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Chiropractic Journal of Australia : December 2011
120 Chiropractic Journal of Australia Volume 41 Number 4 December 2011 reactive leg refex protocols in prone and supine positions were utilized to detect subluxations.16,17 Exclusion Criteria Subjects were excluded from the study if the examining chiropractors discovered evidence of skeletal fractures, severe sciatica resulting from large disc bulges that would warrant surgical intervention, central nervous system diseases or other contra-indications to chiropractic adjustments. Patients that could not commit to one month of gratis treatments were also excluded. INTERVENTION Each of the new cLBP subjects received the following care plan: 2 visits for the frst week, 2 visits for the second week, 1 visit for the third week, and 1 visit for the fourth week. This treatment plan consisted of 6 total visits within approximately 4 weeks. Intervention consisted of analysis and correction of subluxations on each patient visit as per Directional Non- Force Technique® chiropractic protocol.16,17 The diagnostic part of this protocol consists of a structural challenge immediately followed by the DNFT “Reactive Leg Refex™” test that, according to protocol, indicates presence or absence of subluxation, as well as directions of correction. The challenge is a test consisting of a gentle push or pull of an osseous or soft tissue structure. It is theorized that the Reactive Leg Refex is elicited by the combination of challenge and a proprietary foot eversion maneuver; if the test is positive, it produces a temporary shortening of one leg by approximately ¾ inch. The corrective part of DNFT protocol consists of a thumb thrust which, although it has sometimes been included in the general category of "high velocity, low amplitude thrust," differs signifcantly from the traditional chiropractic thrust that also shares this categorization. OUTCOME ASSESSMENTS Outcome measures to assess a variety of interventions for cLBP include the Original or Modifed/Revised Oswestry Low Back Pain Disability Questionnaire (MODQ)32,33 for functional disability, the Dartmouth Primary Care Cooperative Information Project (COOP) charts34 for general health, and an 11-point pain intensity numerical rating scale (PI-NRS) for pain assessment.35 The three subject-reported outcome measurements were utilized to measure present pain intensity and functional status on the frst visit and at the end of the sixth visit within approximately 4 weeks of care. The Dartmouth COOP charts (25 points total) measure physical ftness, social activities, daily activities with diffculties, feelings, and overall health.36 The COOP charts have demonstrated ease of usage, sensitivity to change, reliability and validity.37,38 The PI-NRS form (44 points total) is a measure of pain intensity representing varying episodes distinguished by 4 questions: 1. What is your low back pain level RIGHT NOW? 2. What is your TYPICAL or AVERAGE pain level in your low back? 3. What is your low back pain level AT ITS BEST (How close to "0" does your pain get at its best)? 4. What is your low back pain level AT ITS WORST (How close to "10" does your pain get at its worst)? Below each question was an 11-point pain numerical rating scale with a score of "0" (no pain) to "10" (worst possible pain). The PI-NRS has demonstrated predictive validity and is used to measure chronic low back pain intensity.35 The MODQ (50 points total) has been shown to have high reliability and construct validity in the measure of functional disability with cLBP.39 The MODQ contains 10 questions pertaining to Pain Intensity, Personal Care, Lifting, Walking, Sitting, Standing, Sleeping, Social Life, Traveling, and Changing Degree of Pain. Each response is scored from a scale of "0" to "5" with a score of "5" equating to the highest level of disability from low back pain. Data Analysis Data from each subject was entered into SPSS 17.0 (SPSS Inc, Chicago Ill) for analysis. A paired sample t-test was used for comparing the pre-and post-intervention total scores of the COOP charts, the Pain Intensity scales, and the Modifed Oswestry. A signifcance level equal to 0.05 was applied to the statistical analyses. RESULTS A total of 131 (68 males, 59 males, 4 missing) adult patients suffering from cLBP,with an average age of 46.75 years (range 19 to 99 years), met the inclusion criteria and were included in this study. The chief complaint of cLBP (LBP ≥ 3 months) had a mean duration of 132.08 months (range 3 months to 576 months). The patients were under care with a mean number of weeks at 3.19 ± 0.56 weeks, which also represents the average time between data collection. The patients were treated by 22 DNFT chiropractors between April 2004 and September 2005. Of the 22 chiropractors, 14 of them treated exactly 6 patients as requested totalling 84 subjects (64% of total patients). The remainder of the chiropractors treated various numbers of subjects giving a mean of 5.95 patients per chiropractor. Paired samples t-tests were used to analyse pre- and post- treatment scores on the COOP, MODQ, and PI-NRS. Only data from subjects that completely flled-out both the pre-and post-treatment forms were included in data analyses. The mean baseline total COOP score was 13.16 (± 3.83, n=130, 99.2% response) and post-intervention was 10.52 (± 3.54). The 2.64-point average improvement (20.1% decrease in score) was statistically signifcant (p < .01).The baseline for the total MODQ score was 17.72 (± 6.70, n=120, 91.6%) and post-intervention was 8.92 (± 6.62) representing an 8.8-point (49.7%) statistically signifcant improvement (p< .01). The baseline mean PI-NRS was 18.18 (± 5.92, n=128, 97.7%) and post-intervention was 10.60 (± 6.80) resulting in a 7.58-point (41.7%) statistically signifcant improvement (p< .01). There were no adverse reactions to care reported. DISCUSSION In the current study, a statistically signifcant improvement in all three valid outcome measures was observed after 4 weeks (6 adjustments) of DNFT chiropractic care. This is CHIROPRACTIC CARE IMPROVES CHRONIC LBP KHAUV • JOHN
CJA March 2012