BeNe chiropractic cohort study: role of the psychosocial factors in patients with neck and low-back pain (WC2008-095)

Background

Starting date: 01/09/2009 Neck and low-back pain are common musculoskeletal problems, which represent a significant burden to society.1,2 Various therapies exist for its treatment, and are the principal reason why patients seek chiropractic care.3-5 In the Netherlands, the majority of patients have chronic, recurrent complaints, which have been demonstrated in numerous musculoskeletal studies to be predictive of a poor outcome.6-13

In order to improve outcomes with care, it is important for practitioners to be able to identify at the first encounter who is likely to recover or improve with the proposed therapy. Identification of predictors can facilitate the selection of patients most likely to benefit from a particular intervention, and allow the practitioner to modify his/her care or direct patients to other disciplines if recovery or improvement seems unlikely. Determining who is unlikely to benefit from care is essential in order to limit over-utilization and improve patient satisfaction.

Demonstrating who is unlikely to benefit with chiropractic care, however, has met with limited success. In a recent study conducted in the Netherlands, which examined sociodemographic and clinical predictors of outcome in patients with neck pain, only one variable, duration of the complaint, was associated with all outcome measures examined.14 Recent prognostic modelling for patients with low-back pain in a chiropractic setting in Scandinavia has met with better success, and has lead to the identification of various sub-groups associated with a poor outcome.15-18 Other elements, which could influence recovery or improvement, such as psychological factors, however, have received very little attention in a chiropractic setting.19,20

The biopsychosocial model,21 which emphasizes the role of psychological and social factors in the development or persistence of neck or low-back pain, has irrevocably replaced the biomedical model, which is based upon pain as a signal of tissue damage. The biopsychosocial model has gained ubiquitous acceptance within the spine care community,22 and “… it is now widely recognized that spinal pain and disability can only be understood and managed according to the biopsychosocial model”.23 Furthermore, the recently published review on course and prognostic factors by the Neck Pain Task Force concludes that several psychosocial factors are prognostic of outcome.24 In contrast, only two recent studies have specifically examined the role of the psychological factors in a chiropractic setting,20,25 one of which concluded that clinical variables were more important than the psychosocial variables,20 while the other concluded that there was only some evidence that certain psychosocial variables were associated with improved outcomes.26 However, these two studies were hampered by a much smaller sample size than is proposed here, and a poor follow-up response in one of the studies.20 Despite this, it is questionable whether this model applies to chiropractic care. Chiropractor’s goal of treatment is principally to restore range of motion in fixated segments, thereby improving function, so treatment would seem to be principally mechanically oriented. However, unless the biopsychosocial model is evaluated in a chiropractic setting, chiropractors run the risk of being viewed to be archaic in their treatment approach. At the least, unless this is evaluated using a large sampling of patients in a prospective, systematic manner, these predictors cannot be definitively ruled in or out.

References

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