Cervical Arterial Dysfunction

Cervical arterial dysfunction (CAD) is an umbrella term used in manual therapy and physiotherapy to cover a range of vascular pathologies which may lead to cervico-cranial ischaemia. CAD is inclusive of all known vascular pathologies and anatomical structures that may be compromised by movement or manual therapy. Further, the clinical model of CAD incorporates the notion of assessing for patients presenting to physiotherapists with neuromusculoskeletal neck and head pain who may have an increased risk of developing an associated pathology. (Physiopedia)

Association Between Utilization Of Chiropractic Services For Treatment Of Low Back Pain And Use Of Prescription Opioids

Among New Hampshire adults with office visits for non-cancer low back pain, the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with non-recipients. The underlying cause of this correlation remains unknown, indicating the need for further investigation. Whedon et al. (2018) Journal of Alternative and Complementary Medicine


A study by RAND updated the randomized controlled trials evidence for these manual procedures and concludes: “There is moderate quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.” Coulter I, Crawford C, Hurwitz E, et al. Manipulation and Mobilization for Treating Chronic Low Back Pain: A Systematic Review and Meta-Analysis. The Spine Journal (2018)

Prevention And Treatment Of Low Back Pain: Evidence, Challenges, And Promising Directions

The Lancet published a three-part series on low back pain, which addresses the issues around low back pain and calls for worldwide recognition of the disability associated with the disorder and the removal of harmful practices. In the second paper, recommendations for the treatment of low back pain are outlined, including spinal manipulation, which is most often performed by a doctor of chiropractic, and the scarcity of research into prevention of low back pain. Foster et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet (2018).

Chiropractic Integrated Care Pathway For Low Back Pain In Veterans: Results Of A Delphi Consensus Process

The modified Delphi process was conducted in July to December 2016. Most (93 percent) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards,

tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and inter-professional collaboration and referrals between doctors of chiropractic and primary care and mental health providers. Conclusion: This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain. Lisi et al. (2018) Journal of Manipulative and Physiological Therapeutics

The American College of Physicians (ACP)

ACP developed this guideline to present the evidence and provide clinical recommendations for non-invasive treatment of low back pain. Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and non-pharmacologic treatments for low back pain.  Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians(2017)   

Association Of Spinal Manipulative Therapy With Clinical Benefit And Harm For Acute Low Back Pain: Systematic Review And Meta-Analysis

In a 2017 study published in the Journal of the American Medical Association, Paige et al., completed a systematic review of randomized controlled trials (RCTs) on the effectiveness and harms of Spinal Manipulative Therapy (SMT) for acute (6 weeks) low back pain. Of 26 eligible studies identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain, and twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function. The RCTs represented studies of adults with low back pain treated in ambulatory settings with spinal manipulative therapy compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. The authors conclude that among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. Paige et al. (2017) Journal of the American Medical Association

Variations In Patterns Of Utilization And Charges For The Care Of Headache In North Carolina, 2000-2009: A Statewide Claims’ Data Analysis

During 2000-2009, utilization and expenditures for headache treatment increased across all providers. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk adjusted charges were significantly less for DC-only care. Hurwitz et al. (2016) Journal of Manipulative and Physiological Therapeutics.

Integrated Chronic Pain Program (Icpp): Summary Of Results

Advanced Medicine Integration Group (AMI) of Rhode Island’s ongoing Integrated Chronic Pain Program reduced per member per year total average medical costs by 27 percent, decreased the average number of ER visits by 61 percent, lowered the number of average total prescriptions by 63 percent and reduced the average number of opioid scripts by 86 percent for enrolled Community of Care (CoC) Medicaid members with chronic pain conditions. Client validated, these reductions exceeded by 2 to 3 times those reported for a non-enrolled control group of conventionally managed CoC chronic pain patients. Every $1 spent on CAM services, including chiropractic, and AMI program fees resulted in $2.41 of medical expense savings. AMI Group, L.P. (2016)

Upper Cervical And Upper Thoracic Manipulation Versus Mobilization And Exercise In Patients With Cervicogenic Headache: A Multi-Center Randomized Clinical Trial

One hundred and ten participants with cervicogenic headache were randomized to receive both cervical and thoracic spinal manipulation, or combined mobilization and exercise. The findings indicated that manipulation was more effective at reducing headache intensity and disability. Additionally, the manipulation group experienced significantly reduced duration and frequency of headaches. These findings suggest that high-velocity low-amplitude manipulation was more effective in the treatment of cervicogenic headache than the slow mobilization technique intervention. Dunning et al. (2016) BioMed Central Musculoskeletal Disorders

Manipulation And Mobilization For Neck Pain Contrasted Against An Inactive Control Or Another Active Treatment

Gross et al., in a review of randomized controlled trials found that for acute to subacute neck pain, cervical spine manipulation was more effective than various combinations of prescription medications for improving pain and functional improvement. Gross et al. (2015) Cochrane Database Systemic Review

A Comparison Of Spinal Manipulation Methods And Usual Medical Care For Acute And Sub-Acute Low Back Pain: A Randomized Clinical Trial

A randomized controlled trial with six-month follow-up reports that 94 percent of manual-thrust manipulation recipients under chiropractic care had a 30 percent reduction in low back pain at week four while only 56 percent of medical care recipients had a 30 percent reduction in low back pain at week four. This represents a 38 percent (94% – 56%) increase in effectiveness by seeing a doctor of chiropractic first. The study also determined that patients are best served when informed of non-pharmacological therapies for low back pain before electing riskier, less effective treatments. Manual-thrust manipulation, performed by doctors of chiropractic, achieves a greater short-term reduction in pain compared with common medical treatments. Schneider et al. (2015) Spine Journal

Early Predictors Of Lumbar Spine Surgery After Occupational Back Injury: Results From A Prospective Study Of Workers In Washington State

In the U.S., back injuries are the most prevalent occupational injury. Using Disability Risk Identification Study Cohort data, this study examined the early predictors of lumbar spine surgery within three years among Washington State workers, with new workers’ compensation temporary total disability claims for back injuries. Approximately 42.7 percent of workers who first saw a surgeon had surgery, in contrast to only 1.5 percent of those who saw a doctor of chiropractic. There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables. Keeney et al. (2013) Spine Journal

Value Of Chiropractic Services At An On-Site Health Center

The study concludes that chiropractic services offered at onsite health centers may promote lower utilization of certain health care services, while improving musculoskeletal function.  Krause et al. (2012) Journal of Occupational and Environmental Medicine.

Spinal Manipulation, Medication, Or Home Exercise With Advice For Acute And Subacute Neck Pain: A Randomized Trial

Bronfort et al., in a randomized controlled trial funded by the National Institute of Health’s National Center for Complementary and Alternative Medicine, undertook a study of the effectiveness of different treatment approaches for mechanical neck pain. The 272 study participants were divided into three groups, one receiving spinal manipulative therapy from a doctor of chiropractic, a group receiving pain medication (over-the-counter pain relievers, narcotics and muscle relaxants), and another received exercise recommendations. After 12 weeks, approximately 57 percent of those under chiropractic treatment, and 48 percent of the subjects that exercised reported at least a 75 percent reduction in pain, compared to 33 percent of the subjects in the medication group. Bronfort et al. (2012) Annals of Internal Medicine

Upper Cervical And Upper Thoracic Thrust Manipulation Versus Nonthrust Mobilization In Patients With Mechanical Neck Pain: A Multicenter Randomized Clinical Trial

In a study of patients with mechanical neck pain randomized to receive a spinal manipulation compared to non-thrust mobilization, the results indicated that the participants, “…receiving a combination of upper cervical and upper thoracic spinal manipulation experienced significantly greater reductions in disability (50.5 percent) and pain (58.5 percent) than those of 12 the non-thrust mobilization group following treatment.” The study further concluded that the spinal manipulation group had significantly greater improvement in both passive upper cervical (C1-2) rotation range of motion and motor performance. Dunning et al. (2012) Journal of Orthopaedic and Sports Physical Therapy

Health Maintenance Care In Work-Related Low Back Pain And Its Association With Disability Recurrence

In work-related non-specific low back pain, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment. Cifuentes et al. (2011) Journal of Occupational and Environmental Medicine.

Cost Of Care For Common Back Pain Conditions Initiated With Chiropractic Doctor Vs Medical Doctor/Doctor Of Osteopathy As First Physician: Experience Of One Tennessee-Based General Health Insurer

This study analyzed 85,000 Blue Cross Blue Shield beneficiaries in Tennessee over a two-year span and concluded that back pain initiated with a doctor of chiropractic saves 20 to 40 percent on health care costs when compared with care initiated through a medical doctor.  Liliedahl et al. (2010) Journal of Manipulative and Physiological Therapeutics.

Dose Response And Efficacy Of Spinal Manipulation For Chronic Cervicogenic Headache: A Pilot Randomized Controlled Trial

Haas et al. in a randomized study looking at pain intensity, and frequency of cervicogenic headache found spinal manual therapy (SMT) to be more effective at reducing pain intensity and disability when compared to light massage. The effects were greater after 16 treatment sessions than after 8 sessions. The mean number of cervicogenic headaches was reduced for the SMT group, with improvement maintained at a 24 week follow-up. Haas et al. (2010) Spine Journal

Cost-Effectiveness Of Medical And Chiropractic Care For Acute And Chronic Low Back Pain

Chiropractic care appeared relatively cost-effective for the treatment of chronic low back pain. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapies. This evidence can guide physicians, payers and policy makers in evaluating chiropractic as a treatment option for low back pain. Haas et al. (2005) Journal of Manipulative and Physiological Therapeutics.

Manual Therapy, Physical Therapy, Or Continued Care By A General Practitioner For Patients With Neck Pain. A Randomized, Controlled Trial

“In our randomized, controlled trial, we compared the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) as for the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care, and manual therapy and physical therapy each resulted in statistically significant less analgesic use than continued care.” Hoving et al. (2002) Annals of Internal Medicine

To review literature regarding chiropractic care and ophthalmologic disturbances, Click here for abstract.


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