Clinical Prediction Rules

This section was compiled by Frank M. Painter, D.C.
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Clinical Prediction Rule Articles

Clinical Decision Guides for Chiropractic Management A Unique Series of 3 Articles Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 651–664   ~ FULL TEXT This review describes evidence-based diagnostic criteria for common conditions contributing to neuromusculoskeletal low back pain. Understanding the accuracy of tests and the evidence basis from which diagnostic criteria are derived can inform management decisions and the amount of confidence placed in a working diagnosis. Adopting IASP-applicable terminology is recommended to improve communication among health professionals, patients, and researchers, and to improve the quality of diagnosis-related research. Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 665–676   ~ FULL TEXT Based on a systematic review of the literature, this article describes an office-based examination leading to working diagnoses for common conditions causing or contributing to LBP. A practical diagnostic checklist for clinical evaluation at a primary spine care level may help to efficiently demonstrate evidence for or against working diagnoses. Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 677–693   ~ FULL TEXT This article offers an evidence-based clinical decision aid for multimodal chiropractic care for veterans with LBP. A 4ñpage document outlines the management process, evidence-based treatments for specific conditions, intervention descriptions, and definitions for 6 essential components of chiropractic care. The decision aid was validated through a web-based consensus process including DCs practicing in VA health care facilities.

	Broad External Validation and Update of a Prediction Model for Persistent Neck Pain After 12 Weeks Spine (Phila Pa 1976). 2019 (Nov 15); 44 (22): E1298–E1310 ~ FULL TEXT This study is one of few to independently externally validate a prediction model for neck pain. [11] We did not find that the original model was predictive in this sample of patients managed by chiropractors. The betweenpopulation-heterogeneity might be a limitation when transferring prediction models to different settings. An attempt to update the model resulted in a new prediction model that was able to predict patients with a favorable outcome. It is, however still pre-mature to be used in clinical decisionguidance and would need further evaluation and perhaps updating before implementation is considered.
	The Association Between Depressive Symptoms or Depression and Health Outcomes in Adults with Low Back Pain with or without Radiculopathy: Protocol of a Systematic Review Systematic Reviews 2019 (Nov 8); 8 (1): 267 ~ FULL TEXT Overall, findings from our systematic review will be relevant to patients, health care providers, researchers, and decision-makers. Understanding the impact of depressive symptoms and depression is necessary to guide expectations and clinical management of LBP among patients and health care providers. Information about prognostic factors can help health care providers identify patients at risk of developing chronic LBP and disability. In turn, appropriate care and management of depressive symptoms and depression in this patient population may help improve LBP recovery. From a health system perspective, our research will help guide better resource allocation for health programs and strategies targeting key prognostic factors for LBP. Our systematic review will also identify key knowledge gaps related to depressive symptoms, depression, and LBP prognosis to inform future research directions. Ultimately, understanding the impact of depressive symptoms and depression on health outcomes for LBP will help tailor resources, health services delivery, and quality of care to improve health outcomes in adults with LBP.
	Model Simulations Challenge Reductionist Research Approaches to Studying Chronic Low Back Pain J Orthop Sports Phys Ther. 2019 (Jun); 49 (6): 477–481 ~ FULL TEXT Research to identify the factors, or group of factors, that contribute to LBP and to understand the ef­ficacy of individual treatment interven­tions is necessary but not sufficient to address the LBP problem effectively. As demonstrated by our unstructured mul­tifactorial model of LBP, simply identi­fying components within the model and not the structure of the model (ie, the in­teractions between these components) is not likely to lead to robust classification or better treatment effects.   To advance LBP research, more so­phisticated modeling methods that con­sider the structure of the system being studied [9, 18] and possibly the dynamics of the system[1] (LBP symptoms and treat­ment effects are not static and change with time) are needed. Future research should involve a paradigm shift toward a systems approach, which allows for integration of knowledge in a more sys­tematic and effective way. [26] A systems approach has been specifically devel­oped to address complexity and success­fully implemented in engineering. Such an approach appears to be well suited for studying medical conditions that are multifactorial in nature. [1]
	Who will have Sustainable Employment After a Back Injury? The Development of a Clinical Prediction Model in a Cohort of Injured Workers J Occup Rehabil. 2017 (Sep); 27 (3): 445–455 ~ FULL TEXT Our analysis suggests that using information gathered during the initial clinical encounter may assist health care practitioners to better predict an injured worker’s post-back injury employment pattern. We created a promising clinical prediction model to predict sustainable employment following a work-related back injury. Our models suggest that clinicians might gain insight about sustainable employment approximately 1 month after claim-initiation by measuring back pain intensity, mental health-related quality of life (SF-12), claim litigation and type of employer. Similarly, examining physical and mental health-related quality of life (SF-12), claim litigation, and type of employer are adequate for predicting those with a sustainable employment pattern approximately 6 months post-injury.
	Clinical Classification in Low Back Pain: Best-evidence Diagnostic Rules Based on Systematic Reviews BMC Musculoskelet Disord. 2017 (May 12); 18 (1): 188 ~ FULL TEXT This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.
	Failure to Define Low Back Pain as a Disease or an Episode Renders Research on Causality Unsuitable: Results of a Systematic Review Chiropractic & Manual Therapies 2017 (Jan 9); 21: 6 ~ FULL TEXT Recent literature concerning the causality of LBP does not differentiate between the ‘disease’ of LBP and its recurring episodes mainly due to a lack of a clear definition of absence of LBP at baseline. Therefore, current research is not capable of providing a valid answer on this topic.
	Validity and Reliability of Clinical Prediction Rules used to Screen for Cervical Spine Injury in Alert Low-risk Patients with Blunt Trauma to the Neck: Part 2. A Systematic Review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration European Spine Journal 2017 (Sep 22) [Epub] ~ FULL TEXT Our review adds new evidence to the Neck Pain Task Force and supports the use of clinical prediction rules in emergency care settings to screen for cervical spine injury in alert low-risk adult patients with blunt trauma to the neck. The Canadian C-spine rule consistently demonstrated excellent sensitivity and negative predictive values. Our review, however, suggests that the reproducibility of the clinical predictions rules varies depending on the examiners level of training and experience.
	How Can Latent Trajectories of Back Pain be Translated into Defined Subgroups? BMC Musculoskelet Disord. 2017 (Jul 3); 18 (1): 285 ~ FULL TEXT This study was the first to demonstrate that suggested definitions of LBP trajectory subgroups can be readily applied to individuals’ observed data resulting in subgroups that match well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with infrequent and mild LBP. Further, we suggest that minor fluctuations in pain intensity might be conceptualised as ‘ongoing LBP’. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP. There are more articles like this at our Trajectories of Low Back Pain page.
	Leg Pain Location and Neurological Signs Relate to Outcomes in Primary Care Patients Low Back Pain BMC Musculoskelet Disord. 2017 (Mar 31); 18 (1): 133 ~ FULL TEXT The Quebec Task Force categories (QTFC) identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals' outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.
	Prediction of Outcome in Patients with Low Back Pain -- A Prospective Cohort Study Comparing Clinicians' Predictions with those of the Start Back Tool Manual Therapy 2016 (Feb); 21: 120–127 ~ FULL TEXT The accuracies of predictions made by clinicians (AUC .58-.63) and the STarT Back Screening Tool (SBT) (AUC .50-.61) were comparable and low. No substantial increase in the predictive capability was achieved by combining clinicians' expectations and the SBT. In conclusion, chiropractors' predictions were associated with well-established prognostic factors but not simply a product of these. Chiropractors were able to predict differences in outcome on a group level, but prediction of individual patients' outcomes were inaccurate and not substantially improved by the SBT.
	Do Participants with Low Back Pain who Respond to Spinal Manipulative Therapy Differ Biomechanically From Nonresponders, Untreated Controls or Asymptomatic Controls? Spine (Phila Pa 1976). 2015 (Sep 1); 40 (17): 1329–1337 ~ FULL TEXT After the first SMT, SMT responders displayed statistically significant decreases in spinal stiffness and increases in multifidus thickness ratio sustained for more than 7 days; these findings were not observed in other groups. Similarly, only SMT responders displayed significant post-SMT improvement in apparent diffusion coefficients.   Those reporting post-SMT improvement in disability demonstrated simultaneous changes between self-reported and objective measures of spinal function. This coherence did not exist for asymptomatic controls or no-treatment controls. These data imply that SMT impacts biomechanical characteristics within SMT responders not present in all patients with LBP. This work provides a foundation to investigate the heterogeneous nature of LBP, mechanisms underlying differential therapeutic response, and the biomechanical and imaging characteristics defining responders at baseline
	Report of the NIH Task Force on Research Standards for Chronic Low Back Pain J Pain 2014 (Jun);   15 (6):   569–585 ~ FULL TEXT Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The NIH Pain Consortium therefore charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination.
	Prediction of Pain Outcomes in a Randomized Controlled Trial of Dose-response of Spinal Manipulation for the Care of Chronic Low Back Pain BMC Musculoskelet Disord. 2015 (Aug 19); 16: 205 ~ FULL TEXT Internal validation of prediction models showed that participant characteristics preceding the start of care were poor predictors of at least 50% improvement and the individual's future pain intensity. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best.
	Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain at Risk of Developing Chronic Pain Spine J. 2015 (Jul 1); 15 (7): 1577–1586 ~ FULL TEXT Despite these limitations, we conclude that our study provides a clinical decision rule that is urgently needed for one of the most frequent and most costly conditions in primary care. [50] It contains 8 items for the 6-month and 8 items for the 2-year risk classification (5 are common to both) into 3 levels of risk for developing chronic pain in patients presenting in primary care with a new-onset episode of strictly defined acute low back pain. The next step is to prospectively validate this tool in an independent population.
	Low Back Pain: Guidelines for the Clinical Classification of Predominant Neuropathic, Nociceptive, or Central Sensitization Pain Pain Physician. 2015 (May); 18 (3): E333–346   ~ FULL TEXT Modern pain neuroscience has advanced our understanding about pain, including the role of central sensitization (CS) in amplifying pain experiences. CS is defined as “an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” [11], “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input” [3], or “an augmentation of responsiveness of central neurons to input from unimodal and polymodal receptors”. [12] Although one might say that these definitions differ substantially, they all point to the same underlying neurophysiological mechanism of increased neuronal response to stimuli in the central nervous system (i.e., central hyperexcitability). The definitions originate from laboratory research, but the awareness that the concept of CS should be translated to the clinic is growing. [13, 14]
	Clinical Examination Findings as Prognostic Factors in Low Back Pain: A Systematic Review of the Literature Chiropractic & Manual Therapies 2015 (Mar 23); 23: 13 ~ FULL TEXT A total of 5,332 citations were retrieved and screened for eligibility, 342 articles were assessed as full text and 49 met the inclusion criteria. Due to clinical and statistical heterogeneity, qualitative synthesis rather than meta-analysis was performed. Associations between clinical tests and outcomes were often inconsistent between studies. In more than one third of the tests, there was no evidence of the tests being associated with outcome. Only two clinical tests demonstrated a consistent association with at least one of the outcomes: centralization and non-organic signs.
	Evaluation of a Modified Clinical Prediction Rule For Use With Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Clinical Trial Chiropractic & Manual Therapies 2014 (Nov 18); 22 (1): 41 ~ FULL TEXT Recent literature has highlighted the lack of definitive data to emerge from RCTs evaluating Chronic Lower Back Pain (CLBP), with no treatment producing consistently superior outcomes. [29-32] In keeping with this previous literature and supporting our first hypothesis, we found clinically and statistically significant improvements in outcomes from baseline to follow up in the groups receiving Spinal Manipulative Therapy (SMT) and Active Exercise Therapy (AET), which are both recognized as evidence based interventions for CLBP. [10, 31]
	An Evidence-based Diagnostic Classification System For Low Back Pain J the Canadian Chiropractic Association 2013 (Sep); 57 (3): 189–204 ~ FULL TEXT Health professionals across such disciplines as orthopedics, physical therapy, and chiropractic have shared the goal of categorizing patients with musculoskeletal low back pain (LBP) according to evidence-based classification systems. [1, 2] To this end, several investigators have generated classification systems for LBP diagnosis and treatment. [3–8] Identifying specific pathophysiology causing LBP has the potential to positively impact clinical research and practice by providing opportunities to test, validate or reject treatments targeted at specific diagnoses. [1,2] Clinical prediction rules [4, 6] and symptom or treatment-based classification systems [7, 8] lack the pathophysiological component(s) clinicians sometimes use to better understand a condition and make clinical decisions. Patho-anatomic diagnoses address pain arising from more specific anatomic structures or pathological processes. However, definitively confirming pain sources for LBP continues to be a challenge.
	Predictors of Outcome in Neck Pain Patients Undergoing Chiropractic Care: Comparison of Acute and Chronic Patients Chiropractic & Manual Therapies 2012 (Aug 24); 20: 27 ~ FULL TEXT The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients. There are many similar articles at our Diagnosis and Management Page
	Clinical Decision Rules, Spinal Pain Classification and Prediction of Treatment Outcome: A Discussion of Recent Reports in the Rehabilitation Literature Chiropractic & Manual Therapies 2012 (Jun 22); 20 (1): 19 ~ FULL TEXT Clinical decision rules are an increasingly common presence in the biomedical literature and represent one strategy of enhancing clinical-decision making with the goal of improving the efficiency and effectiveness of healthcare delivery. In the context of rehabilitation research, clinical decision rules have been predominantly aimed at classifying patients by predicting their treatment response to specific therapies. Traditionally, recommendations for developing clinical decision rules propose a multistep process (derivation, validation, impact analysis) using defined methodology. Research efforts aimed at developing a "diagnosis-based clinical decision rule" have departed from this convention. Recent publications in this line of research have used the modified terminology "diagnosis-based clinical decision guide." Modifications to terminology and methodology surrounding clinical decision rules can make it more difficult for clinicians to recognize the level of evidence associated with a decision rule and understand how this evidence should be implemented to inform patient care. We provide a brief overview of clinical decision rule development in the context of the rehabilitation literature and two specific papers recently published in Chiropractic and Manual Therapies.
	Predictors for Identifying Patients With Mechanical Neck Pain Who Are Likely to Achieve Short-Term Success with Manipulative Interventions Directed at the Cervical and Thoracic Spine J Manipulative Physiol Ther 2011 (Mar); 34 (3): 144–152 ~ FULL TEXT This newly published JMPT study attempted to identify those prognostic clinical factors that may potentially identify, a priori, patients with mechanical neck pain who are likely to experience a rapid and successful response to spinal manipulation of the cervical and thoracic spine. Data from 81 subjects were included in the analysis, of which 50 had experienced a successful outcome (61.7%). Five variables were found to be associated with a positive response.
	Psychosocial Risk Factors For Chronic Low Back Pain in Primary Care — A Systematic Review Family Practice 2011 (Feb); 28 (1): 12–21 ~ FULL TEXT Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.
	A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature Chiropractic & Osteopathy 2008 (Aug 11); 16: 7 ~ FULL TEXT Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.
	A Primary Care Back Pain Screening Tool: Identifying Patient Subgroups For Initial Treatment (The STarT Back Screening Tool) Arthritis Rheum. 2008 (May 15); 59 (5): 632–641 ~ FULL TEXT We have developed and validated a simple, brief, and practical way to subgroup patients with nonspecific low back pain in primary care. The new STarT Back Screening Tool identifies potentially modifiable prognostic indicators that may be appropriate targets for primary care interventions. The tool included 9 items: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0–3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk.
	Predictors For Immediate and Global Responses to Chiropractic Manipulation of the Cervical Spine J Manipulative Physiol Ther 2008 (Mar); 31 (3): 172–183 ~ FULL TEXT Data were collected from 28,807 treatment consultations (in 19,722 patients) and 13,873 follow-up treatments. The presenting symptoms of: “neck pain”, “shoulder, arm pain”, “reduced neck, shoulder, arm movement, stiffness”, “headache”, “upper, mid back pain”, and “none or one presenting symptom” emerged in the final model as significant predictors for an immediate improvement.   The presence of any 4 of these predictors raised the probability for an immediate improvement in presenting symptoms after treatment from 70% to approximately 95%.
	A Theoretical Model for the Development of a Diagnosis-based Clinical Decision Rule for the Management of Patients with Spinal Pain BMC Musculoskelet Disord. 2007 (Aug 3); 8: 75 ~ FULL TEXT In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.
	Development of a Clinical Prediction Rule for Guiding Treatment of a Subgroup of Patients With Neck Pain: Use of Thoracic Spine Manipulation, Exercise, and Patient Education Physical Therapy 2007 (Jan); 87 (1): 9–23 ~ FULL TEXT The clinical prediction rule (CPR) provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.
	Pragmatic Application of a Clinical Prediction Rule in Primary Care to Identify Patients with Low Back Pain with a Good Prognosis Following a Brief Spinal Manipulation Intervention BMC Fam Pract. 2005 (Jul 14); 6 (1): 29 ~ FULL TEXT Individuals with "non-specific" LBP are not a homogenous group, and different sub-groups of patients are likely to preferentially respond to different therapeutic management strategies. One sub-group consists of those patients with a good prognosis following spinal manipulation intervention. The results of this study demonstrate an association between two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, and outcome of a manipulation intervention.
	A Clinical Model for the Diagnosis and Management of Patients with Cervical Spine Syndromes Australasian Chiropractic & Osteopathy 2004 (Nov); 12 (2): 57–71 ~ FULL TEXT Neck pain and related disorders are a group of conditions that are common and often disabling. It can be argued that the importance of these disorders is under-appreciated. Because of the prevalence of low back pain and its great cost to society, much clinical attention and research dollars are focused on the low back. But epidemiological research suggests that cervical related disorders are as common and may be more costly to society than low back disorders. [1–4]
	A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely to Benefit from Spinal Manipulation: A Validation Study Annals of Internal Medicine 2004 (Dec 21); 141 (12): 920–928 ~ FULL TEXT Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7).
	A Clinical Prediction Rule for Classifying Patients with Low Back Pain who Demonstrate Short-term Improvement with Spinal Manipulation Spine (Phila Pa 1976). 2002 (Dec 15); 27 (24): 2835–2843 ~ FULL TEXT Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.
	Predictive Factors for 1-year Outcome of Low-back and Neck Pain in Patients Treated in Primary Care: Comparison Between the Treatment Strategies Chiropractic and Physiotherapy Pain. 1998 (Aug); 77 (2): 201–207 The inability to predict outcome in patients with low back/neck pain leads to inappropriate or unnecessary treatment. The aims of the study were to identify prognostic factors for disability at 1-year follow-up in patients with back pain visiting primary care, and to compare the effect of these in two treatment strategies--chiropractic and physiotherapy. Data were taken from a randomised trial on patients with back/neck pain visiting the general practitioner, in which patients were allocated to chiropractic and physiotherapy as primary management. Three hundred and twenty-three patients, aged 18-60 years, who had no contraindications to manipulation and who had not been treated within the previous month were included in the study. Multiple regression analysis was used to identify prognostic factors. Dependent variables were mean Oswestry score and mean change in Oswestry score at 12-month follow-up. The multiple regression analysis revealed five significant (P < 0.001-0.01) prognostic factors; duration of current episode, Oswestry score at entry, expectations of treatment, number of localisations, and well-being. Besides, the regression coefficients for the significant factors were compared between the two treatment strategies.

Reference Materials

	Chiropractors as the Spinal Health Care Experts A Chiro.Org article collection Enjoy these articles about chiropractors as first-contact Spinal Health Care Experts.
	Pain Management and Chiropractic A Chiro.Org article collection Explore this collection of articles that discusses the relationship between tissue injury and various pyschosocial factors that may contribute towards developing chronic pain.
	Chronic Neck Pain and Chiropractic A Chiro.Org article collection Review this extensive collection of studies detailing how chiropractic and spinal manipulation are effective for the relief of spinal pain.
	Neck and Back Pain in Children and Chiropractic A Chiro.Org article collection We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for spinal pain in children.
	Radiculopathy and Chiropractic Page A Chiro.Org article collection We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for radiculopathy.
	Low Back Pain and Chiropractic A Chiro.Org article collection Ditto.
	The Biopsychosocial Model A Chiro.Org article collection The late George Engel believed that to understand and respond adequately to patients’ suffering — and to give them a sense of being understood — clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness. He offered a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century. [1] His new model came to be known as the biopsychosocial model.
	Integrated Health Care and Chiropractic A Chiro.Org article collection This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.

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