Abstract
Objective
This pilot project investigates the effectiveness of the Toftness system of chiropractic adjusting on subjects with pain syndromes.
Methods
Patients were recruited from 13 doctors' offices. All subjects received Toftness chiropractic adjustments. The visual analog scale (VAS) and Oswestry low back pain questionnaire were used for all subjects before and after chiropractic adjustments.
Results
A total of 42 patients were recruited. Twenty-eight patients had acute or chronic back pain and 14 experienced other types of pain (eg, neck pain, knee pain, shoulder pain, etc). The average age of the patient population (18 male, 24 female) was 53 ± 16 years. After 6 to 8 weeks of chiropractic adjustments, pain as analyzed using the visual analog scale was reduced significantly from 73.6 ± 12.790 to 17.0 ± 13.363 (P < .001). The Oswestry score decreased significantly from 69.3 ± 18.525 to 12.4 ± 10.504 (P < .001). There were no adverse treatment effects reported by the participating patients.
Conclusion
The Toftness system of chiropractic adjusting reduced low back and other pain syndromes in the subjects studied. It suggests that the Toftness system of chiropractic adjusting was safe and effective to use in low back pain and other pain-related conditions.
Introduction
Low back pain (LBP) is an enormous burden on health care systems and on the economics of developed countries.1 More than 50% of Americans experience back pain each year for at least a week.2 The cost for treating back pain is estimated at $25 billion annually and another $50 billion is spent on lost productivity and disability payments.3 Low back pain is the third or fourth most commonly reported symptom in the elderly.4 Given the possible consequences of unmanaged LBP, such as depression, functional disability, and compromised quality of life, further research into alternative treatment approaches may be warranted.5 Despite the high prevalence of back pain, effective treatment that is supported by scientific evidence is still lacking. The limited effectiveness of conventional treatments has contributed to a high level of patient dissatisfaction with medical care for back pain.6-8 Therefore, this study proposed low-force chiropractic adjustment as a potential treatment of LBP.
Low-force adjusting has been used clinically for many years by multiple adjusting techniques. One form of low-force adjustments is the Toftness adjusting method, which primarily uses a handheld instrument to determine where to adjust and uses a pressure applicator to deliver the adjustment of the entire spine. Although there are no randomized controlled trials on the effectiveness of this chiropractic adjustment technique, research studies on Toftness adjusting have demonstrated some positive findings.9-12 It has been suspected that the Toftness adjustment might be related to body surface electromagnetic force (EMF). Changes in EMF after adjustments were reported in a recent study.13 However, laboratory testing did not confirm that the handheld device was capable of detecting EMF changes within the testing range that was available to the laboratory.14 Further study and testing on the mechanism of the Toftness system of adjusting are needed.
Low-force chiropractic adjustments may minimize potential risks associated with adjustments, especially as they relate to the osteoporotic patient (ie, fracture). The specific aim of this study is to assess the effectiveness of low-force spinal adjusting, using Toftness methods, for subjects with LBP and other pain syndromes in a multicenter setting.
Methods
Participants
Forty-two subjects who have pain were recruited to receive 2 to 3 adjustments a week for 4 to 6 weeks. Eighteen licensed chiropractors from 13 private clinics provided the low-force Toftness chiropractic adjustments. The conditions included 14 acute LBP conditions, 14 chronic LBP conditions, and 14 other conditions (ie, shoulder pain, knee pain, neck pain, etc).
Inclusion criteria
Adult males or females with any ethnic background were accepted if they had LBP, neck pain, or joint pain in the previous 6 months. All subjects were in good health, ambulatory, and cognizant. They were fluent and literate in the English language at the fifth grade level and had transportation to the clinic. Those subjects agreeing to participate and meeting all the inclusion criteria were asked to sign an informed consent form. This study was approved by the Logan College of Chiropractic institutional review board.
Exclusion criteria
Subjects were excluded from the study if there was evidence of central nervous system disease or contraindications to spinal manipulative therapy. Subjects with systemic disease potentially affecting the musculoskeletal system such as nonskin malignancy were also excluded. Morbidly obese subjects were excluded. Morbid obesity was defined as the subject being more than 40% over the ideal body weight. Ideal body weight for men was defined as 106 lb plus 6 lb for every inch over 5 feet, and for women as 100 lb plus 5 lb for every inch over 5 feet. Subjects were also excluded if they were currently receiving care at any facility for pain, taking prescription narcotics, had a life-threatening coexisting disease, had a severe psychological disorder, or were involved in litigation in regard to a health-related item.
Treatment protocols
Each subject was scheduled for 2 to 3 adjustments per week for 4 to 6 weeks for at least 8 adjustments. The practitioner delivered a low-force (2-32 oz) Toftness chiropractic adjustment by the use of a metered handheld pressure applicator at the cervical, thoracic, lumbar, or sacral contact site.9 The applicator is a rubber-tipped, spring-loaded device that indicates the amount of force that is being applied at the contact site. The adjustment contact line of drive, amount of force applied, and duration of the contact are determined by constant monitoring of the adjustment site with the sensometer, which consists of an open cone and a Mylar membrane (Toftness, Amery, MI).9
Primary outcome measures
The pain measurements included the patients' perceived level of pain, measured with the visual analog scale (VAS).15-17 The VAS is a 10-cm line on which the patient places a single vertical line to record the amount of pain perceived. Measuring the distance from the left end of the horizontal line to the vertical line, which the patient has marked, scores the VAS. The score is then totaled out of a possible 100. In the present study, the VAS was administered at baseline and after each chiropractic adjustment. The Oswestry Disability Questionnaire scores were also obtained on each of the subjects at the beginning and end of delivering low-force Toftness chiropractic adjusting. These scores establish the amount of disability of the subjects as it pertains to the activities of daily living.
Data analysis
Data for each patient were reviewed by the investigators at the conclusion of each patient's participation in the treatment regimen and again upon study completion. Student t test was used for comparisons of the VAS and Oswestry scores before and after treatment. A probability of less than .05 was considered significant. SPSS 11.5 (SPSS Inc, Chicago, Ill) was used for all data analysis.
Results
A total of 42 patients were recruited. Acute or chronic back pain was experienced by 28 patients, and 14 had other types of pain (ie, neck pain, knee pain, shoulder pain, etc). The average age of the patient population (18 male, 24 female) was 53 ± 16 years. After 6 to 8 weeks of chiropractic adjustments, pain as analyzed using the VAS was reduced from 73.6 ± 12.79 to 17.0 ± 13.36 (P < .001). The Oswestry score decreased from 69.3 ± 18.52 to 12.4 ± 10.50 (P < .001). There were no adverse treatment effects reported by the participating patients (Table 1).
Table 1.
Demographics and study data for the participants
| Patient No. | Age | Sex | Type | No. of Adjustments | VAS (0-100) |
Oswestry Scores |
||
|---|---|---|---|---|---|---|---|---|
| Before | After | Before | After | |||||
| 1 | 35 | M | Chronic Back Pain | 7 | 65 | 0 | 75 | 10 |
| 2 | 63 | F | Acute Neck Pain | 10 | 70 | 20 | 68 | 8 |
| 3 | 54 | F | Chronic Back Pain | 20 | 88 | 28 | 92 | 12 |
| 4 | 22 | M | Acute Back Pain | 8 | 78 | 22 | 80 | 10 |
| 5 | 66 | F | Chronic Back Pain | 28 | 92 | 0 | 88 | 2 |
| 6 | 72 | F | Right Knee Pain | 12 | 68 | 2 | 78 | 6 |
| 7 | 68 | M | Chronic Back Pain | 32 | 80 | 40 | 82 | 32 |
| 8 | 45 | F | Left Shoulder Pain | 15 | 66 | 4 | 78 | 10 |
| 9 | 32 | F | Acute Neck Pain | 6 | 80 | 4 | 88 | 8 |
| 10 | 28 | M | Left Knee Pain | 14 | 65 | 12 | 78 | 15 |
| 11 | 48 | F | Acute Back Pain | 14 | 78 | 16 | 80 | 12 |
| 12 | 32 | M | Chronic Back Pain | 26 | 58 | 4 | 60 | 10 |
| 13 | 23 | F | Acute Neck Pain | 15 | 48 | 2 | 42 | 10 |
| 14 | 72 | M | Chronic Back Pain | 34 | 78 | 24 | 80 | 26 |
| 15 | 46 | F | Chronic Back Pain | 28 | 64 | 24 | 80 | 26 |
| 16 | 57 | M | Left Leg Pain | 16 | 78 | 78 | 68 | 10 |
| 17 | 42 | F | Acute Back Pain | 25 | 62 | 24 | 70 | 12 |
| 18 | 87 | F | Chronic Back Pain | 34 | 80 | 26 | 90 | 36 |
| 19 | 35 | F | Right Shoulder Pain | 21 | 56 | 12 | 68 | 14 |
| 20 | 46 | M | Acute Neck Pain | 14 | 68 | 4 | 78 | 2 |
| 21 | 26 | M | Left Knee Pain | 6 | 68 | 2 | 58 | 4 |
| 22 | 75 | F | Acute Back Pain | 32 | 80 | 24 | 78 | 12 |
| 23 | 25 | F | Left Elbow Pain | 10 | 62 | 10 | 78 | 2 |
| 24 | 56 | F | Right Knee Pain | 12 | 50 | 10 | 56 | 14 |
| 25 | 48 | M | Right Shoulder Pain | 17 | 70 | 20 | 78 | 12 |
| 26 | 26 | F | Left Leg Pain | 6 | 48 | 0 | 56 | 4 |
| 27 | 70 | F | Chronic Back Pain | 9 | 88 | 0 | 82 | 6 |
| 28 | 60 | F | Chronic Back Pain | 9 | 78 | 0 | 74 | 2 |
| 29 | 44 | F | Acute Back Pain | 8 | 62 | 28 | 85 | 8 |
| 30 | 46 | M | Chronic Back Pain | 5 | 92 | 42 | 28 | 4 |
| 31 | 55 | F | Acute Back Pain | 12 | 53 | 12 | 42 | 6 |
| 32 | 48 | F | Chronic Back Pain | 34 | 72 | 8 | 66 | 30 |
| 33 | 52 | F | Chronic Neck Pain | 8 | 58 | 3 | 1 | 14 |
| 34 | 50 | F | Right Shoulder Pain | 11 | 78 | 10 | 82 | 16 |
| 35 | 55 | F | Acute Back Pain | 9 | 68 | 0 | 64 | 2 |
| 36 | 34 | M | Right Leg Pain | 8 | 62 | 28 | 85 | 8 |
| 37 | 44 | M | Acute Back Pain | 15 | 92 | 32 | 38 | 4 |
| 38 | 55 | F | Acute Back Pain | 12 | 53 | 12 | 42 | 6 |
| 39 | 48 | F | Left Knee Pain | 34 | 72 | 8 | 76 | 20 |
| 40 | 52 | F | Chronic Neck Pain | 8 | 58 | 3 | 26 | 14 |
| 41 | 32 | M | Acute Back Pain | 10 | 68 | 8 | 48 | 4 |
| 42 | 43 | M | Right Knee Pain | 12 | 58 | 4 | 42 | 5 |
Discussion
The intent of this study was to expand on the initial observations of the clinical benefit of the Toftness system of chiropractic for subjects with acute back pain.10 This study demonstrated that subjects with acute back pain, after receiving a series of Toftness adjustments, had a significant reduction in pain and restoration of activities of daily living. This study was also designed to determine if Toftness practitioners could obtain similar results as stated in the latter study to further evaluate the clinical utility of this adjusting procedure. Despite the unanswered questions of this technique, one of the main components is the adjusting procedure. This procedure is based on the chiropractic principles of the application of force to a specific site on the spine for the purposes of restoring normal spinal alignment and reducing the stress on the nervous system. Furthermore, the Toftness adjustment is quantitative in that it is measurable with respect to the amount of force applied and the amount of time that that force is applied to that contact.
There are a number of limitations in the current study. The first limitation is the small sample size, with only 42 patients who received treatment. The second limitation is lack of a control group due to the clinical observational nature of the study. A third limitation of this study is the possibility that in health and disease the normal course of remission may have caused improvement regardless of the therapy applied. However, with additional effort, it is possible to design a study with a control group similar to other Toftness studies. The positive findings in this pilot study provided the reason for continued research with a control group. Because of the limitations of the study, no firm conclusion could be drawn regarding the symptomatic reductions observed after the Toftness chiropractic care; however, this study does confirm that it is possible to collect positive data in a multicenter setting.
Conclusion
In conclusion, it was found that Toftness chiropractic system adjusting in a multicenter setting resulted in improvement in LBP and other symptoms in chiropractic patients.
Footnotes
This project was partially funded by the Foundation for the Advancement of Chiropractic Research (Amery, WI) and the Logan College of Chiropractic (Chesterfield, Mo).
References
- 1.Deyo B.A., Cherkin D., Conrad D., Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health. 1991;12:141–156. doi: 10.1146/annurev.pu.12.050191.001041. [DOI] [PubMed] [Google Scholar]
- 2.Sternback R.A. Survey of pain in the United States: the Nuprin pain report. Clin J Pain. 1986;2:49–53. [Google Scholar]
- 3.Frymoyer J.W., Cats-Baril W.L. An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991;22:263–271. [PubMed] [Google Scholar]
- 4.Goel V., Iron K., Williams J.I. Indicators of health determinants and health status. In: Goel V., Williams J.I., Anderson G.M., Blackstien-Hirsch P., Fooks C., Naylor C.D., editors. Patterns of health care in Ontario. The ICES Practice Atlas. 2nd ed. Canadian Medical Association; Ottawa: 1996. pp. 5–26. [Google Scholar]
- 5.Cherkin D.C., Sherman K.J., Deyo R.A., Shekelle P.G. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med. 2003;138:898–906. doi: 10.7326/0003-4819-138-11-200306030-00011. [DOI] [PubMed] [Google Scholar]
- 6.Hoiriis K.T., Pfleger B., McDuffie F.C., Cotsonis G., Elsangak O., Hinson R. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for sub acute low back pain. J Manipulative Physiol Ther. 2004;27(6):388–398. doi: 10.1016/j.jmpt.2004.05.003. [DOI] [PubMed] [Google Scholar]
- 7.Sherman K.J., Cherkin D.C., Connelly M.T., Erro J., Savetsky J.B., Davis R.B. Complementary and alternative medical therapies for chronic low back pain: what treatments are patients willing to try? BMC Complement Altern Med. 2004;4(1):9. doi: 10.1186/1472-6882-4-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Haas M., Jacobs G.E., Rahpael R., Petzing K. Low back pain outcome measurement assessment in chiropractic teaching clinics: responsiveness and applicability of two functional disability questionnaires. J Manipulative Physiol Ther. 1995;18:79–87. [PubMed] [Google Scholar]
- 9.Zhang Q., Snyder B.J. The effect of low force chiropractic adjustments for four weeks on body surface electromagnetic field. J Manipulative Physiol Ther. 2005;28:159–163. doi: 10.1016/j.jmpt.2005.02.009. [DOI] [PubMed] [Google Scholar]
- 10.Hawkinson E.J., Snyder B.J., Sanders G.E. Evaluation of the Toftness system of chiropractic adjusting for the relief of acute pain of musculoskeletal origin. Chiropr Tech. 1992;4:57–60. [Google Scholar]
- 11.Snyder B.J., Sanders G.E. Evaluation of the Toftness system of chiropractic adjusting for subjects with chronic back pain, chronic tension headaches, or primary dysmenorrhea. Chiropr Tech. 1996;8:3–9. [Google Scholar]
- 12.Snyder B.J. Thermographic evaluation for the role of the sensometer: evidence in the Toftness system of chiropractic adjusting. Chiropr Tech. 1999;11(2):57–61. [Google Scholar]
- 13.Zhang J.Q., Snyder B.J., Vernor L. The effect of chiropractic adjustments on body surface electromagnetic field. J Can Chiropr Assoc. 2004;48(1):29–35. [PMC free article] [PubMed] [Google Scholar]
- 14.Zhang J.Q., Toftness D., Snyder B., Nosco D., Balcavage W., Nindl G. Comparison of a triaxial fluxgate magnetometer and Toftness sensometer for body surface EMF measurement. J Can Chiropr Assoc. 2004;48(4):273–312. [PMC free article] [PubMed] [Google Scholar]
- 15.Love A., Leboeuf C., Crisp T.C. Chiropractic chronic low back pain sufferers and self-report assessment methods. I. Part, A reliability study of the Visual Analogue Scale, the Pain Drawing, and the McGill Pain Questionnaire. J Manipulative Physiol Ther. 1989;12(1):21–25. [PubMed] [Google Scholar]
- 16.Huskisson E.C. Visual analogue pain rating scales. In: McDowell I., Newell C., editors. Measuring health: a guide to rating scales and questionnaires. Oxford University Press; Oxford: 1987. pp. 235–239. [Google Scholar]
- 17.Goddard G., Karibe H., McNeill C. Reproducibility of visual analog scale (VAS) pain scores to mechanical pressure. Cranio. 2004;22(3):250–256. doi: 10.1179/crn.2004.030. [DOI] [PubMed] [Google Scholar]