Chiropractic Management Research Articles

Cost Minimization Analysis of Low Back Pain Claims Data for Chiropractic Vs Medicine in a Managed Care Organization

Objective A managed care organization (MCO) examined differences in allowed cost for managing low back pain by medical providers vs chiropractors in an integrated care environment. The purpose of this study is to provide a retrospective cost analysis of administrative data of chiropractic vs medical management of low back pain in a managed care setting. Methods All patients with a low back pain–related diagnosis presenting for health care from January 2004 to June 2004 who were insured by an MCO in northeast Wisconsin were tracked. The cumulative health care costs incurred by this MCO during the 2-year period from January 2004 to December 2005 related to these back pain diagnoses were collected. Results Allowed costs of chiropractic treatment were 12% greater than medical primary care and 60% less per case than other types of medical care combined, on a per-case basis: median cost of medical primary care was $365.00, chiropractic care was $417.00, and medical nonprimary care was $669.00. Conclusion This study of an MCO's low back pain allowed costs may be better redirected to primary care or chiropractic, given equivalent levels of case complexity. This study suggests chiropractic management as less expensive compared with medical management of back pain when care extends beyond primary care. Primary care management alone is virtually indistinguishable from chiropractic management in terms of costs.

Functional Scores and Subjective Responses of Injured Workers With Back or Neck Pain Treated With Chiropractic Care in an Integrative Program: A Retrospective Analysis of 100 Cases

Objective The purpose of this study is to report on integrative care for the treatment of injured workers with neck or back pain referred to a doctor of chiropractic from a medical or osteopathic provider. Methods This retrospective case series study evaluated data on 100 patients referred for chiropractic care of work-related spinal injuries involving workers' compensation claims. Deidentified data included age, sex, visual analog scale scores for pain, pre- and posttreatment Functional Rating Index (FRI) scores, and subjective response to chiropractic care. Based on date of injury to first chiropractic treatment, patients were subdivided as acute, subacute, or chronic injured workers. Cases were analyzed for differences in pretreatment FRI scores, posttreatment FRI scores, FRI change scores (posttreatment FRI minus pretreatment FRI score), and subjective percentage improvement using a 1-way analysis of variance. Treatment included manual therapy techniques and exercise. Results Injured workers with either an acute or subacute injury had significantly lower posttreatment FRI scores compared with individuals with a chronic injury. The FRI change scores were significantly greater in the acute group compared with either the subacute or chronic injured workers. Workers in all categories showed improved posttreatment tolerance for work-related activities and significantly lower posttreatment subjective pain scores. Conclusions The study identified positive effects of chiropractic management included in integrative care when treating work-related neck or back pain. Improvement in both functional scores and subjective response was noted in all 3 time-based phases of patient status (acute, subacute, and chronic).

Contribution of Chiropractic Therapy to Resolving Suboptimal Breastfeeding: A Case Series of 114 Infants

Objective The purpose of this study was to describe the circumstances, clinical features, role, and results of chiropractic management of infants who were referred to a chiropractic clinic for failure to adequately feed at the breast. Methods Clinical case series of 114 infant cases of hospital-diagnosed or lactation consultant diagnosed feeding problems that were treated with chiropractic therapy in addition to routine care and followed to short-term result. Results The most common age of referral was 1 week (mean, 3 weeks; range, 2 days-12 weeks), and the most common physical findings were cervical posterior joint dysfunction (89%), temporomandibular joint imbalance (36%), and inadequate suck reflex (34%). Treatment was chiropractic therapy in addition to any support given elsewhere. All children showed some improvement with 78% (N = 89) being able to exclusively breast feed after 2 to 5 treatments within a 2-week time period. Conclusion Cooperative multidisciplinary care to support breastfeeding was demonstrated in this population. Chiropractic treatment may be a useful adjunct to routine care given by other professionals in cases of diagnosed breastfeeding problems with a biomechanical component.

Diagnosis and Chiropractic Treatment of Infant Headache Based on Behavioral Presentation and Physical Findings: A Retrospective Series of 13 Cases

Objective This case series presents information on diagnosis and treatment of 13 cases of benign infant headache presenting to a chiropractic teaching clinic. Clinical Features A retrospective search was performed for files of infants presenting with probable headache revealing 13 cases of headache from 350 files. Intervention and Outcomes Thirteen cases (6 females, 7 males) from 2 days old to 8.5 months old were identified by behavioral presentation, parental, or medical diagnosis. In the cohort, historical findings included: birth trauma, assisted birth, familial headache history and feeding difficulty. Examination and behavioral findings were grabbing or holding of the face, ineffective latching, grimacing and positional discomfort, rapping head against the floor, photophobia and anorexia. Posterior joint restrictions of the cervical spine were found in these cases. No cases of malignant headache were found. All infants received a trial of chiropractic care including manual therapy. Conclusion This case series offers information about potential signs of benign infant headache. The patients in this study responded favorably to chiropractic management.

Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report

Objective This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic. Clinical Features The 43-year–old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis. Intervention and Outcome A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire. Conclusions Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

Chiropractic manual intervention in chronic adult dyspepsia: A pilot study

To investigate the effects of chiropractic management of patients with symptoms of idiopathic dyspepsia. Prospective, sequential, longitudinal pilot cohort study using a structured questionnaire to determine pre- and post-treatment outcomes. Private chiropractic clinic in south-west England. Eighty-three consecutive patients presenting to the clinic who confirmed the presence of pain of digestive origin in the central chest or epigastric area of greater than 2-years duration. Chiropractic spinal manipulative therapy and adjunctive soft tissue modalities. Patients showed an improvement in the severity ( P < 0.001) and frequency of their symptoms ( P < 0.001) without any reported adverse events. Thirty-seven of 83 patients were able to downgrade their medication ( P < 0.001) suggesting a possible saving in healthcare costs. Patients with chronic idiopathic dyspepsia may benefit from conservative chiropractic management in terms of decreased symptom frequency and severity over a 3-month period and dependence on palliative pharmacological interventions. The pilot study offers scope for a larger controlled trial to investigate efficacy.

Introduction

To determine if U.S. female veterans had demonstrable improvements in neck pain after chiropractic management at a Veterans Affairs (VA) hospital.This was a retrospective cross-sectional study of medical records from female veterans attending a VA chiropractic clinic for neck pain from 2009 to 2015. Paired t-tests were used to compare baseline and discharge numeric rating scale (NRS) and Neck Bournemouth Questionnaire (NBQ) scores with a minimum clinically important difference (MCID) set at a 30% change from baseline.Thirty-four veterans met the inclusion criteria and received a mean of 8.8 chiropractic treatments. For NRS, the mean score improvement was 2.7 (95%CI, 1.9–3.5, p < .001). For the NBQ, the mean score improvement was 13.7 (95%CI, 9.9–17.5, p < .001). For the MCID, the average percent improvement was 45% for the NRS and 38% for the NBQ.Female veterans with neck pain experienced a statistically and clinically significant reduction in NRS and NBQ scores.

Non-synostotic deformational plagiocephaly: An evidence-based case report

Summary Objective This article addresses the key questions facing a manual physician when presented with an infant with manifestations of plagiocephaly. The issues highlighted include an evidence-based approach to: long-term health and developmental implications secondary to plagiocephaly; the scope of safe and effective conservative management, including manual therapy; various outcome measures; prognosis; and alternative treatment modalities. Design An evidence-based case report. Setting A chiropractic clinic in the United Kingdom. Subject A 15-week-old male presenting with overt manifestations of plagiocephaly. Methods A systematic database search and critical review of best evidence to answer typical clinical questions that might arise in everyday practice. Results Several systematic reviews, clinical guideline reports, and cohort studies were returned from a systematic database search. Critical review of these articles generated a simple but effective evidence-based approach to the chiropractic management of infantile plagiocephaly. The literature provides the best evidence to consider the aim and scope of treatment. A photographic method of assessment is suggested for baseline recording and as an outcome measure, with a structured approach on when, why and how to refer to an alternative medical provider if chiropractic management proves unsuccessful. Conclusions A simple guideline approach to safe and effective chiropractic management of an infant with plagiocephaly was established, based upon the best available evidence from the literature in conjunction with the paediatric training available to a chiropractor.

Chiropractic management of a 47-year–old firefighter with lumbar disk extrusion

Objective This case report describes the effect of exercise-based chiropractic treatment on chronic and intractable low back pain complicated by lumbar disk extrusion. Clinical Features A 47-year–old male firefighter experienced chronic, unresponsive low back pain. Pre- and posttreatment outcome analysis was performed on numeric (0-10) pain scale, functional rating index, and the low back pain Oswestry data. Secondary outcome assessments included a 1-rep maximum leg press, balancing times, push-ups and sit-ups the patient performed in 60 seconds, and radiographic analysis. Intervention and Outcome The patient was treated with Pettibon manipulative and rehabilitative techniques. At 4 weeks, spinal decompression therapy was incorporated. After 12 weeks of treatment, the patient's self-reported numeric pain scale had reduced from 6 to 1. There was also overall improvement in muscular strength, balance times, self-rated functional status, low back Oswestry scores, and lumbar lordosis using pre- and posttreatment radiographic information. Conclusion Comprehensive, exercise-based chiropractic management may contribute to an improvement of physical fitness and to restoration of function, and may be a protective factor for low back injury. This case suggests promising interventions with otherwise intractable low back pain using a multimodal chiropractic approach that includes isometric strengthening, neuromuscular reeducation, and lumbar spinal decompression therapy.

Chiropractic Management of Low Back Disorders: Report From a Consensus Process

Objective Although a number of guidelines addressing manipulation, an important component of chiropractic professional care, exist, none to date have incorporated a broad-based consensus of chiropractic research and clinical experts representing mainstream chiropractic practice into a practical document designed to provide standardized parameters of care. The purpose of this project was to develop such a document. Methods Development of the document began with seed materials, from which seed statements were distilled. These were circulated electronically to the Delphi panel until consensus was reached, which was considered to be present when there was agreement by at least 80% of the panelists. Results The panel consisted of 40 clinically experienced doctors of chiropractic, representing 15 chiropractic colleges and 16 states, as well as both the American Chiropractic Association and the International Chiropractic Association. The panel reached 80% consensus of the 27 seed statements after 2 rounds. Specific recommendations regarding treatment frequency and duration, as well as outcome assessment and contraindications for manipulation were agreed upon by the panel. Conclusions A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-Back Pain in a National Health Service Outpatient Clinic

To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain (CLBP) when managed in a hospital by either a regional pain clinic or a chiropractor. The study was a pragmatic, randomized, controlled trial. The trial was performed at a National Health Service (NHS) hospital outpatient clinic (pain clinic) in the United Kingdom. Patients with CLBP (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an NHS hospital setting. The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student's t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated. Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023). This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.

Glenoid Hypoplasia: A Report of 2 Patients

Objective This article discusses the imaging findings, clinical findings, and conservative chiropractic management of 2 patients with glenoid hypoplasia. Clinical Features Conventional radiographs of both patients revealed a hypoplastic glenoid bilaterally. Notch-like defects along with signs of degenerative disease were evident within the lower portion of the glenoid rims bilaterally in 1 patient and in the left glenoid rim of the other patient. Magnetic resonance imaging revealed a degenerative cyst or cortical defect in one patient along the anterior humeral head. The second patient showed a small slightly lobulated cystic region just posterior to the glenoid rim, consistent with the appearance of a synovial or ganglion cyst. Computed tomography with 3-dimensional reconstruction in 1 patient confirmed the presence of large posterior and superior osteophytes arising from the significantly hypoplastic glenoid. These images also revealed a slight posterior subluxation of the humeral head, widening of the anterior glenohumeral joint space, and retroversion of the glenoid. Intervention and Outcome Treatment consisted of manual joint manipulation, soft tissue therapies, and therapeutic exercise for both patients. Both patients experienced improvements in symptoms, function, and physical examination findings. Conclusions Glenoid hypoplasia is a developmental anomaly of the scapular neck which is predominantly bilateral and symmetric. Cross-sectional imaging studies should be considered in patients with symptoms that fail to improve over time. Conservative chiropractic care may be effective in managing symptoms in patients with glenoid hypoplasia.

Chiropractic Management of Chronic Low-Back Pain: Commentary on Wilkey et al.

The Journal of Alternative and Complementary MedicineVol. 14, No. 5 EDITORIALChiropractic Management of Chronic Low-Back Pain: Commentary on Wilkey et al.Daniel RedwoodDaniel RedwoodSearch for more papers by this authorPublished Online:19 Jun 2008https://doi.org/10.1089/acm.2008.0080AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Chiropractic Management of Chronic Low-Back Pain: Commentary on Wilkey et al.." , 14(5), pp. 451–452FiguresReferencesRelatedDetails Volume 14Issue 5Jun 2008 Information© 2008 Mary Ann Liebert, Inc.To cite this article:Daniel Redwood.Chiropractic Management of Chronic Low-Back Pain: Commentary on Wilkey et al..The Journal of Alternative and Complementary Medicine.Jun 2008.451-452.http://doi.org/10.1089/acm.2008.0080Published in Volume: 14 Issue 5: June 19, 2008Online Ahead of Print:June 4, 2008PDF download

Post-traumatic upper cervical subluxation visualized by MRI: a case report.

BackgroundThis paper describes MRI findings of upper cervical subluxation due to alar ligament disruption following a vehicular collision. Incidental findings included the presence of a myodural bridge and a spinal cord syrinx. Chiropractic management of the patient is discussed.Case presentationA 21-year old female presented with complaints of acute, debilitating upper neck pain with unremitting sub-occipital headache and dizziness following a vehicular collision. Initial emergency department and neurologic investigations included x-ray and CT evaluation of the head and neck. Due to persistent pain, the patient sought chiropractic care. MRI of the upper cervical spine revealed previously unrecognized clinical entities.ConclusionThis case highlights the identification of upper cervical ligamentous injury that produced vertebral subluxation following a traumatic incident. MRI evaluation provided visualization of previously undetected injury. The patient experienced improvement through chiropractic care.

Australian chiropractic sports medicine: half way there or living on a prayer?

Sports chiropractic within Australia has a chequered historical background of unorthodox individualistic displays of egocentric treatment approaches that emphasise specific technique preference and individual prowess rather than standardised evidence based management. This situation has changed in recent years with the acceptance of many within sports chiropractic to operate under an evidence informed banner and to embrace a research culture. Despite recent developments within the sports chiropractic movement, the profession is still plagued by a minority of practitioners continuing to espouse certain marginal and outlandish technique systems that beleaguer the mainstream core of sports chiropractic as a cohesive and homogeneous group. Modern chiropractic management is frequently multimodal in nature and incorporates components of passive and active care. Such management typically incorporates spinal and peripheral manipulation, mobilisation, soft tissue techniques, rehabilitation and therapeutic exercises. Externally, sports chiropractic has faced hurdles too, with a lack of recognition and acceptance by organized and orthodox sports medical groups. Whilst some arguments against the inclusion of chiropractic may be legitimate due to its historical baggage, much of the argument appears to be anti-competitive, insecure and driven by a closed-shop mentality.sequently, chiropractic as a profession still remains a pariah to the organised sports medicine world. Add to this an uncertain continuing education system, a lack of protection for the title 'sports chiropractor', a lack of a recognized specialist status and a lack of support from traditional chiropractic, the challenges for the growth and acceptance of the sports chiropractor are considerable. This article outlines the historical and current challenges, both internal and external, faced by sports chiropractic within Australia and proposes positive changes that will assist in recognition and inclusion of sports chiropractic in both chiropractic and multi-disciplinary sports medicine alike.

Likelihood-Evidential Support and Bayesian Analysis on a Prospective Cohort of Children and Adolescents with Mild Scoliosis Under Chiropractic Management

ABSTRACT A previous study using frequentist analytic methods on a single cohort showed no difference in forty-one patients under chiropractic management for mild or early stage scoliosis. The grantor requested a re-analysis. Plain film radiographs of 41 children and adolescents were re-measured by Risser-Ferguson and Cobb methods. Three magnitudes and three types of change were constructed to cover various notions of scoliosis change: magnitudes of 1°, 3°, or 5°, and types that alternatively included or omitted no change as a possible successful outcome (arrested progression). Improvement was assessed from using three filters across three definitions of progression: 1) curve improved or stable, 2) improved only, and 3) those that either improved or progressed. Data were then analyzed by evidential support methods and Bayesian analyses at each filter and type of progression to establish whether improvement was likely attributable to treatment or spine characteristics. Intra-class correlation for intra-exam...

The scope of chiropractic practice: A survey of chiropractors in the UK

In the UK, chiropractic has undergone significant change in recent years, particularly with the advent of statutory regulation and an increasing emphasis on evidence-based and multidisciplinary health care. Little is known about what effect, if any, such changes have had on the profession's view of its scope of practice. To ascertain the opinion of UK chiropractors regarding chiropractic beliefs and philosophy, the benefit of chiropractic intervention in paediatric, adolescent and adult conditions and its relationship with the National Health Service (NHS). Differences in opinion between chiropractors from different UK chiropractic associations – the British Chiropractic Association (BCA), McTimoney Chiropractic Association (MCA), the Scottish Chiropractic Association (SCA) and the United Chiropractic Association (UCA) – were also investigated. A one-shot postal questionnaire was sent to 490 randomly selected chiropractors in the UK registered with the General Chiropractic Council (GCC) (Sample 1). Subjects were selected by a simple random probability sample design. Sample 2 comprised a further 45 randomly chosen subjects from the same sampling frame and was used to test whether Sample 1 was representative of the population. Data were subjected to descriptive analysis using SPSS v10. Differences between groups were investigated by Chi-square analysis and the Kruskal–Wallis H -test. The response rate for Samples 1 and 2 was 54% and 53%, respectively. There was no difference between the two samples in terms of gender, age, college of graduation and chiropractic association membership. Internal consistency of the questionnaire was proven to be weak-moderate ( r = −.265 [interclass correlation (IC): −256; 95% confidence interval (CI): −368 to −.136] to .591 [IC: 583; 95% CI: .494–.659]). Overall, mechanical conditions of the musculoskeletal system were felt to be treated effectively by chiropractic intervention and there was 100% agreement that it was beneficial in treating mechanical dysfunctions of the spine. Non-musculoskeletal conditions in adults, including asthma (64%), gastro-intestinal complaints (61%) and pre-menstrual syndrome (PMS) (70%), were considered conditions that can benefit from chiropractic management. Opinions on the treatment of osteoporosis (43%), obesity (26%), hypertension (42%) and infertility (30%) were less conclusive. Childhood musculoskeletal and muscular conditions, infantile colic, otitis media and asthma were perceived to benefit from chiropractic intervention by more than 50% of the respondents. Statistically significant differences between chiropractors of different associations in the UK were present, particularly regarding the benefits of chiropractic treatment for non-musculoskeletal conditions. The chiropractors in this study may not view themselves as neuromusculoskeletal (NMS) specialists only. Respondents reported treating visceral/organic conditions and expressed a belief that patients with these complaints can benefit from chiropractic. Differences in opinion appear to remain between the professional associations, particularly in relation to treatment benefits for viscero-somatic conditions and philosophical relevance. However, these findings need to be explored in a more representative sample.

The treatment of shoulder pain: Current trends in chiropractic and manual therapy management

Background: The chiropractic literature contains no standardised approach to the management of shoulder pain, and is supported only by low-grade evidence based upon published case reports. The common denominator of chiropractic management is the use of a multimodal treatment approach incorporating soft tissue therapy, electrotherapeutics, manipulation and exercises. Other accepted forms of conservative treatment for shoulder disorders include the use of oral non-steroidal anti-inflammatory drugs, corticosteroids: oral and injections, manipulation under anaesthesia and physiotherapy approaches including exercise, mobilisation, taping and electrotherapeutics.

Chiropractic Management of Cow's Milk Protein Intolerance in Infants With Sleep Dysfunction Syndrome: A Therapeutic Trial

Objective In addition to the more usual cutaneous, gastrointestinal, and respiratory problems, infants with cow's milk intolerance (CMI) may present with a disturbed sleep pattern. Frustrated mothers may turn to their doctor of chiropractic for assistance. This pilot study shows how a therapeutic trial may offer a realistic, noninvasive approach to the chiropractic management of infants with this clinical problem. Methods A pilot study to describe the presentation and treatment of infants presenting with disturbed sleep patterns to a chiropractic clinic was undertaken. Infants fulfilling a clinical screening protocol for CMI were selected for a therapeutic trial. The sleep behavior of subjects was monitored over a 4-week period during which they were managed by dietary change and a high-impulse, low-amplitude whole-of-body chiropractic management protocol. Results Fifty-nine infants presented with disturbed sleep. Of these, 19 met the clinical criteria used to establish the diagnosis CMI. The mothers of breast-fed infants were counseled on how to implement a dairy-free diet, and those infants who were artificially fed were changed from cow's milk–based formulae to either a partially or wholly hydrolyzed formula. Fourteen achieved a stable sleep pattern within the study period. In 5 instances, the sleep pattern remained problematic, but other clinical evidence of hypersensitivity reactions attributable to CMI disappeared. By the end of the study, no subject had demonstrable evidence of either biomechanical derangement or functional neurologic imbalance. Conclusion CMI should be considered as a possibility in infants with disturbed sleep patterns who present for chiropractic care. This study describes how a therapeutic trial involving dietary modification, parental counseling, and comprehensive chiropractic care may offer a noninvasive approach to excluding and/or managing this condition. Further research is required before definitive recommendations can be made.

A randomized clinical trial and subgroup analysis to compare flexion–distraction with active exercise for chronic low back pain

Many clinical trials on chiropractic management of low back pain have neglected to include specific forms of care. This study compared two well-defined treatment protocols. The objective was to compare the outcome of flexion-distraction (FD) procedures performed by chiropractors with an active trunk exercise protocol (ATEP) performed by physical therapists. A randomized clinical trial study design was used. Subjects, 18 years of age and older, with a primary complaint of low back pain (>3 months) were recruited. A 100 mm visual analogue scale (VAS) for perceived pain, the Roland Morris (RM) Questionnaire for low back function, and the SF-36 for overall health status served as primary outcome measures. Subjects were randomly allocated to receive either FD or ATEP. The FD intervention consisted of the application of flexion and traction applied to specific regions in the low back, with the aid of a specially designed manipulation table. The ATEP intervention included stabilizing and flexibility exercises, the use of modalities, and cardiovascular training. A total of 235 subjects met the inclusion/exclusion criteria and signed the informed consent. Of these, 123 were randomly allocated to FD and 112 to the ATEP. Study patients perceived significantly less pain and better function after intervention, regardless of which group they were allocated to (P<0.01). Subjects randomly allocated to the flexion-distraction group had significantly greater relief from pain than those allocated to the exercise program (P=0.01). Subgroup analysis indicated that subjects categorized as chronic, with moderate to severe symptoms, improved most with the flexion-distraction protocol. Subjects categorized with recurrent pain and moderate to severe symptoms improved most with the exercise program. Patients with radiculopathy did significantly better with FD. There were no significant differences between groups on the Roland Morris and SF-36 outcome measures. Overall, flexion-distraction provided more pain relief than active exercise; however, these results varied based on stratification of patients with and without radiculopathy and with and without recurrent symptoms. The subgroup analysis provides a possible explanation for contrasting results among randomized clinical trials of chronic low back pain treatments and these results also provide guidance for future work in the treatment of chronic low back pain.