Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. A Population‐Based Study of Spinal Pain Among 35‐45‐Year‐Old Individuals: Prevalence, Sick Leave, and Health Care Use Spinal pain in adolescents: prevalence, incidence, and course: a school-based two-year prospective cohort study in 1,300 Danes aged 11–13 Can Chronic Disability Be Prevented?: A Randomized Trial of a Cognitive-Behavior Intervention and Two Forms of Information for Patients With Spinal Pain Low Back Pain in the Young A Prospective Three‐Year Follow‐up Study of Subjects With and Without Low Back Pain Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care. The MRC Spine Stabilization Trial: Surgical Methods, Outcomes, Costs, and Complications of Surgical Stabilization Supervised Exercise With and Without Spinal Manipulation Performs Similarly and Better Than Home Exercise for Chronic Neck Pain: A Randomized Controlled Trial Spinal Range of Motion, Muscle Endurance, and Back Pain and Function at Least 20 Years After Fusion or Brace Treatment for Adolescent Idiopathic Scoliosis: A Case-Control Study Two-Year Follow-up of a Randomized Clinical Trial of Spinal Manipulation and Two Types of Exercise for Patients with Chronic Neck Pain Spine surgery research: on and beyond current strategies. Medical versus surgical treatment for low back pain: evidence and clinical practice. Epidural steroids in the management of chronic spinal pain and radiculopathy. Predictors of surgical outcome in degenerative lumbar spinal stenosis. Aprotinin Reduces Blood Loss During Spinal Surgery in Children ISSLS Prize Winner: Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER) A Factorial Randomized Trial to Determine Whether the Functional Outcome of Spinal Surgery Can Be Improved Assessing the Needs of Patients in Pain: A Matter of Opinion? Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation A Randomized Clinical Trial of Exercise and Spinal Manipulation for Patients With Chronic Neck Pain Spinal Cord Injury Rehabilitation Evidence: Methods of the SCIRE Systematic Review. Neuropathic pain post spinal cord injury part 1: systematic review of physical and behavioral treatment. Complications in the Use of rhBMP-2 in PEEK Cages for Interbody Spinal Fusions Altered spinal kinematics and muscle recruitment pattern of the cervical and thoracic spine in people with chronic neck pain during functional task.
BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain Study Design . A question naire was mailed to 3000 r and omly selected 35‐45‐year‐old individuals in three communities in central Sweden . Objectives . To study the 1‐year prevalence of spinal pain and its ramifications in the form of pain , function , sick leave , and health care use . Summary of Background Data . Previous research ers have used a variety of definitions and population s , but primarily have investigated the occurrence of pain . Comprehensive data are needed concerning health care use , the degree of the pain problem , functional disturbances , and sick leave . Method . Participants in the study completed a question naire regarding spinal pain during the past year including the degree of their experienced pain , functional impairment , lost work days , and health care use . Results . A total of 2305 people ( 78.5 % ) responded to the question naire . Nonrespondents had similar characteristics but a slightly lower 1‐year prevalence rate than did respondents . For respondents , the prevalence of spinal pain during the past year was 66.3 % , with women having a slightly higher prevalence than men . Approximately 25 % of the respondents indicated that they had a substantial problem based on ratings of pain , functional impairment , and sick leave . Work absenteeism reported to the Public Social Insurance Office involved 19 % of those with pain , but an additional 15 % indicated unreported absenteeism . On average , those with pain visited health care providers three times during the past year , but a small number of those who experienced pain consumed large amounts of health care and illness benefits . An important gender difference was shown , such that when pain was at its worst , men took sick leave , whereas women sought health care . Conclusions . Taken together , these data indicate that spinal pain is common among 35‐45‐year‐old men and ‐ women , and that it is related to marked problems for approximately one fourth of those who experience pain . Gender differences exist in the pattern of sick leave and health care use , and a small proportion of those with pain consume very large amounts of the re sources . Consequently , there is a need for early , effective , preventive treatments Background The severity and course of spinal pain is poorly understood in adolescents . The study aim ed to determine the prevalence and two-year incidence , as well as the course , frequency , and intensity of pain in the neck , mid back , and low back ( spinal pain ) . Methods This study was a school-based prospect i ve cohort study . All 5th and 6th grade students ( 11–13 years ) at 14 schools in the Region of Southern Denmark were invited to participate ( N = 1,348 ) . Data were collected in 2010 and again two years later , using an e-survey completed during school time . Results The lifetime prevalence of spinal pain was 86 % and 89 % at baseline and follow-up , respectively . A group of 13.6 % ( 95 % CI : 11.8 , 15.6 ) at baseline and 19.5 % ( 95 % CI : 17.1 , 22.0 ) at follow-up reported that they had pain frequently . The frequency of pain was strongly associated with the intensity of pain , i.e. , the majority of the participants reported their pain as relatively infrequent and of low intensity , whereas the participants with frequent pain also experienced pain of higher intensity . The two-year incidence of spinal pain varied between 40 % and 60 % across the physical locations . Progression of pain from one to more locations and from infrequent to more frequent was common over the two-year period . Conclusions Spinal pain is common at the age of 11–15 years , but some have more pain than others . The pain is likely to progress , i.e. , to more locations , higher frequency , and higher pain intensity over a two-year period Study Design . A r and omized controlled design superimposed on treatment as usual was used to compare the effects of a cognitive-behavior intervention aim ed at preventing chronicity with two different forms of information . Objective . To develop a coping-oriented preventive intervention applicable in primary care , and to compare its impact with educational information . Summary of Background Data . Preventing long-term disability result ing from spinal pain has proved difficult . The information provided by health care professions and early interventions aim ed at preventing long-term disability may be important , but little scientific evidence exists concerning their use . Methods . A protocol for a six-session cognitive-behavior group intervention was developed on the basis of earlier research . The main focus was to prevent long-term disability by changing patients ’ behaviors and beliefs so they can cope better with their problems . Comparison groups received either a pamphlet shown earlier to have an effect , or a more extensive information package consisting of six installments . All the groups continued to receive treatment as usual in primary care . There were 243 patients with acute or subacute spinal pain who perceived that they were at risk for developing a chronic problem . These patients were r and omized to the cognitive-behavioral intervention or one of the two information groups . Because the aim was to prevent long-term disability , the key outcome variables at the 1-year follow-up assessment were sick absenteeism and health care use . Other variables were pain , function , fear-avoidance beliefs , and cognitions . Results . The comparison groups reported benefits . However , the risk for a long-term sick absence developing was lowered ninefold for the cognitive-behavior intervention group as compared with the risk for the information groups ( relative risk , 9.3 ) . Participants in the cognitive-behavior group also reported a significant decrease in perceived risk . In addition , the cognitive-behavior group demonstrated a significant decrease in physician and physical therapy use as compared with two groups receiving information , in which such use increased . All three groups tended to improve on the variables of pain , fear-avoidance , and cognitions . Conclusions . This study demonstrates that a cognitive-behavior group intervention can lower the risk of a long-term disability developing . These findings underscore the significance of early interventions that specifically aim to prevent chronic problems . This approach might be applied to primary care setting Study Design . This was a prospect i ve 3-year follow-up study of r and omized matched subgroups of 15-year-old school children with or without low back pain initially . Objective . In addition to low back pain and leisure time physical activity , spinal mobility , trunk muscle strength , and early degenerative findings of the lumbar spine were evaluated . Summary of Background Data . Reliable epidemiologic studies on the prevalence of low back pain and development of early degenerative changes of the lumbar spine in young persons have been sparse . Along with several other characteristics , the relationship of these changes to frequent low back pain in young persons is not known . Methods . After a question naire-based survey was administered , subjects with or without low back pain were examined initially and at follow-up with special reference to leisure time physical activity , anthropometry , spinal mobility , trunk muscle strength , and magnetic resonance imaging findings of the lumbar spine . Results . At baseline and at follow-up , those subjects with initial low back pain were characterized by a low frequency of physical activity and decreased spinal function . During follow-up , the occurrence of disc degeneration increased significantly more in the original group with low back pain than among asymptomatic subjects . Furthermore , disc degeneration at baseline significantly predicted future frequent low back pain . Initial disc protrusion also predicted future frequent low back pain . Conclusion . After the rapid physical growth period , there seemed to be a causal relationship between the early evolution of the degenerative processes of the lower lumbar discs and frequent low back pain in several subjects BACKGROUND Spinal pain is common and frequently disabling . Management guidelines have encouraged referral from primary care for spinal manipulation . However , the evidence base for these recommendations is weak . More pragmatic trials and economic evaluations have been recommended . OBJECTIVES Our aim was to assess the effectiveness and health care costs of a practice -based osteopathy clinic for subacute spinal pain . METHODS A pragmatic r and omized controlled trial was carried out in a primary care osteopathy clinic accepting referrals from 14 neighbouring practice s in North West Wales . A total of 201 patients with neck or back pain of 2 - 12 weeks duration were allocated at r and om between usual GP care and an additional three sessions of osteopathic spinal manipulation . The primary outcome measure was the Extended Aberdeen Spine Pain Scale ( EASPS ) . Secondary measures included SF-12 , EuroQol and Short-form McGill Pain Question naire . Health care costs were estimated from the records of referring GPs . RESULTS Outcomes improved more in the osteopathy group than the usual care group . At 2 months , this improvement was significantly greater in EASPS [ 95 % confidence interval ( CI ) 0.7 - 9.8 ] and SF-12 mental score ( 95 % CI 2.7 - 10.7 ) . At 6 months , this difference was no longer significant for EASPS ( 95 % CI -1.5 to 10.4 ) , but remained significant for SF-12 mental score ( 95 % CI 1.0 - 9.9 ) . Mean health care costs attributed to spinal pain were significantly greater by 65 UK pounds in the osteopathy group ( 95 % CI 32 - 155 UK pounds ) . Though osteopathy also cost 22 UK pounds more in mean total health care cost , this was not significant ( 95 % CI - 159 to 142 UK pounds ) . CONCLUSION A primary care osteopathy clinic improved short-term physical and longer term psychological outcomes , at little extra cost . Rigorous multicentre studies are now needed to assess the generalizability of this approach Study Design . A review of the surgical costs and results in a group of patients r and omly allocated to surgery as part of a large prospect i ve r and omized trial of patients with chronic back pain . Objective . To report the observational data from the surgical arm of a r and omized trial comparing surgery with intensive rehabilitation for chronic low back pain . Clinical and economic data are reported . Summary of Background Data . Surgery for chronic low back pain is a well established but unproven intervention . The most cost-effective technique for spinal stabilization is still not established . Methods . One hundred six patients with chronic low back pain were r and omized to the surgical group of a r and omized trial comparing spinal fusion of the lumbar with a 3 week intensive rehabilitation program . The primary outcomes were the Oswestry Disability Index ( ODI ) and the Shuttle Walking Test measured at baseline and 2 years postr and omization . Patients were stratified by preoperative diagnosis , smoking habit , and litigation . Complications were assessed and costs analyzed . Results . Of the 176 surgical patients , 56 underwent postero-lateral fusion , 57 underwent interbody fusion , and 24 underwent flexible stabilization of the spine . The mean ODI for all patients in the surgical arm of the trial improved from a baseline of 46.5 ( SD 14.6 ) to 34.2 ( SD 21 ) at 2 years . Health care costs were higher ( £ 3109 difference ) for more complex procedures , and nearly 6 times as many early complications occurred with the more complex procedures . Smoking and unemployment were associated with worse results whereas litigation did not adversely affect the outcome . Conclusion . These observational changes in the ODI after surgery are similar to those reported from other studies of spinal fusion . More complex surgery is more expensive with more complications than postero-lateral fusion Study Design . R and omized controlled trial using mixed methods . Objective . To evaluate the relative effectiveness of high-dose supervised exercise with and without spinal manipulation and low-dose home exercise for  chronic neck pain .  Summary of Background Data . Neck pain is a common global health care complaint with considerable social and economic impact . Systematic review s have found exercise therapy ( ET ) to be effective for neck pain , either alone or in combination with spinal manipulation . However , it is unclear to what extent spinal manipulation adds to supervised exercise or how supervised high-dose exercise compares with low-dose home exercise . Methods . Two hundred and seventy patients with chronic neck pain were studied at an outpatient clinic . Patients were r and omly assigned one of the following interventions : ( 1 ) high-dose supervised strengthening exercise with spinal manipulation ( exercise therapy combined with spinal manipulation therapy [ ET + SMT ] ) , ( 2 ) high-dose supervised strengthening exercise ( ET ) alone , or ( 3 ) low-dose home exercise and advice ( HEA ) . The primary outcome was patient-rated pain at baseline and at 4 , 12 , 26 , and 52 weeks . Secondary measures were disability , health status , global perceived effect , medication use , and satisfaction . Results . At 12 weeks , there was a significant difference in patient-rated pain between ET + SMT and HEA ( 1.3 points , P < 0.001 ) and ET and HEA ( 1.1 points , P = 0.001 ) . Although there were smaller group differences in patient-rated pain at 52 weeks ( ET + SMT vs. HEA , 0.2 points , P > 0.05 ; ET vs. HEA , 0.3 points , P > 0.05 ) , linear mixed model analyses incorporating all time points yielded a significant advantage for the 2 supervised exercise groups ( ET + SMT vs. HEA , P = 0.03 ; ET vs. HEA , P = 0.02 ) . Similar results were observed for global perceived effect and satisfaction . Conclusion . Supervised strengthening exercise with and without spinal manipulation performed similarly , yielding better outcomes than home exercise particularly in the short term . Various stakeholders ' perspectives should be considered carefully when making recommendations regarding these therapies , taking into account side effects , preferences , and costs Study Design . A consecutive series of patients with adolescent idiopathic scoliosis ( AIS ) , treated between 1968 and 1977 before 21 years of age with either distraction and fusion using Harrington rods ( ST , n = 156 ; 145 females and 11 males ) or with brace ( BT , n = 127 ; 122 females and 5 males ) , were followed at least 20 years after completion of the treatment . Objectives . To determine the long-term outcome in terms of spinal mobility and muscle strength and its possible correlations to present back pain and function in patients surgically or brace treated for AIS . Summary of Background Data . Few reports on long-term outcome on these variables have previously been presented for this group of patients . Methods . A total of 135 ( 87 % ) of ST and 102 ( 80 % ) of BT patients underwent a complete examination by two unbiased observers incl . evaluation of lumbar muscle endurance and spinal mobility , curve size ( Cobb method ) , vali date d question naires in terms of general and disease-specific quality of life aspects , as well as present back function and pain . An age- and sex-matched control group of 100 persons was r and omly selected and subjected to the same examinations . Results . For both ST and BT groups , lumbar spinal motion as well as muscle endurance were significantly decreased compared with controls . For ST patients , better lumbar extensor and flexor muscle endurance or lumbar spinal mobility correlated with a better physical function . The length of fusion into the lumbar spine correlated inversely with lumbar range of motion , but the finger-floor distance was not affected . BT patients with reduced lumbar spinal mobility experienced lumbar back pain more often than controls . Conclusions . For both brace treated and surgically treated AIS patients , spinal mobility and muscle endurance were reduced more than 20 years after completed treatment . The physical function was not severely restricted Study Design . R and omized clinical trial . Objectives . To compare the effects of spinal manipulation combined with low-tech rehabilitative exercise , MedX rehabilitative exercise , or spinal manipulation alone in patient self-reported outcomes over a two-year follow-up period . Summary of Background Data . There have been few r and omized clinical trials of spinal manipulation and rehabilitative exercise for patients with neck pain , and most have only reported short-term outcomes . Methods . One hundred ninety-one patients with chronic neck pain were r and omized to 11 weeks of one of the three treatments . Patient self-report question naires measuring pain , disability , general health status , improvement , satisfaction , and OTC medication use were collected after 5 and 11 weeks of treatment and 3 , 6 , 12 , and 24 months after treatment . Data were analyzed taking into account all time points using repeated measures analyses . Results . Ninety-three percent ( 178 ) of r and omized patients completed the 11-week intervention phase , and 76 % ( 145 ) provided data at all evaluation time points over the two-year follow-up period . A difference in patient-rated pain with no group-time interaction was observed in favor of the two exercise groups [ F(2141 ) = 3.2;P = 0.04 ] . There was also a group difference in satisfaction with care [ F(2143 ) = 7.7;P = 0.001 ] , with spinal manipulation combined with low-tech rehabilitative exercise superior to MedX rehabilitative exercise ( P = 0.02 ) and spinal manipulation alone ( P < 0.001 ) . No significant group differences were found for neck disability , general health status , improvement , and OTC medication use , although the trend over time was in favor of the two exercise groups . Conclusion . The results of this study demonstrate an advantage of spinal manipulation combined with low-tech rehabilitative exercise and MedX rehabilitative exercise versus spinal manipulation alone over two years and are similar in magnitude to those observed after one-year follow-up . These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers . Further studies are needed to examine the cost effectiveness of these therapies and how spinal manipulation compares to no treatment or minimal intervention BACKGROUND CONTEXT Systematic review s of the literature are powerful tools in evidence -based medicine . However , the design and report of systematic review s in spinal surgery contain many aspects amenable to improvement . PURPOSE To discuss the issues especially relevant for systematic review s in spinal surgery . METHODS From our experience of systematic review s and meta-analyses of clinical trials in  spinal surgery  , we infer guidance for the design and execution of systematic literature review s. RESULTS There are many difficulties associated with the design as well as conduct of clinical trials and consequently appraising evidence in spinal surgery . New treatments should be compared with the gold st and ard before other comparisons are investigated . Studies should present data as thoroughly as possible regarding all subgroups and follow-up moments , possibly in supplementary material . To provide the highest level of evidence , systematic review s should be as rigorously design ed as possible . CONCLUSIONS Gathering information on clinical effectiveness in spinal surgery can be improved both at the clinical study level and at the systematic review level . Alternatives to r and omized controlled trials such as comparative studies can be valuable tools on the clinical effectiveness of treatments in spinal surgery . The experience reflected in this article can support the scientific efforts in this field CONTEXT Although low back pain is one of the most common health problems , it is still difficult to choose between surgical and medical treatment . OBJECTIVE To examine the evidence of the efficacy of  surgical and medical treatment of the two most common indications for spinal surgery for low back pain -- lumbar disc herniation and spinal stenosis-- and to assess geographic variation in the use of surgery for these conditions in the United States . METHODS The MEDLINE data base ( 1966 - 1999 ) was search ed for all studies that compared surgical and medical treatments for low back pain .  Data from the Health Care Financing Administration were used to examine geographic variation in  spinal surgery rates for patients enrolled in Medicare ( 1996 - 1997 ) . RESULTS Eight observational studies and one r and omized clinical trial were identified . In general , these studies suggest better short-term outcomes ( e.g. , functional status and employability ) with surgery than with medical approaches , but they indicate that long-term results are similar with both types of treatment . Method ologic flaws in the observational studies , particularly selection bias , preclude definitive conclusions about relative efficacy . In 1996 and 1997 , more than 98,000 Medicare enrollees had surgery for disc herniation or spinal stenosis . Among hospital referral regions , rates of surgery for disc herniation varied 8-fold , from 0.24 to 1.96 per 1000 Medicare enrollees , and rates of surgery for spinal stenosis varied 12-fold , from 0.29 to 3.34 per 1000 Medicare enrollees . CONCLUSIONS The literature comparing the efficacy of surgical and medical treatment for low back pain is limited . Not surprisingly , the use of surgery for low back pain varies widely across the United States . To establish clinical consensus , we need better evidence about the efficacy of surgery Epidural injections with or without steroids are used extensively in the management of chronic spinal pain . However , evidence is contradictory with continuing debate about the value of epidural steroid injections in chronic spinal syndromes . The objective of this systematic review is to determine the effectiveness of epidural injections in the treatment of chronic spinal pain . Data sources include relevant literature identified through search es of MEDLINE , EMBASE ( Jan 1966- Mar 2003 ) , manual search es of bibliographies of known primary and review articles , and abstract s from scientific meetings . Both r and omized and non-r and omized studies were included in the review based on the criteria established by the Agency for Healthcare Research and Quality ( AHRQ ) . Studies were excluded from the analysis if they were simply review or descriptive and failed to meet minimum criteria . The results showed that there was strong evidence to indicate effectiveness of transforaminal epidural injections in managing lumbar nerve root pain . Further , evidence was moderate for caudal epidural injections in managing lumbar radicular pain . The evidence in management of chronic neck pain , chronic low back pain , cervical radiculopathy , spinal stenosis , and post laminectomy syndrome was limited or inconclusive . In conclusion , the evidence of effectiveness of  transforaminal epidural injections  in managing lumbar nerve root pain was strong , whereas , effectiveness of caudal epidural injections  in managing lumbar radiculopathy was moderate , while there was limited or inconclusive evidence of effectiveness of epidural injections  in managing chronic spinal pain without radiculopathy , spinal stenosis , post lumbar laminectomy syndrome , and cervical radiculopathy STUDY DESIGN A prospect i ve , observational study . OBJECTIVES To identify outcome predictors of surgery for degenerative lumbar spinal stenosis . SUMMARY OF BACKGROUND DATA Degenerative lumbar spinal stenosis is the most frequent indication for spine surgery in the elderly . More than 25 % of surgical patients have a poor outcome , yet little is known about factors that predict the outcome of surgery . METHODS Surgery was performed on 199 patients with degenerative lumbar spinal stenosis , and they were observed for 2 years after surgery in four referral centers . Surgery consisted of decompressive laminectomy with or without arthrodesis . Outcomes included vali date d measures of symptom severity , walking capacity , and satisfaction with the results of surgery . Potential predictors of outcome included sociodemographic factors and physical examination , as well as radiographic , psychological , social , and clinical history variables . RESULTS The proportion of patients with severe pain decreased from 81 % before surgery to 31 % by 2 years afterward . The most powerful preoperation predictor of greater walking capacity , milder symptoms , and greater satisfaction was the patient 's report of good or excellent health before surgery . Low cardiovascular comorbidity also predicted a favorable outcome . CONCLUSIONS Patient 's assessment s of their own health and comorbidity are the most cogent outcome predictors of surgery for spinal stenosis Study Design . A prospect i ve blinded , r and omized controlled study compared the effect of a perioperative infusion of aprotinin versus placebo during long segment spinal fusions in children . Objectives . To determine whether aprotinin decreases blood loss and transfusion requirements in pediatric patients with spinal deformities undergoing posterior spinal fusions of seven or greater segments . Summary of Background Data . Blood loss is a major cause of morbidity during long segment spinal fusion . Several preoperative and intraoperative techniques are currently used to reduce blood loss and transfusion requirements . Aprotinin , an antifibrinolytic and anti-inflammatory agent , has been used to decrease blood loss in cardiac surgical patients . We design ed a prospect i ve , r and omized , and blinded controlled study to evaluate aprotinin ’s efficacy in reducing bleeding during pediatric spine surgery . Methods . After obtaining informed written consent , we studied 44 children and adolescents who were anticipated to be at higher risk for major blood loss during posterior spinal fusion . Children were r and omly assigned to receive high dose aprotinin or placebo infusion during the perioperative period . Patients were assessed for blood loss , transfusion requirements , days in the intensive care unit , and days in hospital . Results . Demographics in the two groups of patients were similar . The study demonstrated a significant reduction in estimated blood loss  ( aprotinin 545 cc , placebo 930 cc ) and transfusion requirements  ( aprotinin 1.1 U , placebo 2.2 U ) . The duration of intensive care unit admission was similar in the two groups , as was the time until discharge . Conclusions . This r and omized , blinded study suggests that aprotinin significantly decreased blood loss and transfusion requirements in pediatric and adolescent scoliosis surgical patients at increased risk for intraoperative bleeding Study Design . This was a multicenter , factorial , r and omized , controlled trial on the postoperative management of spinal surgery patients , with r and omization stratified by surgeon and operative procedure . Objective . This study sought to determine whether the functional outcome of two common spinal operations could be improved by a program of postoperative rehabilitation that combines professional support and advice with grade d active exercise commencing 6 weeks after surgery and /or an educational booklet based on evidence -based messages and advice received at discharge from hospital , each compared with usual care . Summary of Background Data . Surgical interventions on the spine are increasing , and while surgery for spinal stenosis and disc prolapse have been shown to be superior to conservative management , functional outcome , and patient satisfaction are not optimal . Methods . The study compared the effectiveness of a rehabilitation program and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery , each compared with “ usual care ” using a 2 × 2 factorial design , r and omizing patient to four groups ; rehabilitation-only , booklet-only  , rehabilitation-plus-booklet , and usual care only . The primary outcome measure was the Oswestry Disability Index ( ODI ) at 12 months , with secondary outcomes including visual analog scale measures of back and leg pain . Results . Three hundred thirty-eight patients were recruited into the study and measurements were obtained preoperatively and then repeated at 6 weeks , 3 , 6 , 9 and 12 months postoperatively . Twelve months postoperatively the observed effect of rehabilitation  on ODI was −2.7 ( 95 % CI : −6.8 to 1.5 ) and the effect of booklet was 2.7 ( 95 % CI : −1.5 to 6.9 ) . Conclusion . This study found that neither intervention had a significant impact on long-term outcome Study Design . A prospect i ve cohort study including patients with nonspecific spinal pain was performed . Objectives . To investigate whether the use of expert judgment in routine practice can provide a basis for reliable decision making concerning the need for intervention in patients with spinal pain and their ability to benefit from treatment . Summary of Background Data . A wide range of instruments and techniques are used to assess and treat patients with spinal pain . Many instruments are used without being clinimetrically tested . Methods . A question naire concerning the patients ’ need of treatment and their potential to assimilate it was sent to experts in the health care arena : physicians , physical therapists , social insurance officers . The experts included were those connected with patients participating in a larger outcome study . Two cohorts of patients ( sample 1 , n = 217 ; sample 2 , n = 257 ) were followed for 6 and 12 months , during which time the patients ’ health and work status were mapped . Results . No acceptable agreement was found between any of the experts ’ ratings of patients ’ needs and potential for rehabilitation . Logistic regression showed that the experts ’ judgments were based almost solely on the age of the patient . The prediction analyses showed that the most consistent predictor of the patients ’ status at the 6-month follow-up assessment was the patients ’ own belief in the existence of effective treatments and their perceived ability for learning to cope with the condition . Conclusions . Expert judgment as exercised in routine practice can not be used as basis for reliable decision making concerning the need of the patient with spinal pain for intervention and the patient ’s ability to benefit from treatment Study Design . A r and omized controlled clinical trial was conducted . Objective . To compare medication , needle acupuncture , and spinal manipulation for managing chronic ( > 13 weeks duration ) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain . Summary of Background Data . Between February 1999 and October 2001 , 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital ’s multidisciplinary spinal pain unit . Methods . One of three separate intervention protocol s was used : medication , needle acupuncture , or chiropractic spinal manipulation . Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index ( Oswestry ) , the Neck Disability Index ( NDI ) , the Short-Form-36 Health Survey question naire ( SF-36 ) , visual analog scales ( VAS ) of pain intensity and ranges of movement . These instruments were administered again at 2 , 5 , and 9 weeks after the beginning of treatment . Results . R and omization proved to be successful . The highest proportion of early ( asymptomatic status ) recovery was found for manipulation ( 27.3 % ) , followed by acupuncture ( 9.4 % ) and medication ( 5 % ) . Manipulation achieved the best overall results , with improvements of 50 % ( P = 0.01 ) on the Oswestry scale , 38 % ( P = 0.08 ) on the NDI , 47 % ( P < 0.001 ) on the SF-36 , and 50 % ( P < 0.01 ) on the VAS for back pain , 38 % ( P < 0.001 ) for lumbar st and ing flexion , 20 % ( P < 0.001 ) for lumbar sitting flexion , 25 % ( P = 0.1 ) for cervical sitting flexion , and 18 % ( P = 0.02 ) for cervical sitting extension . However , on the VAS for neck pain , acupuncture showed a better result than manipulation ( 50%vs 42 % ) . Conclusions . The consistency of the results provides , despite some discussed shortcomings of this study , evidence that in patients with chronic spinal pain , manipulation , if not contraindicated , results in greater short-term improvement than acupuncture or medication . However , the data do not strongly support the use of only manipulation , only acupuncture , or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain . The results from this exploratory study need confirmation from future larger studies Study Design . A r and omized , parallel-group , single-blinded clinical trial was performed . After a 1-week baseline period , patients were r and omized to 11 weeks of therapy , with posttreatment follow-up assessment 3 , 6 , and 12 months later . Objectives . To compare the relative efficacy of rehabilitative neck exercise and spinal manipulation for the management of patients with chronic neck pain .  Summary of Background Data . Mechanical neck pain is a common condition associated with substantial morbidity and cost . Relatively little is known about the efficacy of spinal manipulation and exercise for chronic neck pain . Also , the combination of both therapies has yet to be explored . Methods . Altogether , 191 patients with chronic mechanical neck pain were r and omized to receive 20 sessions of spinal manipulation combined with rehabilitative neck exercise ( spinal manipulation with exercise ) , MedX rehabilitative neck exercise , or spinal manipulation alone . The main outcome measures were patient-rated neck pain , neck disability , functional health status ( as measured by Short Form-36 [ SF-36 ] ) , global improvement , satisfaction with care , and medication use . Range of motion , muscle strength , and muscle endurance were assessed by examiners blinded to patients ’ treatment assignment . Results . Clinical and demographic characteristics were similar among groups at baseline . A total of 93 % of the patients completed the intervention phase . The response rate for the 12-month follow-up period was 84 % . Except for patient satisfaction , where spinal manipulative therapy and exercise were superior to spinal manipulation with ( P = 0.03 ) , the group differences in patient-rated outcomes after 11 weeks of treatment were not statistically significant ( P = 0.13 ) . However , the spinal manipulative therapy and exercise group showed greater gains in all measures of strength , endurance , and range of motion than the spinal manipulation group ( P < 0.05 ) . The spinal manipulation with exercise group also demonstrated more improvement in flexion endurance and in flexion and rotation strength than the MedX group ( P < 0.03 ) . The MedX exercise group had larger gains in extension strength and flexion – extension range of motion than the spinal manipulation group ( P < 0.05 ) . During the follow-up year , a greater improvement in patient-rated outcomes were observed for spinal manipulation with exercise and for MedX exercise than for spinal manipulation alone ( P = 0.01 ) . Both exercise groups showed very similar levels of improvement in patient-rated outcomes , although the spinal manipulation and exercise group reported greater satisfaction with care ( P < 0.01 ) . Conclusions . For chronic neck pain , the use of strengthening exercise , whether in combination with spinal manipulation or in the form of a high-technology MedX program , appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone . The effect of low-technology exercise or spinal manipulative therapy alone , as compared with no treatment or placebo , and the optimal dose and relative cost effectiveness of these therapies , need to be evaluated in future studies The Spinal Cord Injury Rehabilitation Evidence ( SCIRE ) is a synthesis of the research evidence underlying rehabilitation interventions to improve the health of people living with SCI . SCIRE covers a comprehensive set of topics and in this issue we present six papers relevant to SCI rehabilitation clinicians ( SCI inpatient rehabilitation practice s , gait strategies , upper extremity reconstructive surgery , spasticity treatments , cardiovascular health and bone health ) . The SCIRE used a systematic and well-defined protocol to assess and synthesize the evidence . Each article was scored for its method ological quality using either the Physiotherapy Evidence Data base ( PEDro ) Score for r and omized controlled trials or the Downs and Black Tool for other types of studies . Following the individual study assessment , conclusions were drawn about the accumulated studies for each topic of interest based on the levels of evidence , quality of studies and concurring evidence . The SCIRE project was design ed for health professionals to inform them of best practice BACKGROUND Neuropathic pain has various physiologic and psychosocial aspects . Hence , there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury ( SCI ) . OBJECTIVE The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI . METHODS MEDLINE , CINAHL , EMBASE , and PsycINFO data bases were search ed for articles addressing nonpharmacological treatment of pain post SCI . Articles were restricted to the English language . Article selection was conducted by 2 independent review ers with the following inclusion criteria : the subjects participated in a treatment or intervention for neuropathic pain ; at least 50 % of the subjects had an SCI ; at least 3 subjects had an SCI ; and a definable intervention was being studied . Data extracted included study design , study type , subject demographics , inclusion and exclusion criteria , sample size , outcome measures , and study results . R and omized controlled trials ( RCTs ) were assessed for quality using the Physiotherapy Evidence Data base ( PEDro ) assessment scale . Levels of evidence were assigned to each intervention using a modified Sackett scale . RESULTS The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI : physical and behavioral treatments . The pooled sample size of all studies included 433 participants . Of the 16 studies included , 7 were level 1 , 3 were level 2 , and 6 were level 4 studies . CONCLUSIONS Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain . Of these interventions , transcranial electrical stimulation had the strongest evidence of reducing pain . Despite a growing body of literature , there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain Study Design All patients of spinal interbody fusion using polyetheretherketone ( PEEK ) cages and recombinant human bone morphogenetic protein (rhBMP)-2 performed over a 16-month period were review ed . Objective To determine the suitability of PEEK cages when used in conjunction with rhBMP-2 in interbody spinal fusion . Summary of Background Data Bone morphogenetic proteins are increasingly being used in spinal fusion to promote osteogenesis . PEEK is a semicrystalline aromatic polymer that is used as a structural spacer to maintain the disc and foraminal height . Their use has led to increased and predictable rates of fusion . However , not many reports of the adverse effects of their use are available . Methods Fifty-nine consecutive patients of interbody spinal fusion in the cervical or lumbar spine using a PEEK cage and rhBMP-2  were followed for an average of 26 months after surgery . A clinical examination and a record of Oswestry Disability Index , Visual Analog Scale for pain , and a pain diagram were performed preoperatively and at every follow-up visit . All patients had plain radiographs carried out to assess fusion . Ten patients of lumbar spine fusion were additionally evaluated with a computed tomography scan . Results All cases demonstrated an appreciable amount of new bone formation by 6 to 9 months in the cervical spine and by 9 to 12 months in the lumbar spine . End plate resorption was visible radiologically in all cervical spine fusions and majority of lumbar fusions . Cage migration was observed to occur maximally in patients with transforaminal lumbar interbody fusion and posterior lumbar interbody fusion . Disc space subsidence was seen in both cervical and lumbar arthrodesis with the latter showing a lesser incidence , but with a greater degree of collapse . Conclusions PEEK cages and rhBMP-2 when used in spinal fusion give consistently good fusion rates . However , the early role of BMP in the resorptive phase may cause loosening , cage migration , and subsidence Knowledge on the spinal kinematics and muscle activation of the cervical and thoracic spine during functional task would add to our underst and ing of the performance and interplay of these spinal regions during dynamic condition . The purpose of this study was to examine the influence of chronic neck pain on the three-dimensional kinematics and muscle recruitment pattern of the cervical and thoracic spine during an overhead reaching task involving a light weight transfer by the upper limb . Synchronized measurements of the three-dimensional spinal kinematics and electromyographic activities of cervical and thoracic spine were acquired in thirty individuals with chronic neck pain and thirty age- and gender-matched asymptomatic controls . Neck pain group showed a significantly decreased cervical velocity and acceleration while performing the task . They also displayed with a predominantly prolonged coactivation of cervical and thoracic muscles throughout the task cycle . The current findings highlighted the importance to examine differential kinematic variables of the spine which are associated with changes in the muscle recruitment in people with chronic neck pain . The results also provide an insight to the appropriate clinical intervention to promote the recovery of the functional disability commonly reported in patients with neck pain disorders
Results of these studies indicate that school-based spinal health interventions may be effective in increasing spinal care knowledge and decreasing the prevalence of spinal pain .
However , overall the evidence is inconclusive regarding spinal care behaviors .
The poor quality of the review ed studies limits the conclusions that can be made regarding the effectiveness of school-based spinal health interventions
OBJECTIVES To establish the effectiveness of  school-based spinal health interventions  in terms of : 1 ) improving knowledge about the spine/spinal care ; 2 ) changing spinal care behaviors ; and 3 ) decreasing the prevalence of spinal pain .
SUMMARY OF BACKGROUND DATA Spinal pain is a significant problem in children and adolescents that has been addressed through school-based spinal health interventions .
No systematic review has been carried out on this topic to date .