conservative treatment of low back pain in the older adult: a

Adams, T. Low Back Pain in Older Adults 1

Conservative Treatment of Low Back Pain in the Older

Adult: A Literature Review

By: Tara Adams

Faculty Advisor: Rodger Tepe, PhD

A senior research project submitted in partial requirement

for the degree Doctor of Chiropractic

April 10, 2012


ABSTRACT

Objective

This review provides an overview and analysis of the most recent literature concerning the

efficacy of the most common conservative and invasive treatments for low back pain. Emphasis

was given to articles that focused specifically on the treatment of low back pain in the older

adult, although studies focused on a younger adult population have also been included.

Emphasis is given to an inter-comparison of the conservative care options as well as a

comparison between conservative care and surgery for similar conditions.

Data Collection

Computer searches using GoogleScholar, PubMed, Index to Chiropractic Literature and

MANTIS/ChiroAccess from 1999-2012, were searched with a combination of the following

keywords: low-back, pain, aged or elderly or older adult along with a combination of the

following terms: alternative treatment, conservative treatment, spinal manipulation, acupuncture,

exercise, counseling, massage, and surgery. Sources were compiled from the searches as well as

from Dr. Enix’s accumulated research articles and references within the articles.

Conclusions

A consensus of selective reviews and controlled studies, support the recommendation of a trial of

conservative care in the treatment of low back pain. Emerging evidence shows that

psychological factors such as anxiety, depression and fear avoidance all play a role in the

propagation and perseverance of pain. There is no one strategy that has proven pain relief across

the board, yet a combination of the following education/counseling, exercise/stretches, massage,

spinal manipulation, and acupuncture elicits the best outcomes. Sometimes, a combination of

drugs with conservative therapy is necessary. For those whose conservative treatments have

failed, there are always more invasive options. More research is needed on the efficacy of

specific interventions used to combat low back pain in the older adult.


INTRODUCTION

Low back pain is a common musculoskeletal disorder that affects 80% of the population during

some point of their life.1 “More than 17 million people aged 65 years or older in the United

States experience at least one episode of low back pain (LBP) in a calendar year2. Six million of

those individuals suffer from compromised quality of life because of frequent episodes2.

Consequences of chronic pain in those investigations highlight physical disability3,4,5,6

,

depression and anxiety5,7,8

, sleep disturbance9,10

, and increased utilization of health care

resources11

.”12

In the United States, low back pain is one of the most common reasons people miss work and it

is the most common cause of job-related disability.13

Approximately 149 million days of work

are lost per year specifically attributable to lumbar injuries; with approximately two thirds of

these days lost due to occupational injuries.14

The annual productivity losses resulting from lost

work days are estimated to be $28 billion, and “a small percentage of patients with chronic LBP

accounts for a large fraction of the costs”14

Although low back pain can originate from non-musculoskeletal etiologies, these will not be

discussed in this paper. This review will focus on the most common etiologies of low back pain

in the elderly, as well as efficacy of the following common conservative treatments employed for

chronic or acute low back pain: spinal manipulation, massage, acupuncture, exercise therapy,

electrical therapies, counseling and education.

The differences between the allopathic and alternative models of treatment for low back pain as

well as cost effectiveness and patient satisfaction will also be discussed. Although there are

thousands of research articles studying the treatment of low back pain in the general population,

there are but a handful of studies focusing specifically on treatment of low back pain in the older

patient.


DISCUSSION

Incidence and trends

“According to government reports, the US population of elderly citizens is increasing

dramatically. In the 1900s, people over 65 comprised 4% of the US population. By 1968, this

had increased to 12.4%, and by 2032, it is estimated that this proportion will increase to 22%.

Foster et al2 noted that approximately 30% of people aged 65 or older used at least 1 alternative

medicine modality in the preceding year.15

Chiropractic was the most frequent provider accessed

at 11%. Del Mundo et al3 have reported that alternative medicine use in rural communities is

significant.16

Seventeen percent of all respondents (all ages) indicated that they used chiropractic

services in the past year.”17

A telephone survey performed of 4437 adults in North Carolina

attempted to disseminate the incidence of low back pain and which treatments had been sought

for the condition. Of the 73% “of those who sought care, 91% went to a medical doctor, 29%

saw a PT, and 25% saw a chiropractor. 37% received a computed tomography scan, 25%

received a magnetic resonance imaging scan, and 10.4% underwent surgery.” 18

Approximately 12.5% of the 65 years of age and older population surveyed, reported low back

pain at that time; with approximately 20% stating they had low back pain within the previous

year.19

According to a survey performed of adults aged 70-79, 36% reported low-back pain.20

In

two different British surveys of the general population, 38% of respondents reported a significant

episode of low-back pain within the last year.21

Over the last 20 years, Britain has also noticed an

exponential increase in the amount of disability benefits being paid due to back pain.21

Similar increases in the incidence of low back pain have also been seen in Australia and the

United States. “By the age of 30 years almost half the population will have experienced a

substantive episode of low back pain.”21

One could conclude that low back pain is becoming

increasingly common throughout the world in both the young and old. Unfortunately, increasing

age is a large predilector of having low-back pain.


Epidemiology of low back pain in older adults

“Care from doctors of chiropractic emphasizes spinal manipulation, which has been shown to be

effective in several randomized trials.22

A study completed in North Carolina, demonstrated that

39 percent of persons seeking care for acute back pain go to a chiropractor first.23

”24

Several

studies concluded that being female was a common predictor of CAM use. 25,26

One study,

however, by Ness et al reported that men were more likely to go to chiropractors specifically, but

less likely to go to a CAM practitioner in general.27

Other studies concluded that the more

educated26,28,29

and those with a higher income27,29,30

were more likely to see a chiropractor.

Greater than average use of alcohol27,30

as well as the ability to drive,30

also increased their

chances of visiting a chiropractor. A study of older patients showed that those who self-reported

that they are more spiritual,25,26,28

as well as those who were Caucasian,25,30

also had increased

visits to CAM practitioners. The most common reasons the elderly seek out CAM providers

were for pain-related symptoms26,30,31,32,33

usually due to arthritis31,32

, or to improve their quality

of life30

, or for health maintenance30,32

. The majority of older patients reported being satisfied

with the care they received28,34

while others believed the care they received was beneficial31

.

Earlier studies done by Hawk et al.35

and Rupert et al.36

had similar findings.

Etiology of low back pain in older adults

Low back pain can be mechanical or non-mechanical. Non-mechanical low back pain can be

from a neurologic syndrome, a systemic disorder, referred pain or a fracture. A 2001 statistic

states that osteoporosis affects approximately 25 million Americans annually.37

Long term use of

corticosteroids has been shown to increase the risk of osteoporosis. Low bone mass caused by

osteoporosis increases the risk of skeletal fractures. Evidence of vertebral deformities were

found in 39% of men and women.38

The following activities have been shown to increase the likelihood of low back pain; manual

lifting, bending, twisting and whole body vibration.39

“Our data give strong support for a role of


regular heavy lifting in the etiology of low-back pain and add weight to the evidence implicating

occupational driving as a risk factor. At the same time, however, they suggest that such activities

account for only a small proportion of the total burden of low-back pain in the general

population. Our estimates of the fraction of disease attributable to heavy lifting and car driving

are 14 and 4 %, respectively. Even if allowance is made for uncertainties in these figures, a

substantial proportion of cases remain unexplained.”40

Some of the most commonly diagnosed mechanical pathologies of the low back are lumbar

herniated disc, lumbar spinal stenosis, degenerated discs, facet joint problems and sprains and

strains.41

Mechanical low back pain is thought to occur from several different mechanisms. One

of which is from direct compression of a nerve (which also usually presents with buttocks and or

leg pain) by discal material, muscle, or new bone growth. Discs are particularly sensitive pain

structures. One study revealed that “Pain was elicited by using blunt surgical instruments or an

electrical current of low voltage in 30% of patients who had stimulation of the paracentral

annulus fibrosis and in 15% with stimulation of the central annulus fibrosis. However, it is

unclear why mechanical back pain syndromes commonly become chronic, with pain persisting

beyond the normal healing period for most soft-tissue or joint injuries in the absence of

nonphysical or operant influence.”42

The periphery of the disc has a small amount of blood

supply and heals slowly. Although this is a possible explanation for how chronic pain begins,

there is no “direct concordance between structural degeneration and spinal pain.”42

There is,

however, an increased risk of low-back pain if one has had a previous episode of low back

pain.21 “

Research to date suggests that the cause of symptomatic radiculopathy is more complex

than just neural dysfunction due to structural impingement….Neurotransmitters and biochemical

factors may sensitize neural elements in the motion segment so that the normal biomechanical

stresses induced by previously asymptomatic movements or lifting tasks cause pain.

Furthermore, injury and the subsequent neurochemical cascade may modify or prolong the pain

stimulus and initiate the degenerative and inflammatory changes described above, which mediate

additional biochemical and morphologic changes. Whether the biochemical changes that occur


with disk degeneration are the consequence or cause of these painful conditions is unclear.

However, chemical and inflammatory factors may create the environmental substratum on which

biochemical forces cause axial or limb pain with various characteristics and to various degrees.”

42 The following research supports the hypothesis of central sensitization of the spinal cord

facilitating the process of chronic pain.

Facet joint dysfunction is another common pain generator in approximately 15-45% of patients

with low back pain.42

The capsule of the facet has many nerve endings, encapsulated,

unencapsulated and free. Substance P (SP), is one of the neuropeptides that regulates

nociception, and SP filled nerve fibers have been found in degenerated lumbar facets. There is a

direct correlation between those facets with more severe arthritis and those with a larger amount

of SP filled nerve fibers.42

The following statement supports the belief that there is an increase in

nociceptive nerve fibers in areas where previous trauma has occurred.

Muscle strains, trigger points (TrPs) and myofascial pain syndromes are increasingly common

diagnosis related to low back pain. “To date, research suggests that myofascial dysfunction with

characteristic TrPs is a spinal segmental reflex disorder. Animal studies have showed that TrPs

can be abolished by transecting efferent motor nerves or infusing lidocaine; however, spinal

transection above the level of segmental innervation of a TrP-containing muscle does not alter

the TrP response. Simons postulates that abnormal, persistently increased, and excessive

acetylcholine release at the neuromuscular junction generates sustained muscle contraction and a

continuous reverberating cycle.”42

The constant cycle of pain, segmental cord stimulation, pain,

segmental cord stimulation, aforementioned, is thought to be the same cycle that chiropractic

adjustments can interrupt. If not addressed, subconscious reflexive muscle contraction as a result

of neuropathic pain can perpetuate the pain, spasm, pain cycle.

Older adults are at an increased risk for mechanical overload and spasmodic tissues due to a

decrease in hydration, muscle mass and elasticity of connective tissues. Seven articles were

found, detailing chiropractic management of the following conditions commonly faced by

elderly that also present with low back pain; lumbar spinal stenosis 43,44

, spondylolysis of a

lumbar vertebrae45

, far lateral disc herniation46

, lumbar spinal synovial cysts47,48

, and “apparent


mechanical femoral neuropathy”49

. There are many conditions that may present as low back

pain.

Arthritis of the spine, such as osteoarthritis and rheumatoid arthritis, are commonly found in the

elderly patient. Since most elderly are retired or do not perform jobs requiring manual labor, the

causes of low back pain in the elderly can often be attributed to biomechanical adaptions due to

degenerative changes in the spine and atrophy of soft tissues. Degenerative changes can lead to

improper biomechanics and postural adaptions, such as anterior head carriage. Similarly,

improper biomechanics can lead to musculoskeletal adaptions and degenerative changes.

Whether the degenerative changes come first or last is debatable on a case by case basis; but

what is known is that improper biomechanics can lead to low back pain. Only a qualified

practitioner can perform the necessary history, physical and examination necessary to determine

the etiology of pain.

Low Back Pain and Falls

Low back pain is a co-morbid factor directly related to the incidence of falls in the elderly. Low

back pain in older adults doubles their risk for falls compared with people without low back

pain.50

Falls are the leading cause of injury and accidental death in adults over the age of 65

years . 51

The elderly represent more than one third of all hospital injury admissions, and more

than 80% of these injuries are caused by unintentional falls.51

These falls are the leading cause of

non-fatal injuries requiring medical attention in the United States.50

“Balance problems and falls

are common among the elderly and are a leading cause of institutionalization in this group that

result in over five million patient outpatient visits per year. It is estimated that between 28% and

35% of individuals over age 65 fall each year, with a fifth of those requiring medical attention.1

The number of fallers increases to over 40% for those 75 and older.51

A history of falling is also

a robust predictor of morbidity among the elderly.52,53

Low back pain (LBP) is the most

frequently reported musculoskeletal condition in the elderly, with a prevalence ranging from

19.7% in people over the age of 65, to as high as 40 % for individuals over 75.51,52,54

LBP is a

leading comorbid factor directly linked to the incidence of falls in the elderly and is sharply on


the rise; LBP prevalence has increased in the last fourteen years from 3.9% to 10.2%.54,55

LBP in

the elderly can involve a wide range of possible diagnoses and co-morbidities, including a high

incidence of malignant or visceral causes and therefore necessitate a close review of systems in

addition to the usual musculoskeletal examination.55,56

”50

One study attempted to understand the

effect of chiropractic care on balance, chronic pain and dizziness in older adults. They found

that 9 out of the 34 patients studied reported dizziness, all of those who were in the groups that

received chiropractic care showed clinically significant improvement in Dizziness Handicap

Index scores. Those in the non-treatment group had no significant improvement in Dizziness

Handicap Index scores.34

A single-group, pretest/posttest design intervention study of patients

65 years and older revealed that the of 6 patients with significant dizziness at baseline, 3 had

scores of 0 (no dizziness) on the DHI at visit 16.57

Effectiveness and clinical course of healing and prognostic features

It has been demonstrated in several systematic review, that the rapid improvements in low back

pain usually occur within the first three months after initial onset.58,59

After the first three months

there is only a gradual decrease in pain. For example, 6 months after onset, anywhere from 3-

40% of patients are still off -work, and at 12 months post-onset, anywhere from 42-75% of

people still report pain. Recurrences occur often within a year, with approximately 60% with

recurring pain and 33% with recurring absence of work.58

The large population based study completed by Kroft, et al. revealed the following outcomes for

episodes of low back pain seen in general practice. It should be taken into account that patients

self-reported pain and disability and their consultations with providers. Although most people

seeking care from their general practitioner for low back pain did not continue to consult their

Dr. about their symptoms after 3 months, most still had a substantial amount of pain and related

disability. In fact, only 25% of the patients had fully recovered 12 months later.21

It is a falsely

held belief that “90% of episodes of low back pain seen in general practice resolve within one

month.”21

It has been shown that effective early treatment of low back pain can reduce the


incidence and severity of symptoms as well as reducing the social, economic, and medical

impact.21

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. The conclusion

drawn from the above statistics demonstrates that that the results are consistent with the

interpretation that 90% of patients with low back pain in primary care will have stopped

consulting their doctor with symptoms within three months. However, most will still be

experiencing low back pain and related disability one year after consultation.21

Although the

strongest predictor of a delay in the return to normal functioning was a high level of functional

impairment at base line,60

increased age also has a negative impact on recovery.61

Allopathic vs Alternative

The allopathic model’s treatment of low back pain consists of prescribing muscle relaxers and

pain relievers. A physical therapy prescription for exercises is the allopath’s second line of

defense. In the event that those interventions fail and the back pain does not resolve, then more

invasive procedures such as cortisone injections or surgeries are recommended.

The alternative, or chiropractic method of treatment for low back pain normally consists of a

sequential flow through the following stages of treatment: acute, subacute, and wellness. The

commonly utilized stages of care documented by chiropractors are: acute, subacute, chronic,

recurrent/flare-up, and wellness. During the acute phase, passive treatments such as spinal

manipulation and physiotherapy (for example, ice, interferential, ultrasound) are used to help

reduce pain. Patients are also educated on how to manage their condition independently.

A chiropractor will generally explain that the patient’s healing is going to require effort of their

part and they must work together with the doctor to achieve their desired goals. In general,


passive care should lead to active care over the course of 1 to 2 months. During active care

patients are given exercises with the goals of stabilization, and increased function. Upon return

to regular activities it is very important to emphasize to patients that any residual pain they may

feel, does not signify harm to the body.

Following a trial of care with no improvement, all systemic, organic and non-mechanical causes

should always be ruled out before continuing the assumption that pain is of a mechanical nature.

This is especially true in the elderly, for with increased age comes increased risk of co-

morbidities such as cancers, diabetes, genitourinary infections and osteoporosis.

A study completed by Carey et al. compared the outcomes and costs of care for acute low back

pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons.

The status at six months was ascertained for 1555 of the 1633 patients, or 95% of those enrolled

in the study. The times to functional recovery, return to work, and complete recovery from acute

low back pain were similar among patients seen by all six groups of practitioners, but there were

marked differences in the use of health care services. The mean total estimated outpatient

charges were highest for the patients seen by orthopedic surgeons and chiropractors and were

lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest

among the patients who went to the chiropractors.60

Page 914 of the article cited previously

states that the cost data were skewed, but does not mention how the data was skewed.

Spinal manipulation

There is debate over the ultimate goal of spinal manipulation as well as the definition of

“manipulation” across various studies. “Traditional theories, although varied, have tended to

focus on mechanical aspects of manipulation as central to their clinical impact including the

disruption of “adhesions” or release of trapped intra-articular material in spinal joints, and the

realigning of spinal structures.62,63

If reducing restrictions to motion and structural realignment

are the goals of manipulation, the velocity and amplitude of the manipulation may be less

important consideration than the specificity and direction of the technique used because of the

importance of specifically directing the force to the involved spinal segment in the required


direction.64

More recent explanations, however, suggest that the mechanism of effect for

manipulation may be related to the unique sensory input of a high-velocity, low amplitude thrust

on afferent discharge, and the subsequent effects on motoneuronal activity and central motor

excitability.65,66

Afferent response has been shown to vary based on the velocity and amplitude

of the force applied.67,68

If the mechanisms underlying the clinical effects of manipulation are

related to these neurophysio-logic responses, which are determined by the velocity and

amplitude of the force, distinguishing between thrust and nonthrust techniques is likely to be

critical.”69 “

The evidence supporting superior clinical outcomes with the use of manipulation for

a subgroup of patients was corroborated by this retrospective review of patients with

occupational low back pain. The use of thrust manipulation appeared to be more efficient than

the use of nonthrust manipulation for these patients.”70

According to a randomized clinical trial

comparing the effectiveness of thrust versus non-thrust manual therapy techniques, there was a

statistically significant decrease in pain as demonstrated by both the Oswestry Disability

Questionairre and the Numerical Pain Rating Scales at the one and four week follow-ups in the

thrust group as compared to the non-thrust group. 69

Although some believe thrust manipulation techniques are superior to non-thrust,

according to Shearar’s and Hawks’ studies, no significant difference in efficacy was found

between the two.71,72

The use of low-force adjusting techniques, in particular for the elderly and

frail, can be beneficial for reducing low-back pain, while minimizing any risk for fracture or

hematomas. Some of the most common low force techniques employed by chiropractors in the

treatment of low back pain are (in no particular order): Logan Basic, B.E.S.T, Cox Flexion-

Distraction (mechanized or non-mechanized table-assisted procedures), Activator and other

instrument-assisted procedures, SOT (pelvic blocking), and Applied Kinesiology. Activator

Methods is a technique that uses a small instrument to impart a quick and specific impulse to a

bone or tissue. “Neither mechanical-force, manually-assisted nor high-velocity, low-amplitude

adjustments were found to be more effective than the other in the treatment of this patient

population.”72

A randomized controlled trial was done comparing cox flexion distraction with


side posture diversified spinal manipulation and minimal conservative medical care for adults 55

years and older with subacute or chronic low back pain.73

The findings of this study were that

“biomechanically distinct forms of SM did not lead to different outcomes in older LBP patients

and both SM procedures were associated with small yet clinically important changes in

functional status by the end of treatment for this relatively healthy older population.”73

A subgroup of 26 RCTs that assessed manipulation as the sole or predominant component were

chosen from the meta-analysis completed by Assendelft W.J. in 2003. The analysis on the

subgroup of 26 RCTs found “statistically significant benefits only when spinal manipulation was

compared with sham therapies or ineffective therapies. There is no evidence that spinal

manipulation is substantially more or less effective than other conventional therapies for either

chronic or acute back pain.”74

The conventional therapies spinal manipulation was compared

with were general practitioner care, analgesics, physical therapy, exercises and back school.74

Although the mechanisms through which manipulative therapy exerts its effects upon the body is

still in question, it is widely agreed that the desired goals of spinal manipulation include

improved range of motion, decreased muscle spasm and decreased pain.75

In the treatment of

acute low back pain, it has been shown that manipulation tends to shorten the episode of pain,76

74 particularly over the short term. Longterm follow-up suggests that the initial advantage of

manipulation over other therapies is lost with time.77

“Spinal manipulation has small clinical

benefits that are equivalent to those of other commonly used therapies.”76

Eight articles were found that studied the effects of manual therapies on older patients. 34,

57,65,66,67,68,71,78

The one study that utilized mobilization was performed by a physiotherapist.78

The manipulation

studied in seven of the studies was performed by a chiropractor in four of them34,57, 71,73

and an

osteopath in three of them.79-81

Only two of the following eight studies were randomized clinical

trials involving chiropractic adjustments/manipulation and older patients.71,73


Interferential, TENS, traction therapy

Interferential electrical therapy, Transcutaneous Electrical Nerve Stimulation (TENS), and

traction therapy are several adjunct modalities used often by physical therapists and

chiropractors. The following are results of a study done by Werners, Roland MD. A total of 152

patients were recruited. The two treatment groups had similar demographic and clinical baseline

characteristics. The mean Oswestry Disability Index before treatment was 30 for both groups (n

= 147). After treatment, this had dropped to 25, and, at 3 months, were 21 (interferential therapy)

and 22 (motorized lumbar traction and massage). The mean pain visual analog scale score before

treatment was 50 (interferential therapy) and 51 (motorized lumbar traction and massage). This

had dropped, respectively, to 46 and 44 after treatment and to 42 and 39 at 3 months.82

This

study shows a progressive fall in Oswestry Disability Index and pain visual analog scale scores

in patients with low back pain treated with either interferential therapy or motorized lumbar

traction and massage. There was no difference in the improvement between the two groups at the

end of treatment. Although there is evidence from several trials that traction alone is ineffective

in the management of low back pain, this study could not exclude some effect from the

concomitant massage.82

TENS and interferential are the two of the most common electrical therapies used in the

treatment of low back pain. A study by Facci concluded that there was no difference between

TENS and the interferential current therapy for chronic low back pain.83

Although there are few

studies to substantiate the benefits of electrical therapies in the treatment of low back pain, the

study aforementioned showed mean reductions on the visual analog scale of 39.18 mm and

44.86 mm with the treatment of interferential current. 84% of the TENS group and 75% of the

interferential current group stopped using their medications after the treatment.83

Exercise (strengthening and stretching)

A study protocol titled Chiropractic and exercise for seniors with low back pain or neck Pain

describes the design of two randomized clinical trials and states that “treatments for low back

and neck conditions will not only aim to treat the pain specifically, but will also address


associated strength and motion in a manner that enhances general function and improves quality

of life.”84

Research indicates that most back injuries are not due to one specific trauma, but they are caused

by a cumulative result of trivial traumas and associated improper muscle activation patterns and

joint motion.85,86

Therefore a main focus of rehabilitation exercises for low back pain concentrate

on lumbar spine extensor muscle endurance and motor control.85,86

Some believe that

strengthening the core muscles, such as the transverse abdominis, obliques, and muscles of the

pelvic floor provides the most benefit for lumbar spine stabilization. The quadratus lumborum is

also an essential muscle used to stabilize the lumbar spine. It has been shown that stabilization of

the low back should be acquired before and increase in strength.

To date, physical therapists’ protocols for treating low back pain often include the following

exercise, “drawing in”, in their treatment protocol.87,88

Drawing in is where one lies on their

back, with knees bent and attempts to approximate their belly button to their spine. This action is

very similar to just sucking in ones’ belly. They believe that this movement tenses the transverse

abdominis muscles and the tightening of the transverse abdominal muscles and its muscular and

fascial attachments helps to provide stability to the spine.87

Other physical therapists and most

chiropractors, believe that practicing abdominal bracing is a better way to help stabilize the spine.

Recent research from McGill of the US, supports this later view. McGill believes that by bracing

instead of hollowing, the obliques and transversus are activated together. This would lead to a

wider base for the contraction thereby lending better support. Abdominal bracing is usually

prescribed first, with exercises progressing to include abdominal bracing along with marching.88

It is well known that strength and balance training can improve physical function as well as help

to reduce impairments in activities of daily living.89

Stretches are a common home recommendation given by both physical therapist’s and

chiropractors. “An RCT comparing chiropractic care and physical therapy found no difference in

costs or effectiveness90

.”76

Stretches are given to lengthen chronically tight muscles, while

exercises are given to strengthen weak muscles. Achieving an equal balance bilaterally within all

of the planes of movement, allows for proper joint function and movement along the joints axis’.


There are several types of stretching techniques employed by chiropractors and PT’s to help

loosen tight muscles. One of which is post-isometric-relaxation or PIR. PIR is a technique that

uses reciprocal inhibition to enhance relaxation of the muscle being stretched. This can be a

vigorous or gentle technique, depending on the practitioner. Myofascial release is also a common

technique used by massage therapists, PT’s and chiropractors. There are several types of

myofascial release with trademarked names such as John Barne’s Myofascial Release and John

Upledger myofascial release. There are also techniques such as Muscle Energy Technique and

Strain-Counterstrain that have been used for years by Osteopathic Physicians in the treatment of

low back pain.91

“Strain Counterstrain (SCS) is the fourth most commonly used osteopathic

manipulative technique following soft tissue techniques, high velocity low amplitude thrust, and

muscle energy technique (Johnson and Kurtz, 2003). Also known as positional release, SCS is a

passive positional technique aimed at relieving musculoskeletal pain and dysfunction through

indirect manual manipulation (d’Amborgio and Roth, 1997).”92

“MET combined with supervised

motor control and resistance exercises may be superior to neuromuscular re-education and

resistance training for decreasing disability and improving function in patients with acute low

back pain.”93

A study that used ultrasound to assess and monitor the effective sliding motion of

fascial layers in vivo, found that myofascial release techniques “ are effective manual techniques

to release area of impaired sliding fascial mobility, and to improve pain perception over a short

term duration in people with non-specific NP or LBP.”94

All of the aforementioned techniques can be used on people of all ages under the treatment by a

qualified practitioner. “Although the elderly population appears to be under-represented in the

pertinent LBP literature,95

there does not seem to be an age limit for strengthening back muscles.

Even symptomatic geriatric women are able to increase strength with progressive resistance

exercise, which subsequently reduces LBP.96”97

An aerobic exercise program is as effective as

more expensive exercise programs in the treatment of chronic low back pain.98

Five years after

the supervised combined exercise and motivational program, patients had significant

improvements in disability, pain intensity, and working ability.99

In the long term, the combined

exercise and motivation program was superior to the standard exercise program.99

In terms of


costs for days on sick leave, the medical exercise therapy group saved 906,732 Norwegian Kroner

(NOK) ($122,531.00), and the conventional physiotherapy group saved NOK 1,882,560

($254,200.00), compared with the self-exercise group.23

According to Torstensen’s study, those

performing exercises in the group setting have better results than those who performed self-

exercise.100

Acupuncture

After herbal remedies, massage therapy, and chiropractic, according to patient reporting in one

study, the CAM used next most often by older patients was acupuncture.27

Cherkin’s review

concluded that the effectiveness of acupuncture is not clear, because the RCTs evaluating its

effectiveness were deemed of low quality, stating “Recent studies suggest that acupuncture is

more effective than no treatment or sham treatment, is as effective than no treatment or sham

treatment, is as effective as other medical interventions of questionable value (for example TENS

and non-steroidal anti-inflammatory drugs for chronic back pain), but is less effective than

massage.”76

Other studies show that “Patients receiving acupuncture care reported a significantly greater

reduction in worry about their back pain at 12 and 24 months compared with the usual care

group. At 24 months, the acupuncture care group was significantly more likely to report 12

months pain free and less likely to report the use of medication for pain relief.”101

Although the

literature supporting acupuncture’s benefits is limited, due to the low-risk of unwanted side and

its potential to alleviate anxiety, acupuncture is an alternative therapy worth trying.

Massage

“Initial studies have found massage to be effective for persistent back pain.”76 “

Preliminary

evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the

costs of care after an initial course of therapy.” 76

“Three trials designed to evaluate massage as a

treatment for subacute and chronic back pain have all found positive effects, especially on

patient function.” 76

“Initial studies suggest that massage is effective for persistent back pain” 76

A randomized controlled trial comparing Swedish relaxation massage with structural massage

and a control group receiving usual care, produced favorable results for massage.102

There was


no significant difference between the relaxation massage and the structural massage in relieving

disability of symptoms.102

The results of the study are as follows. “The massage groups had

similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI,

1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the

structural massage group than in the usual care group, and adjusted mean symptom

bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and

1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of

relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were

small.”102

Counseling and education

Cognitive-behavioral and self-regulatory treatments were specifically found to be efficacious in

the treatment of low back pain. Multidisciplinary approaches that included a psychological

component, when compared with active control conditions, were also found to have positive

short-term effects on pain interference and positive long-term effects on return to work. The

results demonstrated positive effects of psychological interventions for CLBP.103

It has been

shown to be helpful for physicians to reinforce to their patients in the initial exam “that pain did

not signal harm, to maintain a consistent activity pace, and to stay as active as tolerable.”88

Chronic pain and depression are thought to go hand in hand. This is true for both the elderly and

the non-elderly. The impact of pain on activities of daily living, functional abilities and

perceived control over life should be considered when associating pain with depression.82

“Interference in activities demonstrated the strongest relationship with depressed mood in both

age groups.”104

A randomized controlled trial performed by Francisco Kovacs, MD et al. showed

that among three groups of institutionalized elderly subjects, the greatest improvement in

disability (3.0 (95% CI 1.5–4.5) at the 180 day evaluation) was achieved by the group who

received active education, as compared to the group who received a postural educational talk

followed by a 20 minute group talk, and the control group who received no intervention. The


intervention that focused on active management education also showed improved disability 6

months later and had an even greater effect on subjects with low back pain.105

Drugs, Surgery and Procedures

When people do not receive timely and effective conservative care for their condition, they are

left with much fewer treatment options. When conservative measures such as the ones discussed

above are not sought or do not help to relieve low back pain, more invasive drugs, surgeries, and

procedures are the next options. A common medical procedure for low back pain is injections.

One study found that nerve-root injections were effective in preventing the need for an operation

in more than half of the operative candidates.106

Twenty-nine of the fifty-five patients who had

requested operative intervention and who were considered to be operative candidates by their

treating spine surgeons avoided an operation.106

Compared with injection of bupivacaine alone,

injection of bupivacaine with the steroids was significantly (p < 0.004) more likely to result in

the avoidance of an operation.106

Interestingly, nine of the twenty-seven patients who had

received bupivacaine alone still managed to avoid an operation.106

For people with facet joint arthrosis, injection with depot methylprednisolone or a combination

of a local anesthetic such as lidocaine or bupivacaine and the steroid medication

methylprednisolone are often used. Short term effects of this procedure are a sore back for a day

or two due to the inflammation process caused by the insertion of the needle and the steroid

itself. It usually takes about 5 days or so before pain relief is noted. According to the

MetroHealth Pain Management Group’s website, although the procedure is relatively safe, there

can be some adverse side effects and risks. Several of these are “infection, bleeding, worsening

of symptoms, spinal block, epidural block etc…The risks related to the side effects of cortisone

include weight gain, increase in blood sugar (mainly in diabetics) water retention, suppression of

body’s own natural production of cortisone etc.”107

They also state that “serious side effects and

complications are uncommon.”107

Several other procedures used in the treatment of low back

pain performed at this center are epidurolysis, corticosteroids, intrathecal pump implant (spinal


pain pump), lumbar sympathetic block, sacro-iliac joint injection, radio frequency lesioning,

medial branch blocks for facet joints, spinal cord stimulator, and stellate ganglion injection.

More invasive treatments of discogenic low-back pain include “ablation of intradiscal

nociceptors, lowering intranuclear pressure, removal of herniated nucleus, and radiofrequency

ablation of the nociceptors. Unfortunately, most of these strategies do not meet the minimal

criteria for a positive treatment advice. In particular, single-needle radiofrequency

thermocoagulation of the discus is not recommended for patients with discogenic pain (2 B-).

Interestingly, a little used procedure, radiofrequency ablation of the ramus communicans, does

meet the (2 B+) level for endorsement. There is currently insufficient proof to recommend

intradiscal electrothermal therapy (2 B±) and intradiscal biacuplasty (0). It is advised that ozone

discolysis, nucleoplasty, and targeted disc decompression should only be performed as part of a

study protocol.”108

A separate study revealed that “When conservative treatment fails, in

subacute lumbosacral radicular pain under the level L3 as the result of a contained herniation,

transforaminal corticosteroid administration is recommended (2 B+). In chronic lumbosacral

radicular pain, (pulsed) radiofrequency treatment adjacent to the spinal ganglion (DRG) can be

considered (2 C+). For refractory lumbosacral radicular pain, adhesiolysis and epiduroscopy can

be considered (2 B+/-), preferentially study-related. In patients with a therapy-resistant radicular

pain in the context of a Failed Back Surgery Syndrome, spinal cord stimulation is recommended

(2 A+). This treatment should be performed in specialized centers.”109

A concensus among

literature states that surgery is often more risky for older individuals, and that conservative care

of low back pain for that age group is a viable option.

Surgery vs Conservative Care

Lumbar spinal stenosis is a commonly diagnosed condition in the elderly. Below are results of

two studies performed on the elderly, one study group was treated with conservative care and the

other with surgery. Most literature agrees that conservative measures should be employed first.

The study done by Murphy, Donald R. et al. studies 57 patients with diagnosed spinal stenosis.

Although the age range of patients was from 32-80, this study was included because the mean


age was 65 years old. The interventions employed with all of the patients in the study included

Cox flexion distraction technique and neural mobilization. Some of the patients were also given

the “cat and camel” exercise as well as nerve flossing exercises to do at home. The study also

states that some patients may have also “had other modalities included in their individual

programs, such as mobilization exercises and spinal stabilization exercise”.110

Outcomes were

measured using the Roland Morris Disability Questionnaire and pain levels were obtained with

the Three Level Numerical Rating Scale. Patients were also asked to estimate their percent of

overall improvement. “The mean patient-rated percentage improvement from baseline to the end

to treatment was 65.1%. The mean improvement in disability from baseline to the end of

treatment was 5.1 points….improvement in disability from baseline to the end of treatment was

seen in 66.7% of patients. The mean improvement in "at worst" pain was 3.1 points….The mean

duration of FU was 16.5 months. The mean patient-rated percentage improvement from baseline

to long term FU was 75.6%. The mean improvement in disability was 5.2 points…..improvement

in disability was seen in 73.2% of patients. The mean improvement in "on average" pain

intensity from baseline to long term FU was 3.0 points. The mean improvement in "at worst"

pain was 4.2 points. Only two patients went on to require surgery.”110

The only non-clinically

meaningful improvement statistic was the mean improvement of 1.6 points in "on average" pain

intensity.110

When conservative care for lumbar stenosis fails to produces the wanted results, surgery can be

an option. A study done by Shabat, Shay, concludes subjects with a “mean age of 83.7 years at

the time of surgery, with a follow-up period of 36.8 months on average (minimal follow-up of 1

year), 76% of the operated patients reported that they were very or somewhat satisfied with the

surgical results.”111

The study also states that 52% of the patients suffered complications from

the surgery, but 48% of those who suffered complications, had only minor complications that did

not extend their hospital stay.111

There were many limitations of this study, one of the greatest

being that only 64% of the original 39 patients were able to be followed.111

“The patients

reported VAS score of 8.84 + 1.91 prior to surgery, which improved to 3.6 + 2.35 on latest


follow-up (P\0.001). Furthermore, patients reported a significant (P\0.001) subjective

improvement in the ability to perform daily activities (the Barthel index improved from 62.8 ±

11.46 points before the surgery to 77.0 ± 11.9 points after the surgery (P\0.001). The number of

patients who had limitation in walking distance up to 50 m decreased by 28% (v2 = 3.74, P =

0.053), and the number of patients having no walking limitation increased by 32% (v2 = 5.37, P

= 0.02).”111

Lumbar stenosis can be treated either surgically or conservatively. Although both studies report

generally positive outcomes, it is not possible to statististically compare the results of the two

studies. Different outcome measures were employed and each study reported several limitations.

The conclusions of both studies state that conservative care should always be employed prior to

surgical intervention. “It should be remembered that elderly patients might deteriorate following

surgery. Therefore surgery should be done only after measuring the potential benefits of the

surgery versus the potential risks.111

CONCLUSION

Over 100 articles consisting of literature reviews, systematic reviews, selective reviews and

comparative studies, and case reports were reviewed. Conservative care for low back pain

provides similar improvements in decreased pain as invasive care, with less cost to the insurance

companies in the long run, and less risk to elderly patients for complications. According to the

literature, the conservative care intervention for acute low back pain that offered the best

outcomes, such as decreased pain and decreased numbers of subsequent visits to healthcare

providers, was short term use of pain medicines and massage. The effect size of NSAID use and

manipulation for acute low back pain was shown to be modest.112

Spinal manipulation was

shown to decrease pain, mainly in the acute stages of low back pain, where-as education and

exercise programs focusing on strengthening the core and lumbar spine extensors was most

beneficial to chronic low back pain patients. Spinal manipulation is a slightly more expensive in

the short-term but an equally effective option for treatment of acute low back pain as medicinal


interventions such as pain relieving medicine.113,114

Spinal manipulation has less unwanted side

effects than pharmaceutical management of low back pain in the elderly.

According to the 2011 update of a Cochrane review regarding spinal manipulative therapy for

chronic low back pain, as cited by the article “The Psychology of Chronic Back Pain –

Psychological risk factors for chronicity and our challenge as clinicians: finding the right

treatment mix by David J. Brunarski, DC, MSc, FCCS (C), states that “There was no clinically

relevant difference between spinal manipulative therapy and other interventions for reducing

pain and improving function in patients with chronic low-back pain.”115

Results from most

studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent

or superior improvement in pain and function when compared with other commonly used

interventions, such as physical modalities, medication, education, or exercise, for short,

intermediate, and long-term follow-up.116

A recommendation, although weak recommendation,

stated that chronic LBP patients with depression, neuroticism, and certain personality disorders

should preferentially be treated nonoperatively.117

A systematic review on the effectiveness of physical and rehabilitation interventions for chronic

nonspecific low back pain, published this year in the European Spine Journal, concluded that

"only multidisciplinary treatment, behavioural treatment, and exercise therapy should be

provided as conservative treatments in daily practice in the treatment of chronic low back

pain."113

A June 2011 update of a Cochrane review regarding spinal manipulative therapy for

chronic low back pain stated: "There was no clinically relevant difference between spinal

manipulative therapy and other interventions for reducing pain and improving function in

patients with chronic low-back pain."113,114

“An understanding of the mechanisms behind MT could assist in the identification of individuals

likely to respond to MT by allowing a priori hypotheses as to pertinent predictive factors for

future clinical prediction rules and a better understanding of the factors which are determined as

predictive. A second benefit of the identification of MT mechanisms is the potential for

increased acceptance of these techniques by healthcare providers. Despite the literature


supporting the effectiveness of MT in specific musculoskeletal conditions, healthcare

practitioners at times provide or refer for MT at a lower than expected rate (Jette and Delitto,

1997; Li and Bombardier, 2001; Bishop and Wing, 2003). The lack of an identifiable mechanism

of action for MT may limit the acceptability of these techniques as they may be viewed as less

scientific. Knowledge of mechanisms may promote more appropriate use of MT by healthcare

providers.” 118

According to the clinical guidelines detailed by the National Collaborating Centre for Primary

Care, a course of conservative management is recommended before considering surgery as an

option. They recommend physicians or therapists to “provide people with advice and

information to promote self-management of their low back pain…offer educational advice that

includes information on the nature of non-specific low back pain….encourages the person to be

physically active and continue with normal activities as far as possible.”119

They also recommend offering “one of the following treatment options, taking into account

patient preference: an exercise programme, a course of manual therapy or a course of

acupuncture. Consider offering another of these options if the chosen treatment does not result in

satisfactory improvement.” 119

Those with low back pain should be advised to stay physically

active or begin physical activities. Recommended exercise programs can include the following:

aerobic activity, movement instruction, muscle strengthening, postural control, and stretching. 119

They also suggest offering a course of manual therapy, including spinal manipulation. They do

not suggest offering patients laser or interferential therapy, therapeutic ultrasound, TENS, lumbar

supports or traction. They also recommend offering a course of acupuncture needling. When

conservative measures fail, injections of therapeutic substances are not recommended for non-

specific low back pain. 119

“Consider referral for a combined physical and psychological

treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people

who: have received at least one less intensive treatment and have high disability and/or

significant psychological distress…..Combined physical and psychological treatment

programmes should include a cognitive behavioural approach and exercise.” 119

“Two


independent reviewers screened search results and extracted data. Data extracted included the

type and perspective of the economic evaluation, the treatment comparators, and the relative

cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies

found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or

cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP.”120

The following pharmaceutical interventions are recommended. “Advise the person to take

regular paracetamol as the first medication option. When paracetamol alone provides

insufficient pain relief, offer: non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak

opiods. Give due consideration to the risk of side effects from NSAIDs, especially in: older

people and other people at increased risk of experiencing side effects. When offering treatment

with an oral NSAID/COX-2 (cyclooxygenase 2) inhibitor, the first choice should be either a

standard NSAID or a COX-2 inhibitor. In either case, for people over 45 these should be co-

prescribed with a PPI (proton pump inhibitor), choosing the one with the lowest acquisition

cost.”119

“Consider offering tricyclic antidepressants if other medications provide insufficient pain relief.

Start at a low dosage and increase up to the maximum antidepressant dosage until therapeutic

effect is achieved or unacceptable side effects prevent further increase. Short-term use of strong

opioids can be used for severe pain.” 119

“Consider referral for specialist assessment for people

who may require prolonged use of strong opioids. Give due consideration to the risk of opioid

dependence and side effects for both strong and weak opioids. Base decisions on continuation of

medications on individual response. They believe that selective serotonin reuptake inhibitors

(SSRIs) should not be used for treating pain.” 119

“Consider referral for an opinion on spinal fusion for people who: have completed an optimal

package of care, including a combined physical and psychological treatment programme and still

have severe non-specific low back pain for which they would consider surgery. Offer anyone

with psychological distress appropriate treatment for this before referral for an opinion on spinal

fusion. Refer the patient to a specialist spinal surgical service if spinal fusion is being


considered. Give due consideration to the possible risks for that patient.” 119

Their conclusion

was that people should not be recommended for the following procedures: intradiscal

electrothermal therapy (IDET), percutaneous intradiscal radiofrequency thermocoagulation

(PIRFT), radiofrequency facet joint denervation. 119

No matter the chosen therapy, it is important

for doctors to take into account patient preference. “There is growing evidence that patient

expectations affect outcomes121-123

, allowing patients to choose the treatment they believe will be

most helpful may improve results.” 76

“Evidence-based medicine is not kind to the elderly. This movement trusts only the products of

randomized clinical trial or, preferentially, meta-analyses of those trials. But subjects over the

age of 75 years are rarely found in such trials, thus rendering this population invisible to

scientific medicine. If we teach only what we know, and if we know only what we can measure

in clinical trials, then we can say little of importance about the care of the elderly. The most

important resources required in caring for the old – sufficient time and empathy – are not

included in the critical pathways of managed care”124


REFERENCES

1. Kelsey JL, White AA 3rd. Epidemiology and impact of low-back pain. Spine (Phila Pa 1976).

1980 Mar-Apr;5(2):133-42.

2. Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, Heyse SP, Hirsch

R, Hochberg MC, Hunder GG, Liang MH, Pillemer SR, Steen VD, Wolfe F. Estimates of the

prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis

Rheum 1998;41:778–99.

3. Scudds RJ, McDRobertson J. Empirical evidence of the association between the presence of

musculoskeletal pain and physical disability in communitydwelling senior citizens. Pain

1998;75:229–35.

4. Scudds RJ, Robertson JM. Pain factors associated with physical disability in a sample of

communitydwelling senior citizens. J Gerontol A Biol Sci Med Sci 2000;55:M393–9.

5.Williamson GM, Schulz R. Pain, activity restriction, and symptoms of depression among

community- residing adults. J Gerontol 1992;47:P367–72.

6. Lichtenstein MJ, Dhanda R, Cornell JE, Escalante A, Hazuda HP. Disaggregating pain and its

effect on physical functional limitations. J Gerontol A Biol Sci Med Sci 1998;53:M361–71.

7. Williams AK, Schulz R. Association of pain and physical dependency with depression in

physically ill middle-aged and elderly persons. Phys Ther 1988;68:1226–30.

8. Magni G, Caldieron C, Rigatti-Luchini S, Merskey H. Chronic musculoskeletal pain and

depressive symptoms in the general population. An analysis of the 1st National Health and

Nutrition Examination Survey data. Pain 1990;43:299–307.

9. Gentili A, Weiner DK, Kuchibhatla M, Edinger JD. Factors that disturb sleep in nursing home

residents. Aging Clin Exp Res 1997;9:207–13.

10. Wilson KG, Watson ST, Currie SR. Daily diary and ambulatory activity monitoring of sleep

in patients with insomnia associated with chronic musculoskeletal pain. Pain 1998;75:75–84.


11. Becker N, Bondegaard Thomsen A, Olsen AK, Sjogren P, Bech P, Eriksen J. Pain

epidemiology and health related quality of life in chronic nonmalignant pain patients referred to

a Danish multidisciplinary pain center. Pain 1997;73:393–400.

12. Weiner, Debra K. MD, et. al. How Does Low Back Pain Impact Physical Function in

Independent, Well-Functioning Older Adults? Evidence from the Health ABC Cohort and

Implications for the Future. Pain Medicine 2003; 4(4)

13. Gunnar B J Andersson. Review. Epidemiological features of chronic low back pain. The

Lancet 1999; 354(9178): 581-585

14. Maetzel A, Li L. The economic burden of low back pain: a review of studies published

between 1996 and 2001. Best Pract Res Clin Rheumatol. 2002;16:23–30.

15. Foster DF, Phillips RS, Hamel MB, Eisenberg DM. Alternative medicine use in older

Americans. J Am Geriatr Soc 2000;48:1560-5.

16. Del Mundo WF, Shepherd WC, Marose TD. Use of alternative medicine by patients in a

rural family practice clinic. Fam Med 2002;34:206-12.

17. Joel Alcantara, DC,a Gregory Plaugher, DC,b Richard A. Elbert, DC,c Deborah

Cherachanko, DC,d James E. Konlande, PhD,d and Aaron M. Casselmand. Chiropractic Care of

a Geriatric Patient With an Acute Fracture-Subluxation of the Eighth Thoracic Vertebra. J

Manipulative Physiol Ther 2004;27:e4

18. Carey TS, Evans A, Hadler N, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among

individuals with chronic low back pain. Spine 1995; 20:312–7.

19. Lavsky-Shulan M, Wallace RB, Kohout FJ, Lemke JH, Morris MC, Smith IM. Prevalence

and functional correlates of low back pain in the elderly: The Iowa 65+ Rural Health Study. J

Am Geriatr Soc 1985;33:23–8.

20. Weiner, Debra K. MD, et. al. How Does Low Back Pain Impact Physical Function in

Independent, Well-Functioning Older Adults? Evidence from the Health ABC Cohort and

Implications for the Future. Pain Medicine 2003; 4(4)

21. Peter R Croft, Gary J Macfarlane, Ann C Papageorgiou, Elaine Thomas, Alan J Silman

General practice. Outcome of low back pain in general practice: a prospective study

22. Roland MO. The use of videotape as a research tool. J R Coll Gen Pract (in press).


23. Baker RJ, Nelder JA. The GLIM system. Release 3. Generalised linear interactive

modeling. Oxford: Numerical Algorithms Group, 1978.

24. Roland MO, Morrell DC, Morris RW. Can general practitioners predict the outcome of

episodes of back pain? BMJ 1983;286:5235.

25. Loera JA, Reyes-Ortiz C, Kuo YF. Predictors of complementary and alternative medicine use

among older Mexican Americans. Complement Ther Clin Pract. 2007 November; 13(4):224–31.

26. Callahan LF, Wiley-Exley EK, Mielenz TJ et al. Use of complementary and alternative

medicine among patients with arthritis. Prev Chronic Dis. 2009 April; 6(2):A44.

27. Ness J, Cirillo DJ, Weir DR, Nisly NL, Wallace RB. Use of complementary medicine in

older Americans: results from the Health and Retirement Study. Gerontologist. 2005 August;

45(4):516–24.

28. Ryder PT, Wolpert B, Orwig D, Carter-Pokras O, Black SA. Complementary and alternative

medicine use among older urban African Americans: individual and neighborhood associations. J

Natl Med Assoc. 2008 October; 100(10):1186–92.

29. Ganguli SC, Cawdron R, Irvine EJ. Alternative medicine use by Canadian ambulatory

gastroenterology patients: secular trend or epidemic? Am J Gastroenterol. 2004 February;

99(2):319–26.

30. Wolinsky FD, Liu L, Miller TR et al. The use of chiropractors by older adults in the United

States. Chiropr & Osteopr. 2007 September 6; 15(12):12.

31. Williamson AT, Fletcher PC, Dawson KA. Complementary and alternative medicine. Use in

an older population. J Gerontol Nurs. 2003 May; 29(5):20–8.

32.Cheung CK, Wyman JF, Halcon LL. Use of complementary and alternative therapies in

community dwelling older adults. J Altern Complement Med 2007 November; 13(9):997–1006.

33. Martin CM. Complementary and alternative medicine practices to alleviate pain in the

elderly. Consult Pharm. 2010 May; 25(5):284–90.

34. Hawk C, Cambron JA, Pfefer MT. Pilot study of the effect of a limited and extended course

of chiropractic care on balance, chronic pain, and dizziness in older adults. J Manipulative

Physiol Ther. 2009 July; 32(6):438–47.


35. Hawk C, Long CR, Boulanger KT, Morschhauser E, Fuhr AW. Chiropractic care for patients

aged 55 years and older: report from a practice-based research program. J Am Geriatr Soc. 2000

May; 48(5):534–45.

36. Rupert RL, Manello D, Sandefur R. Maintenance care: health promotion services

administered to US chiropractic patients aged 65 and older, part II. J Manipulative Physiol Ther.

2000; Jan 23(1):10–19.

37. Mannello DM. Osteoporosis: assessment and treatment options. Top Clin Chiropractic 1997;

4 (3):30-33.

38. Pluijm SMF et al. Consequences of vertebral deformities in older men and women. J Bone

Miner Res 2000; 15: 1564-1572.

39. Waddell G, Burton AK. Occupational health guidelines for the management of low back pain

at work: evidence review. Occup Med (Lond) 2001;51:124-35.

40. Walsh K, Varnes N, Osmond C, Styles R, Coggon D. Original Article: Occupational causes

of low-back pain. Scand J Work Environ Health 1989;15(1):54-59

41. Strayer, Andrea. Lumbar spine: common pathology and interventions. Journal of

Neuroscience Nursing. August 2005;37(4).

42. Wheeler AH. Low Back Pain and Sciatica. Medscape Reference (May 16, 2011)

http://emedicine.medscape.com/article/1144130-overview#aw2aab6b4

43. Knapp D. Class IV laser therapy treatment of multifactorial lumbar stenosis with low back

and knee pain: A case report. J Am Chiro Assoc. 2010; 47(1):10–15.

44. Snow GJ. Chiropractic management of a patient with lumbar spinal stenosis. J Manipulative

Physio Ther 2001; 24(4):300–304

45. Young KJ, Koning W. Spondylosis of L2 in identical twins. J Manipulative Physio Ther.

2003; 26(3):196–201.

46. Alcantara J, Plaugher G, Elbert RA et al. Chiropractic care of a geriatric patient with an acute

fracture-subluxation of the eighth thoracic vertebra. J Manipulative Physiol Ther.2004 March;

27(3):E4.

47. Cox JM, Cox JM II. Chiropractic treatment of lumbar spine synovial cysts: A report of two

cases. J Manipulative Physio Ther. 2005; 28(2):143–147.

http://emedicine.medscape.com/article/1144130-overview#aw2aab6b4


48. Taylor DN. Spinal synovial cysts and intersegmental instability: a case report. J Manipulative

Physio Ther. 2007; 30(2):152–157

49. Desmarais A, Descarreaux M. Diagnosis and management of “an apparent mechanical”

femoral mononeuropathy: a case study. J Can Chiro Assoc. 2007; 51(4):210–216.

50. Dennis E. Enix, DC, MBA1*; Joseph H. Flaherty, MD2; Kasey Sudkamp, PT, DPT3; Jessica

Schulz, OT. Balance Problems in the Geriatric Patient. Grand Rounds. MOTR/L4TOPICS IN

INTEGRATIVE HEALTH CARE March 30, 2011;2(1)

51. American Occupational Therapy Association. American Occupational Therapy Association,

Inc Page. http://www.aota.org/Consumers/consumers/Adults/Falls/35156.aspx. Updated March

16, 2007. Accessed March 9, 2011.

52. American Occupational Therapy Association. Policy 5.3.1: Definition of occupational

therapy practice for State Regulation. Amer J Occupational Ther 2004;58:694-695.

53. Di Monaco M, Vallero F, De Toma E, De Lauson L, Tappero R, Cavanna A. A single home

visit by an Occuaptional Therapist reduces the risk of falling after hip fracture in eldery women:

A quasi-randomized controlled trail. J Rehabil Med 2008;40(6):446-50.

54. Leland N, Porell F, Murphy S. Does fall history influence residential adjustments? The

Gerontologist 2010; 51:190-200.

55. Pighills A, Torgerson D, Sheldon T, Drummond A, Bland J. Environmental assessment and

modification to prevent falls in older adults. J Amer Geriatr Soc 2007.

56. Wyman J, Croghan C, Nachreiner N, Gross C, Stock H, Talley K, Monigold M.

Effectiveness of education and individualized counseling in reducing environmental hazards in

the homes of community-dwelling older women. J Amer Geriatr Soc 2007; 55: 1548-1556.

57. Hawk C, Cambron J. Chiropractic care for older adults: Effects on balance, dizziness, and

chronic pain. J Manipulative Physiol Ther. 2009 July; 32(6):431–7.

58. Hestbaek L, Leboeuf C, Manniche C: Low back pain: what is the long-term course? A

review of studies of general patient populations. European Spine Journal 2003, 12(2):149-165.

59. Pengel LH: Acute low back pain: systematic review of its prognosis. BMJ 2003,

327(7410):9.


60. Timothy s. Carey, M.D., M.P.H., et al. The outcomes and costs of care for acute low back

pain among patients seen by primary care practitioners, chiropractor, and orthopedic surgeons.

Special Article. N Engl J Med. 1995 Oct 5;333(14):913-7.

61. Gunnar B J Andersson. Review. Epidemiological features of chronic low back pain. The

Lancet 1999; 354(9178): 581-585

62. Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust

manipulation: previous theories. J Manipulative Physiol Ther 2002; 25:251–62.

63. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low back

pain. Ann Intern Med 1992;117:590–8.

64. Evans DW, Breen AC. A biomechanical model for mechanically efficient cavitation

production during spinal manipulation: prethrust position and the neutral zone. J Manipulative

Physiol Ther 2006;29:72–82.

65. Dishman JD, Dougherty PE, Burke JR. Evaluation of the effect of postural perturbation on

motoneuronal activity following various methods of lumbar spinal manipulation. Spine J

2005;5:650–9.

66. Dishman JD, Greco DS, Burke JR. Motor-evoked potentials recorded from lumbar erector

spine muscles: a study of corticospinal excitability changes associated with spinal manipulation.

J Manipulative Physiol Ther 2008;31:258–70.

67. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J 2002; 2:357–71.

68. Pickar JG, Sung PS, Kang YM, et al. Response of lumbar paraspinal muscles spindles is

greater to spinal manipulative loading compared with slower loading under length control. Spine

J 2007;7:583–95.

69. Joshua A. Cleland, PT, PhD,*† Julie M. Fritz, PT, PhD, ATC,‡§ Kornelia Kulig, PT, PhD,

Todd E. Davenport, DPT,** Sarah Eberhart, PT,† Jake Magel, PT, DSc,†† and John D. Childs,

PT, PhD‡‡ A Randomized Clinical Trial. Comparison of the Effectiveness of Three Manual

Physical Therapy Techniques in a Subgroup of Patients With Low Back Pain Who Satisfy a

Clinical Prediction Rule. SPINE 2009;34(25)2720–2729.


70. Does the evidence for spinal manipulation translate into better outcomes in routine clinical

care for patients with occupational low back pain? A case-control study. Julie M. Fritz, PhD,

PT, ATCa,b,*, Gerard P. Brennan, PhD, PTb, Howard Leaman, MDc. The Spine Journal

2006;6:289–295.

71. Hawk C, Rupert RL, Hall S, Colonvega M, Boyd J. Comparison of Bioenergetic

Synchronization Technique and customary chiropractic care for older adults with chronic

musculoskeletal pain. J Manipulative Physiol Ther. 2006 September; 29(7):540–9.

72. Shearar KA, Colloca CJ, White HL. A randomized clinical trial of manual versus

mechanical force manipulation in the treatment of sacroiliac joint syndrome. J Manipulative

Physiol Ther. 2005 Sep;28(7):493-501.

73. Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A randomized controlled trial

comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55

years and older with subacute or chronic low back pain. J Manipulative Physiol Ther. 2009 June;

32(5):330–43.

74. Assendelft WJ, Morton SC, Yu EI, suttorp MJ, Shekelle PG. Spinal manipulative therapy for

low back pain. Meta-analysis of effectiveness relative to other therapies. Ann Intern Med.

2003;138:871-81.1

75. Joel E. Bialosky a,*, Mark D. Bishop a, Don D. Price b, Michael E. Robinson c, Steven Z.

George A. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A

comprehensive model. Manual Therapy 2009;14:531–538.

76. Cherkin DC, et al. A review of the evidence for the effectiveness, safety, and cost of

acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med.

2003;138(11):898-906.

77. W. H. Kirkaldy-Willis J. D. Cassidy Spinal Manipulation in the Treatment of Low-Back

Pain. Can Fam Physician. 1985 Mar;31:535-40.

78. Bautmans I, Demarteau J, Cruts B, Lemper JC, Mets T. Dysphagia in elderly nursing home

residents with severe cognitive impairment can be attenuated by cervical spine mobilization. J

Rehabil Med. 2008 October; 40(9):755–60.

79.Noll DR, Degenhardt BF, Stuart MK et al. The effect of osteopathic manipulative treatment

on immune response to the influenza vaccine in nursing homes residents: a pilot study. Altern

Ther Health Med. 2004 July; 10(4):74–6.


80. Noll DR, Degenhardt BF, Stuart M, McGovern R, Matteson M. Effectiveness of a sham

protocol and adverse effects in a clinical trial of osteopathic manipulative treatment in nursing

home patients. J Am Osteopath Assoc. 2004 March; 104(3):107–13.

81. Noll DR, Degenhardt BF, Johnson JC, Burt SA. Immediate effects of osteopathic

manipulative treatment in elderly patients with chronic obstructive pulmonary disease. J Am

Osteopath Assoc. 2008 May; 108(5):251–9, 541–2.

82. Werners, Roland MD*; Pynsent, Paul B. PhD†; Bulstrode, Christopher J. K. FRCS‡

Randomized Trial Comparing Interferential Therapy With Motorized Lumbar Traction and

Massage in the Management of Low Back Pain in a Primary Care Setting. Spine: 1 August

1999;24(15)1579

83. Facci LM Effects of transcutaneous electrical nerve stimulation (TENS) and interferential

currents (IFC) in patients with nonspecific chronic low back pain: randomized clinical trial. Sao

Paulo Med J. 2011;129(4):206-16.

84. Maiers, Michele J. Chiropractic and exercise for seniors with low back pain or neck pain: the

design of two randomized clinical trials. BMC Musculoskeletal Disorders 2007, 8:94

85. McGill S. Low back exercises; evidence for improving exercise regimens. Phys Ther 1998;

78: 754-765.

86. Jull GA, Richardson CA. Motor control problems in patients with spinal pain: a new

direction for therapeutic exercise. J Manipulative Physio Ther 2000; 23:115.

87. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis,

MO: Mosby; 2001.

88. Sean D Rundell, Todd E Davenport, Tracey Wagner. A Case Report: Physical Therapist

Management of Acute and Chronic Low Back Pain Using the World Health Organization’s

International Classification of Functioning, Disability and Health. Phys Ther. 2009; 89:82-90.

89. Hawk C, Schneider M, Doherty P. Best Practices recommendations for chiropractic care for

older adults: Results of a consensus process. J Manipulative Physio Ther. 2010; 33:464–473.

90. Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and

effectiveness of chiropractic and physiotherapy as primary management for back pain. Subgroup

analysis, recurrence, and additional health care utilization. Spine. 1998;23:1875-83; discussion

1884. [PMID: 9762745]


91. S. Cislo, M.A. Ramirez, H.R. Schwartz Low back pain: treatment of forward and backward

sacral torsions using counterstrain techniques Journal of the American Osteopathic Association,

91 (1991), pp. 255–259 GET

92. Wong CK. Strain counterstrain: current concepts and clinical evidence. Man Ther. 2012

Feb;17(1):2-8. Epub 2011 Oct 24.

93. Wilson E, Payton O, Donegan-Shoaf L, Dec K. J Orthop Sports Phys Ther. 2003

Sep;33(9):502-12. Muscle energy technique in patients with acute low back pain: a pilot clinical

trial.

94. Tozzi P, Bongiorno D, Vitturini C. Fascial release effects on patients with non-specific

cervical or lumbar pain. J Bodyw Mov Ther. 2011 Oct;15(4):405-16. Epub 2011 Jan 8.

ABSTRACT

95. Bressler HB, Keyes WJ, Rochon PA, Badley E. The prevalence of low back pain in the

elderly. A systematic review of the literature. Spine 1999; 24(17): 1813 ± 1819.

96. Holmes B, Leggett S, Mooney V, Nichols J, Negri S, Hoeyberghs A. Comparison of female

geriatric lumbar-extension strength: asymptotic versus chronic low back pain patients and their

response to active rehabilitation. Journal of Spinal Disorders 1996; 9(1): 17 ± 22.

97. M. Quittan, Management of Back Pain. Disability and Rehabilitation, 2002;24:8:423-434

98. Borenstein, David G. MD. Current Opinion in Rheumatology: Nonarticular rheumatism,

sports-related injuries, and related conditions Epidemiology, etiology, diagnostic evaluation, and

treatment of low back pain. March 2001;13(2)128-134

99. Friedrich, Martin MD*; Gittler, Georg PhD†; Arendasy, Martin PhD†; Friedrich, Klaus M.

MD* Randomized Trial: Long-Term Effect of a Combined Exercise and Motivational Program

on the Level of Disability of Patients With Chronic Low Back Pain. Spine: 1 May

2005;30(9)995-1000

100. Torstensen, Tom Arild BSc (Hons), PT*; Ljunggren, Anne Elisabeth PhD, PT†; Meen,

Helge Dyre MD‡; Odland, Ellen RN‡; Mowinckel, Petter MSc§; af Geijerstam, Svante PT‡

Clinical Studies: Treatment. Efficiency and Costs of Medical Exercise Therapy, Conventional

Physiotherapy, and Self-Exercise in Patients With Chronic Low Back Pain: A Pragmatic,

Randomized, Single-Blinded, Controlled Trial With 1-Year Follow-Up. Spine: 1 December

1998;23(23)2616-2624

http://bigbrother.logan.edu:2067/pubmed/22030379

http://bigbrother.logan.edu:2067/pubmed?term=%22Wilson%20E%22%5BAuthor%5D

http://bigbrother.logan.edu:2067/pubmed?term=%22Payton%20O%22%5BAuthor%5D

http://bigbrother.logan.edu:2067/pubmed?term=%22Donegan-Shoaf%20L%22%5BAuthor%5D

http://bigbrother.logan.edu:2067/pubmed?term=%22Dec%20K%22%5BAuthor%5D


http://bigbrother.logan.edu:2067/pubmed?term=%22Tozzi%20P%22%5BAuthor%5D

http://bigbrother.logan.edu:2067/pubmed?term=%22Bongiorno%20D%22%5BAuthor%5D

http://bigbrother.logan.edu:2067/pubmed?term=%22Vitturini%20C%22%5BAuthor%5D



101. Thomas KJ et al. Longer term clinical and economic benefits of offering acupuncture care

to patients with chronic low back pain. Health Technol Assess. 2005 Aug;9(32):iii-iv, ix-x, 1-

109.

102. Daniel C. Cherkin, PhD; Karen J. Sherman, PhD, MPH; Janet Kahn, PhD; Robert Wellman,

MS; Andrea J. Cook, PhD; Eric Johnson, MS; Janet Erro, RN, MN; Kristin Delaney, MPH; and

Richard A. Deyo, MD, MPH. A Comparison of the Effects of 2 Types of Massage and Usual

Care on Chronic Low Back Pain A Randomized, Controlled Trial. Annals of Internal Medicine

2001 July 5; 155(1):1-9.

103. Hoffman, Benson M.;Papas, Rebecca K.;Chatkoff, David K.;Kerns, Robert D. Meta-

analysis of psychological interventions for chronic low back pain. Health Psychology Jan

2007;26(1)1-9.

104. Herr KA, Mobily PR, Smith C. Depression and the experience of chronic back pain: A

study of related variables and age differences. Clin J Pain 1993; 9:104–14.

105. Kovacs, Francisco MD, PhD et al. A Comparison of Two Short Education Programs for

Improving Low Back Pain-Related Disability in the Elderly A Cluster Randomized Controlled

Trial. Spine 2007; 32(10) 1053–59.

106. K. Daniel Riew, M.D et al. The Effect of Nerve-Root Injections on the Need for Operative

Treatment of Lumbar Radicular Pain. A PROSPECTIVE, RANDOMIZED, CONTROLLED,

DOUBLE-BLIND STUDY*

107. Pain Management Corticosteriods (Steroids).The MetroHealth System (2012)

http://www.metrohealth.org/body.cfm?id=2723&oTopID=2723

108. Kallewaard JW, Terheggen MA, Groen GJ, Sluijter ME, Derby R, Kapural L, Mekhail N,

van Kleef M, Discogenic low back pain. PAIN PRACT 2010 NOV-DEC; 10(6):560-79

109. Van Boxem K, Cheng J, Patijn J, van Kleef M, Lataster A, Mekhail N, Van Zundert J,

Lumbosacral radicular pain. PRACT 2010 JUL; 10(4):339 – 58

110. Murphy Donald R, et al. A non-surgical approach to the management of lumbar spinal

stenosis: A prospective observational cohort study. BMC Musculoskeletal Disorders 2006, 7:16

111. Shabat, Shay, et al. Long-term outcome of decompressive surgery for Lumbar spinal

stenosis in octogenarians. Eur Spine J (2008) 17:193–198

http://www.metrohealth.org/body.cfm?id=2723&oTopID=2723

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=Kallewaard,%20JW%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=Terheggen,%20MA%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=Groen,%20GJ%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=Sluijter,%20ME%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=Derby,%20R%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=Kapural,%20L%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=Mekhail,%20N%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False

http://www.chiroaccess.com/Search/Results.aspx?SearchScope=All&UserSearch=van%20Kleef,%20M%5bau%5d&Discipline=Any&Language=Any&YRbegin=1800&YRend=2011&Display=20&Order=Date&Refereed=False


112. Keller, J. Hayden, C. Bombardier, M. van Tulder Effect sizes of non-surgical treatments of

non-specific low-back pain. Eur Spine J (2007) 16:1776–1788

113. Van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van

Tulder MW. A systematic review on the effectiveness of physical and rehabilitation

interventions for chronic non-specific low back pain. Eur Spine J, 2011;20:19-39.

114. Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, Van Tulder MW. Spinal

manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine, 2011

June;36:E825-E846.

115.Brunarski, DC, MSc, FCCS(C) The Psychology of Chronic Back Pain. Psychological risk

factors for chronicity and our challenge as clinicians: finding the right treatment mix.

116. Simon Dagenais, Ralph E. Gay, Andrea C. Tricco, Michael D. Freeman, John M. Mayer.

NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back

pain. The Spine Journal October 2010;10(10):918-940

117. Daubs MD, Norvell DC, McGuire R, Molinari R, Hermsmeyer JT, Fourney DR, Wolinsky

JP, Brodke D, Fusion versus nonoperative care for chronic low back pain: do psychological

factors affect outcomes? Spine 2011 OCT 1; 36(21 Suppl) pp. S96 – 109.

118. Joel E. Bialosky a,*, Mark D. Bishop a, Don D. Price b, Michael E. Robinson c, Steven Z.

George A. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A

comprehensive model. Manual Therapy 2009;14:531–538.

119. Low Back Pain: Early Management of Persistent Non-specific Low Back Pain [Internet].

NICE Clinical Guidelines, No. 88. National Collaborating Centre for Primary Care (UK).

London: Royal College of General Practitioners (UK); 2009 May.

120. Chung-Wei Christine Lin,1 Marion Haas,2 Chris G. Maher,1 Luciana A. C. Machado,3 and

Maurits W. van Tulder4. Cost-effectiveness of guideline-endorsed treatments for low back pain:

a systematic review. Eur Spine J. 2011 July; 20(7): 1024–1038.

121. Crow R, Gage H, Hampson S, Hart J, Kimber A, Thomas H. The role of expectancies in the

placebo effect and their use in the delivery of health care: a systematic review. Health Technol

Assess. 1999;3:1-96.


122. Kalauokalani D, Cherkin DC, Sherman KJ, Koepsell TD, Deyo RA. Lessons from a trial of

acupuncture and massage for low back pain: patient expectations and treatment effects. Spine.

2001;26:1418-24.

123. Mondloch MV, Cole DC, Frank JW. Does how you do depend on how you think you’ll do?

A systematic review of the evidence for a relation between patients’ recovery expectations and

health outcomes. CMAJ. 2001;165:174-9.

124. Goodwin JS. Geriatrics and the limits of modern medicine. N Eng J of Med. 1999;

340(16):1283–1285.

conservative treatment of low back pain in the older adult: a

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