20 I Summer 2018 www.anjc.info TECHNIQUE Council The 2018 ANJC Fall Summit will feature a powerful combined presentation from both the ANJC Council on Technique and Clinical Excellence and the ANJC Sports Council. These will be hands-on teaching and training seminars to improve our ANJC member doctors’ clinical and adjusting skills to better serve their patients. Presenting at the Fall Summit will be Dr. Christine Foss on ankle diagnosis and treatment; Dr. Greg Doerr on soft tissue treatments for the hip; Dr. Antonio Pugliese on positional testing and treatment of the lumbar spine; and Dr. David Graber on dynamic adjusting of the lumbar spine and pelvis. Dr. Lora Tanis will again be presenting her highly acclaimed Adjusting the Pediatric Patient seminar on Nov. 8. Clinical Predictors of Low Back Pain Several studies this year have given a significant amount of clinical indicators and predictors for low back pain in our patients and the population at large. Below are the summaries of some recent studies that allow us to better refine our diagnoses and prognoses for low back pain, and support our conservative methods of spine care. 1. Taylor, et al. in a systematic review found three clinical findings that predict potential low back pain episodes within the next 12 months: a. Decreased lumbar lordosis b.  Decreased lumbar lateral flexion range of motion c.  Restriction in hamstring range of motion 2. Zheng and Chen confirmed that lumbar disc degeneration is the driver of low back pain as we age. 3. Taylor, et al. in a systematic review and meta-analysis concluded that previous episodes of low back pain is a consistent predictor of future incident. They also found women were at greater risk than men for developing LBP. 4. Tonosuj, et al. found that on lumbar MRI findings consistent with Pfirrmann grade ≥3, disk bulging, and High Intensity Zones may be one of the predictive signs of recurrent severe LBP. 5. Steffans, et al. in a systematic review found that exercise and education are the main interventions to reduce the risk of LBP. 6. Breen, A, et al. demonstrated that patients with treatment-resistant nonspecific back pain have greater aberrant intervertebral motion values than controls, especially if the former have received spinal surgery. 7. Whedon, et al. revealed that low back pain patients who received chiropractic services has less adverse drug events than those who did not receive chiropractic services. 8. D’Aprile, et al. showed that using fat saturated lumbar MRI and a contrast medium to a standard MRI protocol for patients with suspected non-disc- related low back pain could allow a better identification of degenerative- inflammatory changes more likely associated to the pain. 9. Coulter, et al. in a systematic review and meta-analysis revealed that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. 10. Morishita, et al. in a study of 152 participants found that those with degenerative changes in the upper segments of the lumbar spine (L1–2 or L2–3 segments) were more likely to have spondylosis of the cervical spine. 11. Rosenhagen, et al. uncovered that knee misalignment in youth competitive athletes , especially if combined with high training volume (over 7 hours/week), might be predictive for developing chronic low back pain later (7 year follow-up in the study). 12. Suri, et al. found that nonsurgical treatment of patients with lumbar disc herniation and radicular pain had a high (43 percent) recurrence rate for back pain, and a 25 percent recurrence of radicular pain one year following the resolution from treatment. They noted that these recurrence rates are similar for patients who undergo Are Clinical Practice Guidelines Risky? By Dr. David Graber Council on Technique and Clinical Excellence Chairman Figure 1. Image reference panel shows increasing severity of disc degeneration. The pertinent features of each grade are described in Table 1. Three images reflect the inherent variability across each grade. From: Griffith, J.F., Wang, Y., Antonio, G.E., Choi, K.C., Yu, A.B., Ahuja, A.T., & Leung, P. (2007). Modified Pfirrmann grading system for lumbar intervertebral disc degeneration. Spine, 32 24, E708-12.