractic treatment (plus Education & Exercise)
Chronic low back pain (LBP) is associated with poor health, lower quality of life, high costs, and is highly prevalent in veterans. Both chiropractic care and exercise have modestly reduced pain and/or improved function in randomized controlled trials (RCTs) of patients with chronic LBP. However, effects may not apply similarly to all populations. For example, there are no RCT data on chiropractic care for older (age >70) patients with chronic LBP, though with increased spinal arthritis, comorbidities and frailty, such patients may require modified chiropractic techniques and likely differ in response to chiropractic treatment. While a recent systematic review of RCTs predicted that a home exercise program that was individualized, high-dose, therapist-directed, and incorporated stretching and strengthening would be a meaningful treatment for chronic LBP, it also could provide a robust comparison group for other chronic LBP treatments. The combination of such a regimen and chiropractic care is predicted to have additive benefits for chronic LBP but this premise hasn't been directly tested. To further our aim of improving the health of chronic LBP patients, we plan an RCT in veterans with chronic LBP, to compare the effectiveness, cost-effectiveness and cost-utility of a tailored education/exercise (E/E) intervention alone vs. E/E plus chiropractic care. The demographics and medical complexity of the veteran population provide a great opportunity to test the appropriate role of chiropractic care for such patients with chronic LBP and to advance chronic LBP research and clinicalcare.
Subjects will be recruited primarily from patients attending Minneapolis VAMC clinics with complaints of chronic LBP. Thirty eligible veterans will be randomized to E/E alone vs. E/E plus chiropractic care. All participants will receive E/E instruction in four 1-hr individual sessions over 8 weeks, including an individually designed, high dose, therapist-directed home exercise program. Chiropractic care will be delivered by chiropractors and follow standard protocols, with up to 12 sessions over 12 weeks. Participants randomized to E/E alone also will attend 10 weekly "time and attention" visits so that their contact with providers is comparable to that received by participants who also receive chiropractic care. Each "time and attention" session involved a 5 minute exam, 5 minutes of hot pack application to the low back, and 5 minutes of light massage to the low back. During these visits, participants did not receive SMT, mobilization or other active chiropractic treatment. The recruitment goal is to generate the potential to randomize 6-10 participants/month. Recruitment feasibility will be assessed by tracking the number of patients who make initial inquiries, undergo screening and in-clinic evaluation, and are randomized. Further, reasons for nonparticipation and disqualification will be examined and described. Participant adherence to interventions will be defined as completing >3 of 4 education sessions, >20 hrs of home exercise, and >80% of recommended chiropractic visits or nonchiropractic follow-up exam/interviews. Adherence with clinic visits will be assessed with provider treatment logs. Home exercise compliance will be tracked by questionnaire. Participant adherence to data collection will be defined as >90% follow-up rates at each time point and assessed by tracking questionnaire completion rates. Descriptive data for the distributions of the primary and main secondary efficacy outcome measures will be used to calculate sample size and generate power tables for the full-scale trial.
Please refer to this study by its ClinicalTrials.gov identifier: NCT00561652
|United States, Minnesota|
|Minneapolis VA Health Care System|
|Minneapolis, Minnesota, United States, 55417|
|Principal Investigator:||Howard A. Fink, MD MPH||Minneapolis VA Health Care System|