No Association between Radiographic Findings and Response to Chiropractic Care in Older Adults with Back-related Disability: a secondary analysis

No Association between Radiographic Findings and Response to Chiropractic Care in Older Adults with Back-related Disability: a secondary analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article No Association between Radiographic Findings and Response to Chiropractic Care in Older Adults with Back-related Disability: a secondary analysis Michele Maiers, Andrea Albertson, Christopher Major, Heidi Mendenhall, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4669429/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2025 Read the published version in Chiropractic & Manual Therapies → Version 1 posted 9 You are reading this latest preprint version Abstract Background Some chiropractors use spinal x-rays to inform care, but the relationship between radiographic findings and outcomes is unclear. This study examined the association between radiographic findings and 30% improvement in back-related disability in older adults after receiving 12 weeks of chiropractic spinal manipulation and home exercise instruction. Methods This IRB-approved secondary analysis used randomized trial data of community-dwelling adults age > 65 with chronic spinal pain and disability. Data was collected during the parent trial between January 2010-December 2014. The primary outcome was ≥ 30% improvement in Oswestry Disability Index (ODI) at 12 weeks, determined to indicate a clinically important response to care. Two radiologists independently assessed digital lumbar radiographs for pre-specified anatomic, degenerative, and alignment factors; differences were adjudicated. The unadjusted association between baseline radiographic factors and 30% ODI improvement was determined using chi-square tests. Results From the parent trial, 120 adults with baseline lumbar radiographs were included in this study. Mean age was 70.4 years (range 65–81); 59.2% female. Mean baseline disability (ODI = 25.6) and back pain (5.2, 0–10 scale) were moderate. After 12-weeks of treatment, 51 (42.5%) participants achieved 30% improvement in back disability. Disc degeneration (53.3% moderate, 13.3% severe), anterolisthesis (53.3%), retrolisthesis (36.6%) and scoliosis (35.0%) were common. No alignment, degenerative, or anatomic factors were associated with ODI improvement at 12 weeks (all p > 0.05), regardless of severity of radiographic findings. Conclusion We found no association between radiographic findings, based on a predetermined subset of radiographic variables, and 12-week ODI recovery in this sample of older adults with back-related disability. This study suggests that, in the absence of red flags upon clinical exam, imaging may be unnecessary because of its inability to predict response to care. Spinal Manipulation Home exercise Radiography Back pain Older adults Disability Degeneration Alignment Responder Chiropractic Introduction Individuals age 65 and older comprise an increasingly large proportion of the population among high-income nations. 1 Low back pain is highly prevalent among older adults, affecting 21–75% annually. 2 Nonsurgical, nonpharmacologic approaches are of particular interest for older adults with spine-related pain and disability, given their increased risks of complications from pharmacologic interventions and spine surgery. 3–6 Most neck- and back-related complaints in seniors are uncomplicated and mechanical in origin, making them potentially amenable to chiropractic treatment and other nonoperative approaches. 7 There is growing evidence that spinal manipulation reduces pain and pain-related disability in older adults. 8–11 Recent studies estimate that adults ages 65 or older account for 14–16% of adult chiropractic users, and this proportion is increasing over time. 12–16 Spinal radiographs may aid the clinical exam and diagnosis of spine conditions. For providers who perform spinal manipulation, radiographs also identify pathologic conditions that are known or thought to be contraindications to manipulation, such as fractures, malignancies, severe osteoporosis, or abdominal aortic aneurysm. 17 Historically, chiropractors have additionally used spinal radiographs to inform segmental spinal manipulation decisions or to determine who may respond to spinal manipulation, but the extent to which this is currently practiced is not well described in the literature. 18 The association between baseline radiographic findings and clinical outcomes among older adult chiropractic users is unknown. Specifically, it has not been determined whether baseline radiographic findings help predict early pain and functional response to chiropractic spinal manipulation in older adults with back and neck pain. The goal of this study was to classify radiographic degenerative changes and anatomic variants of the lumbar spine, and examine the association between these radiographic findings and 30% improvement in back-related disability in older adults after 12 weeks of chiropractic spinal manipulation (CSM) and home exercise instruction. Methods This retrospective cohort study is a secondary analysis of randomized clinical trial (RCT) data collected on community-dwelling adults ages 65 years or older with chronic spinal pain and disability, and was approved by the Institutional Review Board at Northwestern Health Sciences University. 19–21 Recruitment and data collection for parent RCT began in January 2010 through December 2014. All participants enrolled in the parent RCT received the same study intervention, consisting of CSM plus home exercise instruction for 12 weeks. In this secondary study, we included adults who had baseline radiographs taken of the lumbar spine to determine eligibility for the parent trial. Participants who did not have radiographs taken at baseline had advanced imaging within one year prior to trial enrollment, and were therefore not required to have lumbar radiographs in the absence of new clinical symptoms. 19 Those participants were excluded from this study. Participant demographic information, as well as pain and functional measures collected in the parent RCT, were also included in this analysis. The primary outcome of the study was a clinically significant change in disability, considered to be ≥ 30% improvement in Oswestry Disability Index (ODI) after 12 weeks of study intervention. In this study, a team of three chiropractic radiologists and two researchers agreed on radiographic findings of the lumbar spine conventionally considered to be of clinical importance, including anatomic, degenerative, and alignment factors. Methods for assessing and scoring them were identified based on the literature and common practice among chiropractic radiologists (Appendix 1). 22–33 These methods were further pilot tested by two chiropractic radiologists, who independently assessed a subsample of digital lumbar radiographs. Their experience was used to refine the methods of standardization used by the radiologists in this study. Once the methodology to identify radiographic factors was finalized, two rounds of radiographic readings were undertaken by study radiologists (HM, CM) on the images of 10 study participants each. These were independently evaluated, with the radiologists convening after each round to consult with one another to identify agreement, discuss differences, and reach consensus on findings as needed. This process helped ensure assessment protocols were suitable for the remainder of the analysis, which followed. Findings were independently entered into Excel spreadsheets. Once completed, the study coordinator (AA) compared radiologists’ findings and checked scoring for consistency. Discrepancies were identified and presented to the radiologists for discussion and consensus. A third radiologist (CP) was available to adjudicate disagreements. Descriptive baseline statistics are reported for this subsample of the parent RCT. Analysis for this study includes assessing the unadjusted association between individual baseline radiographic factors and 30% ODI improvement with chi-square tests. The output for this paper was generated using SAS 9.4 software. Results Of 182 participants in the parent trial, 120 (66%) had baseline lumbar radiographs with complete baseline and 12-week data, and were therefore included in this study. Mean participant age was 70.4 years (range 65–81) and 59.2% were female (Table 1 ). Mean baseline back-related disability (ODI = 25.6) and back pain (5.2, 0–10 scale) were moderate, and 40% of adults reported some leg pain at baseline. Common radiographic findings included disc degeneration (53.3% moderate, 13.3% severe), anterolisthesis (53.3%), retrolisthesis (36.6%) and scoliosis (35.0%) (Table 2 ). Table 1 Baseline characteristics of participants with baseline lumbar radiographs Baseline characteristics Overall N = 120 n (%) Demographic Mean age (sd) 70.4 (4.7) Age 70 or older 55 (45.8) Female 71 (59.2) White race 114 (95.0) Lifestyle choices BMI, mean (sd) 28.6 (5.9) Tobacco use (any) 10 (8.3) Average weekly exercise: 2–3 times/week or more 73 (60.8) Amount of physical activity in daily routine: ≥ moderate 65 (54.2) Low back status Low back pain duration, years (median, IQR) 15.0 ( 5 – 30 ) Low back pain severity: mean, past week (0–10) 5.2 (2.2) Low back pain severity ≥ 5.0 54 (45.0) Low back pain + any leg pain (QTF ≥ 2, range 2–4) 48 (40.0) Leg pain severity past week (0–10) mean (sd) 3.1 (2.2) Back-related disability (Oswestry Disability Index) mean (sd) (0-100) 25.6 (9.6) Function Short Performance Physical Battery (SPPB), mean (sd) 8.6 (1.8) SPPB < 10 (at least 1 mobility limitation) 76 (63.3) Psychosocial Geriatric Depression Scale (GDS), mean, (median) 2.0 (2.2) sd = standard deviation; IQR = interquartile range, BMI = Body Mass Index Table 2 Radiographic findings in RCT participants with lumbar spine xrays Variable N = 120 n (%) Coronal measures Scoliosis (> 10 degrees) 42 (35.0) Mean Cobb angle (sd) 17.3 (6.5) Scoliosis levels L1-L5 11/42 (24.4) L2-L5 11/42 (24.4) L1-L4 8/42 (17.8) T12-L5 3/42 (6.7) Other 9/42 (21.4) Trunk shift (≥ 2 cm) 4 (3.3) Sagittal measures Lumbar lordosis (mean, sd) 52.0 (12.1) Sacral base angle (mean, sd) 35.2 (8.6) Ferguson’s weight bearing line* Normal 44 (36.7) Anterior 56 (46.7) Posterior 20 (16.7) A or P weightbearing alteration 76 (63.3) Anterolisthesis (any) 64 (53.3) One level 53/64 (82.8) Two levels 11/64 (17.2) Maximal anterior translation: L4 on L5 40/64 (62.5) L5 on S1 14/64 (21.9) Other 10/64 (15.6) Millimeters of slip** (mean, sd) 3.3 (0.8) Meyerding classification* Grade I 63/64 (98.4) Grade II 1/64 (1.6%) Wiltse-Newman type Type 3 55/64 (85.9) Type 2 9/64 (14.1) Retrolisthesis (any) 44 (36.6) Vertebral wedging 17 (14.2) None 103 (85.8) 1 level 15 (12.5) 2 levels 2 (1.7) Disc degeneration Any level(s) with severe DDD 16 (13.3) Any level(s) with moderate DDD 64 (53.3) Any level(s) with mild DDD 107 (89.2) Any DDD 117 (97.5) L1-L2 Mild 75 (62.5) Moderate 16 (13.3) L2-L3 Mild 70 (58.3) Moderate 29 (24.2) L3-L4 Mild 72 (60.0) Moderate 26 (21.7) L4-L5 Mild 70 (58.3) Moderate 35 (29.2) L5-S1 Mild 55 (45.8) Moderate 44 (36.7) Severe 9 (7.5) Anatomic features Five lumbar vertebrae 119 (99.2) Transitional vertebrae (any) 25 (20.8) Bilateral 20 (16.7) Facet tropism (L5-S1) 5 (4.2) Prior surgery (decompression) 1 (0.8) Blocked vertebrae 0 Hemi-vertebrae 0 Any adjudication 102 (85.0) *Ferguson’s: from middle of L3 body **maximal slip level if > 1 vertebrae Fifty-one adults (42.5%) achieved at least 30% ODI improvement after 12 weeks of treatment. No alignment, degenerative, or anatomic factors identified in lumbar radiographs were associated with this clinically meaningful improvement in disability at 12 weeks (i.e. all p > 0.05), regardless of severity of radiographic findings (Table 3 ). The association between retrolisthesis and 30% improvement in ODI was borderline but did not reach statistical significance in this sample. Table 3 Association between radiographic features and improvement in disability Radiographic feature Overall n = 120 Met 30% ODI reduction Did not meet 30% ODI reduction p value Coronal Scoliosis (> 10 degrees) 42 (35.0) 18 (42.9) 24 (57.1) 0.95 Sagittal Ferguson’s weight bearing line Normal 44 (36.7) - - - Anterior (A) 56 (46.7) 24 (42.9) 32 (57.1) 0.94 Posterior (P) 20 (16.7) 8 (40.0) 12 (60.0) 0.80 A or P weightbearing alteration 76 (63.3) 32 (42.1) 44 (57.9) 0.91 Anterolisthesis (any) 64 (53.3) 27 (42.2) 37 (57.8) 0.94 One level 53 (82.8) - - - Two levels 11 (17.2) 7 (63.6) 4 (36.4) 0.14 Retrolisthesis (any) 44 (36.6) 14 (31.8) 30 (68.2) 0.07 Disc degeneration, any level(s) with: Any DDD 117 (97.5) Mild DDD 107 (89.2) 47 (43.9) 60 (56.1) 0.37 Moderate DDD 64 (53.3) 27 (42.2) 37 (57.8) 0.94 Severe DDD 16 (13.3) 7 (43.8) 9 (56.3) 0.91 Anatomic Transitional vertebrae (any) 25 (20.8) 14 (56.0) 11 (44.0) 0.13 Bilateral 20 (16.7) - - - Discussion Baseline individual lumbar radiographic findings were not associated with recovery from back related disability in this sample of older adults receiving 12 weeks of chiropractic spinal manipulation. While 42% of participants did achieve 30% improvement in back-related disability, neither the presence or absence of degenerative changes or anatomic variants, nor their severity, appear to have influenced this clinical outcome. Even cases with advanced radiographic changes or abnormalities were no more or less likely to respond to the chiropractic and home exercise treatment delivered in the study. While this research is a retrospective analysis of only one sample (n = 120), it adds to the growing debate over the usefulness of routine lumbar imaging for older adults with nonspecific back pain. The American College of Radiology recommendations indicate that radiography, in addition to MRI or CT without contrast, is usually appropriate for “elderly individuals” for back pain. 34 This recommendation is made for older adults with or without radiculopathy and in the absence of evidence of trauma or other variables that give rise to the suspicion of osteoporosis or vertebral fracture. In contrast, Choosing Wisely, an initiative that aims to reduce waste in healthcare and avoid unnecessary tests and procedures, does not identify age as an absolute risk factor for imaging requirements. 35 The American Academy of Family Physicians (AAFP) recommends withholding imaging for low back pain within the first six weeks of symptom onset unless red flags are present. The AAFP does not identify older age as a singular risk factor, unless associated with a minor fall, lifting injury or evidence of osteoporosis. Like the AAFP, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) recommend withholding all imaging in patients with non-specific acute low back pain without red flags; old age is not considered a red flag by the AANS or CNS. Of note, a review of red flag indicators among 16 low back pain guidelines found inconsistencies across most red flags, including age as a frank indicator of additional clinical caution. 36 Further, in the presence of red flags, MRI or CT are recommended modes of imaging over plain film due to higher sensitivity. 37 Other clinical research conducted on this topic has failed to demonstrate a positive relationship between imaging and improved outcomes. A study by Jarvik demonstrated that older adults who had early imaging for an episode of new low back pain did not have better outcomes after one year compared to those with no or delayed imaging. 38 Moreover, those who received early imaging had substantially greater use of interventions and total cost of care compared to a group that did not have earlier imaging. Ash et al found that neither the patient nor the provider having knowledge of diagnostic imaging results impacted clinical outcomes for conservative management of acute low back pain, with the exception of general health status which was more improved among those who were blinded to their imaging results. 39 Jarvik and team conclude that the value of early imaging based on age alone is uncertain despite some guidelines recommending the use of early imaging on older adults. The literature demonstrates that common degenerative changes of the spine, likened to “grey hair or wrinkles”, do not correlate with symptoms of back pain or disability. 35,40 Brinjikji et al recommend that imaging findings must be interpreted in the context of the patient’s clinical condition due to high proportion of asymptomatic patients with spinal degeneration on imaging. 40 One such example is the case of lumbar spinal stenosis, a finding estimated to be present in 1 out of 5 adults over 60 years old and increases with age. Notably, more than 80% of these cases are asymptomatic. 41–42 Recognizing the dissociation between imaging findings and clinical symptoms may be of particular importance here, as stenosis is one of the more common conditions for surgical intervention in older adults. 43 Osteoporosis is also common in old age, and is a safety consideration when treating older adults with manual therapy. 44 A history of osteoporosis increases the likelihood of vertebral compression fracture, underscoring the importance of a thorough account of risk factors for osteoporosis. 45 It is important to note that, if osteoporosis is suspected, radiography is not sensitive for bone loss. 46 Dual-energy x-ray absorptiometry (DXA) is the preferred course of imaging to assess bone loss. 47 As a consideration for individuals with spinal pain with osteoarthritis, a recent meta-analysis found that the frequency of osteoporosis is not greater in individuals with osteoarthritis compared to matched controls. In fact, in this population where osteophyte formation is commonly associated with degenerative changes, bone mineral density can be artificially increased in that region. 48 Some back pain sufferers believe that imaging is a necessary component of care. 49 Worrying and health anxiety, both of which could be either alleviated or potentiated by imaging, has been shown to increase the risk developing of long term back-related disability. 50–53 Risks of unnecessary imaging include psychological distress and fear avoidance behavior resulting from receiving an ‘abnormal’ imaging report, as well as financial, psychological, and potential medical complications associated with follow-up testing for incidental findings. 38,54 Imaging influences expectations regarding prognosis and outcome of spine care. 35,39 As per protocol in this study, all participants who did not have recent lumbar imaging underwent x-rays to help determine inclusion and exclusion criteria. Enrolled participants received assurance that there were no clinical or radiographic indications suggesting the need for referral or that would exclude them from participating in the study. It is possible that this clinical confirmation created psychological receptivity to responding to care. Participants’ previous history of imaging, and in particular how imaging was discussed or used to inform care in the past, may have created the potential for study participants to perceive their condition as either more or less problematic, and possibly perceive themselves as either more or less likely to respond to care. Limitations The parent randomized controlled trial from which this sample was taken excluded participants with significant unmanaged comorbidities, multiple lumbar surgeries, or those at high risk of adverse events with spinal manipulative therapy (e.g. severe osteoporosis). It is possible that a more inclusive sample may have resulted in otherwise not detected associations between imaging and improvement. The small sample in this retrospective study allowed only for unadjusted analyses. Retrolisthesis was the only factor that independently neared statistical significance in unadjusted testing, and could possibly be found to influence recovery in a larger sample. We are unable to report the impact of two or more levels of retrolisthesis with confidence due to the limited number of adults with this condition. Radiographs were not taken on 34% of participants in the parent RCT, due to recent lumbar imaging acquired from other healthcare facilities. In these instances, imaging reports were used in the parent trial to determine eligibility to participate but not included in this analysis due to variation in format (e.g. MRI vs radiograph) and comprehensiveness of radiology reports. Conclusion While exploratory in nature, this secondary analysis may inform future research into the impact of anatomical and degenerative changes in older adults on outcomes of care. The result of this study suggests imaging may be unhelpful for predicting who will be a responder to chiropractic care, and that manual therapy treatment may reasonably proceed without imaging on older adult patients in the absence of red flags or suspected contraindications to care. Finally, these results can inform chiropractic education and provide prevalence estimates of radiographic changes for chiropractors who treat older adults. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The parent randomized control trial was funded by the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA), Bureau of Health Professions (BHPr), Division of Medicine and Dentistry (DMD), grant number R18HP15127. The content and conclusions of this manuscript are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the U.S. government, HHS, HRSA, BHPr, or the DMD. Authors contributions: Conception/design: MM, AA, CP. Acquisition of data: MM. Analysis/Interpretation of data: MM, AA, CM, HM, CP. Drafting and revising manuscript: MM, AA, CM, HM, CP. Approved the submitted version of manuscript: MM, AA, CM, HM, CP. Acknowledgments: The authors would like to acknowledge and thank Mary Forte, PhD, DC for data analysis. Authors information (optional) Northwestern Health Sciences University, 2501 W. 84th Street, Bloomington, MN, 55431, USA Michele Maiers, Andrea Albertson, Christopher Major, Heidi Mendenhall, Christopher Petrie References Werner CA, The Older Population. 2010. 2010 Census Briefs, C2010BR-09. US Census Bureau. https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html Accessed May 17, 2024. de Souza IMB, Sakaguchi TF, Yuan SLK, Matsutani LA, do, Espírito-Santo AS, Pereira CAB, Marques AP, editors. Prevalence of low back pain in the elderly population: a systematic review. Clinics. 2019;74:789. 10.6061/clinics/2019/e789 . PMID: 31664424; PMCID: PMC6807687. O'Neil CK, Hanlon JT, Marcum ZA. Adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics. Am J Geriatr Pharmacother. 2012;10(6):331–42. 10.1016/j.amjopharm.2012.09.004 . Foster NE, Anema JR, Cherkin D, et al. 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Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–6. 10.3174/ajnr.A4173 . Katz JN, Zimmerman ZE, Mass H, Makhni MC. Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022;327(17):1688–99. 10.1001/jama.2022.5921 . Walter KL, O’Toole JE, Lumbar Spinal Stenosis. JAMA. 2022;328(3):310. 10.1001/jama.2022.6137 . Szpalski M, Gunzburg R. Lumbar spinal stenosis in the elderly: an overview. Eur Spine J. 2003;12 Suppl 2(Suppl 2). 10.1007/s00586-003-0612-1 . Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Min Res. 2014;29(11):2520–6. 10.1002/jbmr.2269 . Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029–49. 10.2147/TCRM.S138000 . Genant HK. Current state of bone densitometry for osteoporosis. Radiographics. 1998 Jul-Aug;18(4):913–8. 10.1148/radiographics.18.4.9672976 . Lim LS, Hoeksema LJ, Sherin K, ACPM Prevention Practice Committee. Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice. Am J Prev Med. 2009;36(4):366–75. 10.1016/j.amepre.2009.01.013 . Kim D, Pirshahid AA, Li Y, Varghese T, Pope JE. Prevalence of osteoporosis in osteoarthritis: a systematic review and meta-analysis. Osteoporos Int. 2022;33(8):1687–93. 10.1007/s00198-022-06376-0 . Hall A, Coombs D, Richmond H, Bursey K, Furlong B, Lawrence R, et al. What do the general public believe about the causes, prognosis and best management strategies for low back pain? A cross-sectional study. BMC Public Health. 2021;21(1):682. 10.1186/s12889-021-10664-5 . Jensen OK, Nielsen CV, Stengaard-Pedersen K. One-year prognosis in sick-listed low back pain patients with and without radiculopathy. Prognostic factors influencing pain and disability. Spine J. 2010;10(8):659–75. 10.1016/j.spinee.2010.03.026 . Alhowimel A, Alotaibi M, Coulson N, Radford K. Psychosocial consequences of diagnosing nonspecific low-back pain radiologically: a qualitative study. Physiother Theory Pract. 2022;38(7):890–6. 10.1080/09593985.2020.1802799 . Rajasekaran S, Dilip Chand Raja S, Pushpa BT, Ananda KB, Ajoy Prasad S, Rishi MK. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of 'clinical reporting': results from an RCT and blinded trials. Eur Spine J. 2021;30(7):2069–81. 10.1007/s00586-021-06809-0 . Angst F, Lehmann S, Sandor PS, Benz T. Catastrophizing as a prognostic factor for pain and physical function in the multidisciplinary rehabilitation of fibromyalgia and low back pain. Eur J Pain. 2022;26(7):1569–1580. doi: 10.1002/ejp.1983. Epub 2022 Jun 11. PMID: 35634793. Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005;237(2):597–604. 10.1148/radiol.2372041509 . Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2025 Read the published version in Chiropractic & Manual Therapies → Version 1 posted Editorial decision: Revision requested 27 Aug, 2024 Reviews received at journal 24 Aug, 2024 Reviews received at journal 16 Aug, 2024 Reviewers agreed at journal 02 Aug, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers invited by journal 24 Jul, 2024 Editor assigned by journal 17 Jul, 2024 Submission checks completed at journal 17 Jul, 2024 First submitted to journal 01 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4669429","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":338463622,"identity":"5093bb63-bd9f-4a73-a1d2-97e336f55f6e","order_by":0,"name":"Michele Maiers","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYJCCA0Asx8DAA6QKGBKApAFRWowhWgwMiNMCAokNRGvRnXb44YGPe+rSt0vkHnzww+BPHgN78zYJfFrMbqcZHJzx7HDuzhl5yYY9BgbFDDzHyghoSTA4zHPgQO6G2zlmEjwGBokNEkAGfi3pHw7/OVCXbnA7x/znH5AW+TeEtOQYHGY4wJwA1GLGDLGFh6CWgoM9Bw4bbrj/xlhaxsA4sY0nrdiCgMM2f/hxoE7e4MwZw49vKuQS+9kPb7yBTwsmYCNN+SgYBaNgFIwCbAAATPBPimGPrh8AAAAASUVORK5CYII=","orcid":"","institution":"Northwestern Health Sciences University","correspondingAuthor":true,"prefix":"","firstName":"Michele","middleName":"","lastName":"Maiers","suffix":""},{"id":338463624,"identity":"78d299b8-afac-4439-924a-e2f39234adfd","order_by":1,"name":"Andrea Albertson","email":"","orcid":"","institution":"Northwestern Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Albertson","suffix":""},{"id":338463625,"identity":"165b7969-56ef-48c8-96a9-cbf448d57b65","order_by":2,"name":"Christopher Major","email":"","orcid":"","institution":"Northwestern Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Major","suffix":""},{"id":338463626,"identity":"18891cd2-2627-4142-aa39-502c7aa626f7","order_by":3,"name":"Heidi Mendenhall","email":"","orcid":"","institution":"Northwestern Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Heidi","middleName":"","lastName":"Mendenhall","suffix":""},{"id":338463627,"identity":"354fda8d-58e4-42a9-8847-9ce02340da40","order_by":4,"name":"Christopher Petrie","email":"","orcid":"","institution":"Northwestern Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Petrie","suffix":""}],"badges":[],"createdAt":"2024-07-01 16:34:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4669429/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4669429/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12998-024-00566-9","type":"published","date":"2025-01-07T15:56:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73693916,"identity":"98e40991-77c9-4cb6-aac3-f1fa3b9d9145","added_by":"auto","created_at":"2025-01-13 16:09:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":748497,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4669429/v1/b63fd97d-f44c-426b-9be7-83b5a913d1a0.pdf"},{"id":62309570,"identity":"9548ab3c-066c-417c-a303-d4905a222dd5","added_by":"auto","created_at":"2024-08-12 19:44:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25597,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4669429/v1/5619257576ab8f292704dfc1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"No Association between Radiographic Findings and Response to Chiropractic Care in Older Adults with Back-related Disability: a secondary analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIndividuals age 65 and older comprise an increasingly large proportion of the population among high-income nations.\u003csup\u003e1\u003c/sup\u003e Low back pain is highly prevalent among older adults, affecting 21\u0026ndash;75% annually.\u003csup\u003e2\u003c/sup\u003e Nonsurgical, nonpharmacologic approaches are of particular interest for older adults with spine-related pain and disability, given their increased risks of complications from pharmacologic interventions and spine surgery.\u003csup\u003e3\u0026ndash;6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMost neck- and back-related complaints in seniors are uncomplicated and mechanical in origin, making them potentially amenable to chiropractic treatment and other nonoperative approaches.\u003csup\u003e7\u003c/sup\u003e There is growing evidence that spinal manipulation reduces pain and pain-related disability in older adults.\u003csup\u003e8\u0026ndash;11\u003c/sup\u003e Recent studies estimate that adults ages 65 or older account for 14\u0026ndash;16% of adult chiropractic users, and this proportion is increasing over time.\u003csup\u003e12\u0026ndash;16\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSpinal radiographs may aid the clinical exam and diagnosis of spine conditions. For providers who perform spinal manipulation, radiographs also identify pathologic conditions that are known or thought to be contraindications to manipulation, such as fractures, malignancies, severe osteoporosis, or abdominal aortic aneurysm.\u003csup\u003e17\u003c/sup\u003e Historically, chiropractors have additionally used spinal radiographs to inform segmental spinal manipulation decisions or to determine who may respond to spinal manipulation, but the extent to which this is currently practiced is not well described in the literature.\u003csup\u003e18\u003c/sup\u003e The association between baseline radiographic findings and clinical outcomes among older adult chiropractic users is unknown. Specifically, it has not been determined whether baseline radiographic findings help predict early pain and functional response to chiropractic spinal manipulation in older adults with back and neck pain.\u003c/p\u003e \u003cp\u003eThe goal of this study was to classify radiographic degenerative changes and anatomic variants of the lumbar spine, and examine the association between these radiographic findings and 30% improvement in back-related disability in older adults after 12 weeks of chiropractic spinal manipulation (CSM) and home exercise instruction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective cohort study is a secondary analysis of randomized clinical trial (RCT) data collected on community-dwelling adults ages 65 years or older with chronic spinal pain and disability, and was approved by the Institutional Review Board at Northwestern Health Sciences University.\u003csup\u003e19\u0026ndash;21\u003c/sup\u003e Recruitment and data collection for parent RCT began in January 2010 through December 2014. All participants enrolled in the parent RCT received the same study intervention, consisting of CSM plus home exercise instruction for 12 weeks. In this secondary study, we included adults who had baseline radiographs taken of the lumbar spine to determine eligibility for the parent trial. Participants who did not have radiographs taken at baseline had advanced imaging within one year prior to trial enrollment, and were therefore not required to have lumbar radiographs in the absence of new clinical symptoms.\u003csup\u003e19\u003c/sup\u003e Those participants were excluded from this study.\u003c/p\u003e \u003cp\u003eParticipant demographic information, as well as pain and functional measures collected in the parent RCT, were also included in this analysis. The primary outcome of the study was a clinically significant change in disability, considered to be \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;30% improvement in Oswestry Disability Index (ODI) after 12 weeks of study intervention.\u003c/p\u003e \u003cp\u003eIn this study, a team of three chiropractic radiologists and two researchers agreed on radiographic findings of the lumbar spine conventionally considered to be of clinical importance, including anatomic, degenerative, and alignment factors. Methods for assessing and scoring them were identified based on the literature and common practice among chiropractic radiologists (Appendix 1).\u003csup\u003e22\u0026ndash;33\u003c/sup\u003e These methods were further pilot tested by two chiropractic radiologists, who independently assessed a subsample of digital lumbar radiographs. Their experience was used to refine the methods of standardization used by the radiologists in this study.\u003c/p\u003e \u003cp\u003eOnce the methodology to identify radiographic factors was finalized, two rounds of radiographic readings were undertaken by study radiologists (HM, CM) on the images of 10 study participants each. These were independently evaluated, with the radiologists convening after each round to consult with one another to identify agreement, discuss differences, and reach consensus on findings as needed. This process helped ensure assessment protocols were suitable for the remainder of the analysis, which followed. Findings were independently entered into Excel spreadsheets. Once completed, the study coordinator (AA) compared radiologists\u0026rsquo; findings and checked scoring for consistency. Discrepancies were identified and presented to the radiologists for discussion and consensus. A third radiologist (CP) was available to adjudicate disagreements.\u003c/p\u003e \u003cp\u003eDescriptive baseline statistics are reported for this subsample of the parent RCT. Analysis for this study includes assessing the unadjusted association between individual baseline radiographic factors and 30% ODI improvement with chi-square tests. The output for this paper was generated using SAS 9.4 software.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf 182 participants in the parent trial, 120 (66%) had baseline lumbar radiographs with complete baseline and 12-week data, and were therefore included in this study. Mean participant age was 70.4 years (range 65\u0026ndash;81) and 59.2% were female (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Mean baseline back-related disability (ODI\u0026thinsp;=\u0026thinsp;25.6) and back pain (5.2, 0\u0026ndash;10 scale) were moderate, and 40% of adults reported some leg pain at baseline. Common radiographic findings included disc degeneration (53.3% moderate, 13.3% severe), anterolisthesis (53.3%), retrolisthesis (36.6%) and scoliosis (35.0%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of participants with baseline lumbar radiographs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;120\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.4 (4.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge 70 or older\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (45.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (59.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (95.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLifestyle choices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.6 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobacco use (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage weekly exercise: \u003cem\u003e2\u0026ndash;3 times/week or more\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (60.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmount of physical activity in daily routine: \u0026ge; \u003cem\u003emoderate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (54.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow back status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow back pain duration, years (median, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.0 (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow back pain severity: mean, past week (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow back pain severity\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (45.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow back pain\u0026thinsp;+\u0026thinsp;any leg pain (QTF\u0026thinsp;\u0026ge;\u0026thinsp;2, range 2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg pain severity past week (0\u0026ndash;10) mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBack-related disability (Oswestry Disability Index) mean (sd) (0-100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.6 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShort Performance Physical Battery (SPPB), mean (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.6 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPPB\u0026thinsp;\u0026lt;\u0026thinsp;10 (at least 1 mobility limitation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychosocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeriatric Depression Scale (GDS), mean, (median)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003esd\u0026thinsp;=\u0026thinsp;standard deviation; IQR\u0026thinsp;=\u0026thinsp;interquartile range, BMI\u0026thinsp;=\u0026thinsp;Body Mass Index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiographic findings in RCT participants with lumbar spine xrays\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;120\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCoronal measures\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoliosis (\u0026gt;\u0026thinsp;10 degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (35.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Cobb angle (sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.3 (6.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoliosis levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL1-L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/42 (24.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL2-L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/42 (24.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL1-L4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/42 (17.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT12-L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/42 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/42 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrunk shift (\u0026ge;\u0026thinsp;2 cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSagittal measures\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar lordosis (mean, sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.0 (12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSacral base angle (mean, sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.2 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFerguson\u0026rsquo;s weight bearing line*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (36.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (46.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA or P weightbearing alteration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterolisthesis (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53/64 (82.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/64 (17.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal anterior translation:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL4 on L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40/64 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL5 on S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/64 (21.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/64 (15.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMillimeters of slip** (mean, sd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeyerding classification*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63/64 (98.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/64 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWiltse-Newman type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55/64 (85.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/64 (14.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetrolisthesis (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (36.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertebral wedging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (14.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (85.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisc degeneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny level(s) with severe DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny level(s) with moderate DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny level(s) with mild DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (89.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (97.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL1-L2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL2-L3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (58.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (24.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL3-L4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL4-L5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (58.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (29.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL5-S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (45.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (36.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (7.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAnatomic features\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFive lumbar vertebrae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (99.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransitional vertebrae (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (20.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacet tropism (L5-S1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior surgery (decompression)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlocked vertebrae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemi-vertebrae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny adjudication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (85.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*Ferguson\u0026rsquo;s: from middle of L3 body\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e**maximal slip level if\u0026thinsp;\u0026gt;\u0026thinsp;1 vertebrae\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFifty-one adults (42.5%) achieved at least 30% ODI improvement after 12 weeks of treatment. No alignment, degenerative, or anatomic factors identified in lumbar radiographs were associated with this clinically meaningful improvement in disability at 12 weeks (i.e. all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), regardless of severity of radiographic findings (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The association between retrolisthesis and 30% improvement in ODI was borderline but did not reach statistical significance in this sample.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between radiographic features and improvement in disability\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiographic feature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;120\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMet 30% ODI reduction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDid not meet 30% ODI \u003c/p\u003e \u003cp\u003ereduction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCoronal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoliosis (\u0026gt;\u0026thinsp;10 degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSagittal\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFerguson\u0026rsquo;s weight bearing line\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior (A)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior (P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA or P weightbearing alteration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76 (63.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterolisthesis (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (57.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53 (82.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (17.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetrolisthesis (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (68.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisc degeneration, any level(s) with:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e117 (97.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e107 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60 (56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (57.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere DDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAnatomic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransitional vertebrae (any)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBaseline individual lumbar radiographic findings were not associated with recovery from back related disability in this sample of older adults receiving 12 weeks of chiropractic spinal manipulation. While 42% of participants did achieve 30% improvement in back-related disability, neither the presence or absence of degenerative changes or anatomic variants, nor their severity, appear to have influenced this clinical outcome. Even cases with advanced radiographic changes or abnormalities were no more or less likely to respond to the chiropractic and home exercise treatment delivered in the study. While this research is a retrospective analysis of only one sample (n\u0026thinsp;=\u0026thinsp;120), it adds to the growing debate over the usefulness of routine lumbar imaging for older adults with nonspecific back pain.\u003c/p\u003e \u003cp\u003eThe American College of Radiology recommendations indicate that radiography, in addition to MRI or CT without contrast, is usually appropriate for \u0026ldquo;elderly individuals\u0026rdquo; for back pain.\u003csup\u003e34\u003c/sup\u003e This recommendation is made for older adults with or without radiculopathy and in the absence of evidence of trauma or other variables that give rise to the suspicion of osteoporosis or vertebral fracture. In contrast, Choosing Wisely, an initiative that aims to reduce waste in healthcare and avoid unnecessary tests and procedures, does not identify age as an absolute risk factor for imaging requirements.\u003csup\u003e35\u003c/sup\u003e The American Academy of Family Physicians (AAFP) recommends withholding imaging for low back pain within the first six weeks of symptom onset unless red flags are present. The AAFP does not identify older age as a singular risk factor, unless associated with a minor fall, lifting injury or evidence of osteoporosis. Like the AAFP, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) recommend withholding all imaging in patients with non-specific acute low back pain without red flags; old age is not considered a red flag by the AANS or CNS. Of note, a review of red flag indicators among 16 low back pain guidelines found inconsistencies across most red flags, including age as a frank indicator of additional clinical caution.\u003csup\u003e36\u003c/sup\u003e Further, in the presence of red flags, MRI or CT are recommended modes of imaging over plain film due to higher sensitivity. \u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOther clinical research conducted on this topic has failed to demonstrate a positive relationship between imaging and improved outcomes. A study by Jarvik demonstrated that older adults who had early imaging for an episode of new low back pain did not have better outcomes after one year compared to those with no or delayed imaging.\u003csup\u003e38\u003c/sup\u003e Moreover, those who received early imaging had substantially greater use of interventions and total cost of care compared to a group that did not have earlier imaging. Ash et al found that neither the patient nor the provider having knowledge of diagnostic imaging results impacted clinical outcomes for conservative management of acute low back pain, with the exception of general health status which was more improved among those who were blinded to their imaging results.\u003csup\u003e39\u003c/sup\u003e Jarvik and team conclude that the value of early imaging based on age alone is uncertain despite some guidelines recommending the use of early imaging on older adults.\u003c/p\u003e \u003cp\u003eThe literature demonstrates that common degenerative changes of the spine, likened to \u0026ldquo;grey hair or wrinkles\u0026rdquo;, do not correlate with symptoms of back pain or disability.\u003csup\u003e35,40\u003c/sup\u003e Brinjikji et al recommend that imaging findings must be interpreted in the context of the patient\u0026rsquo;s clinical condition due to high proportion of asymptomatic patients with spinal degeneration on imaging.\u003csup\u003e40\u003c/sup\u003e One such example is the case of lumbar spinal stenosis, a finding estimated to be present in 1 out of 5 adults over 60 years old and increases with age. Notably, more than 80% of these cases are asymptomatic.\u003csup\u003e41\u0026ndash;42\u003c/sup\u003e Recognizing the dissociation between imaging findings and clinical symptoms may be of particular importance here, as stenosis is one of the more common conditions for surgical intervention in older adults.\u003csup\u003e43\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOsteoporosis is also common in old age, and is a safety consideration when treating older adults with manual therapy.\u003csup\u003e44\u003c/sup\u003e A history of osteoporosis increases the likelihood of vertebral compression fracture, underscoring the importance of a thorough account of risk factors for osteoporosis.\u003csup\u003e45\u003c/sup\u003e It is important to note that, if osteoporosis is suspected, radiography is not sensitive for bone loss.\u003csup\u003e46\u003c/sup\u003e Dual-energy x-ray absorptiometry (DXA) is the preferred course of imaging to assess bone loss.\u003csup\u003e47\u003c/sup\u003e As a consideration for individuals with spinal pain with osteoarthritis, a recent meta-analysis found that the frequency of osteoporosis is not greater in individuals with osteoarthritis compared to matched controls. In fact, in this population where osteophyte formation is commonly associated with degenerative changes, bone mineral density can be artificially increased in that region.\u003csup\u003e48\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSome back pain sufferers believe that imaging is a necessary component of care.\u003csup\u003e49\u003c/sup\u003e Worrying and health anxiety, both of which could be either alleviated or potentiated by imaging, has been shown to increase the risk developing of long term back-related disability.\u003csup\u003e50\u0026ndash;53\u003c/sup\u003e Risks of unnecessary imaging include psychological distress and fear avoidance behavior resulting from receiving an \u0026lsquo;abnormal\u0026rsquo; imaging report, as well as financial, psychological, and potential medical complications associated with follow-up testing for incidental findings.\u003csup\u003e38,54\u003c/sup\u003e Imaging influences expectations regarding prognosis and outcome of spine care.\u003csup\u003e35,39\u003c/sup\u003e As per protocol in this study, all participants who did not have recent lumbar imaging underwent x-rays to help determine inclusion and exclusion criteria. Enrolled participants received assurance that there were no clinical or radiographic indications suggesting the need for referral or that would exclude them from participating in the study. It is possible that this clinical confirmation created psychological receptivity to responding to care. Participants\u0026rsquo; previous history of imaging, and in particular how imaging was discussed or used to inform care in the past, may have created the potential for study participants to perceive their condition as either more or less problematic, and possibly perceive themselves as either more or less likely to respond to care.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThe parent randomized controlled trial from which this sample was taken excluded participants with significant unmanaged comorbidities, multiple lumbar surgeries, or those at high risk of adverse events with spinal manipulative therapy (e.g. severe osteoporosis). It is possible that a more inclusive sample may have resulted in otherwise not detected associations between imaging and improvement. The small sample in this retrospective study allowed only for unadjusted analyses. Retrolisthesis was the only factor that independently neared statistical significance in unadjusted testing, and could possibly be found to influence recovery in a larger sample. We are unable to report the impact of two or more levels of retrolisthesis with confidence due to the limited number of adults with this condition. Radiographs were not taken on 34% of participants in the parent RCT, due to recent lumbar imaging acquired from other healthcare facilities. In these instances, imaging reports were used in the parent trial to determine eligibility to participate but not included in this analysis due to variation in format (e.g. MRI vs radiograph) and comprehensiveness of radiology reports.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile exploratory in nature, this secondary analysis may inform future research into the impact of anatomical and degenerative changes in older adults on outcomes of care. The result of this study suggests imaging may be unhelpful for predicting who will be a responder to chiropractic care, and that manual therapy treatment may reasonably proceed without imaging on older adult patients in the absence of red flags or suspected contraindications to care. Finally, these results can inform chiropractic education and provide prevalence estimates of radiographic changes for chiropractors who treat older adults.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe parent randomized control trial was funded by the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA), Bureau of Health Professions (BHPr), Division of Medicine and Dentistry (DMD), grant number R18HP15127. The content and conclusions of this manuscript are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the U.S. government, HHS, HRSA, BHPr, or the DMD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions:\u0026nbsp;\u003c/strong\u003eConception/design: MM, AA, CP. Acquisition of data: MM. Analysis/Interpretation of data: MM, AA, CM, HM, CP. Drafting and revising manuscript: MM, AA, CM, HM, CP. Approved the submitted version of manuscript: MM, AA, CM, HM, CP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors would like to acknowledge and thank Mary Forte, PhD, DC for data analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNorthwestern Health Sciences University, 2501 W. 84th Street, Bloomington, MN, 55431, USA\u003c/p\u003e\n\u003cp\u003eMichele Maiers, Andrea Albertson, Christopher Major, Heidi Mendenhall, Christopher Petrie\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWerner CA, The Older Population. 2010. 2010 Census Briefs, C2010BR-09. 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Radiology. 2005;237(2):597\u0026ndash;604. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/radiol.2372041509\u003c/span\u003e\u003cspan address=\"10.1148/radiol.2372041509\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Spinal Manipulation, Home exercise, Radiography, Back pain, Older adults, Disability, Degeneration, Alignment, Responder, Chiropractic","lastPublishedDoi":"10.21203/rs.3.rs-4669429/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4669429/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSome chiropractors use spinal x-rays to inform care, but the relationship between radiographic findings and outcomes is unclear. This study examined the association between radiographic findings and 30% improvement in back-related disability in older adults after receiving 12 weeks of chiropractic spinal manipulation and home exercise instruction.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis IRB-approved secondary analysis used randomized trial data of community-dwelling adults age\u0026thinsp;\u0026gt;\u0026thinsp;65 with chronic spinal pain and disability. Data was collected during the parent trial between January 2010-December 2014. The primary outcome was \u0026ge;\u0026thinsp;30% improvement in Oswestry Disability Index (ODI) at 12 weeks, determined to indicate a clinically important response to care. Two radiologists independently assessed digital lumbar radiographs for pre-specified anatomic, degenerative, and alignment factors; differences were adjudicated. The unadjusted association between baseline radiographic factors and 30% ODI improvement was determined using chi-square tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom the parent trial, 120 adults with baseline lumbar radiographs were included in this study. Mean age was 70.4 years (range 65\u0026ndash;81); 59.2% female. Mean baseline disability (ODI\u0026thinsp;=\u0026thinsp;25.6) and back pain (5.2, 0\u0026ndash;10 scale) were moderate. After 12-weeks of treatment, 51 (42.5%) participants achieved 30% improvement in back disability. Disc degeneration (53.3% moderate, 13.3% severe), anterolisthesis (53.3%), retrolisthesis (36.6%) and scoliosis (35.0%) were common. No alignment, degenerative, or anatomic factors were associated with ODI improvement at 12 weeks (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), regardless of severity of radiographic findings.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe found no association between radiographic findings, based on a predetermined subset of radiographic variables, and 12-week ODI recovery in this sample of older adults with back-related disability. This study suggests that, in the absence of red flags upon clinical exam, imaging may be unnecessary because of its inability to predict response to care.\u003c/p\u003e","manuscriptTitle":"No Association between Radiographic Findings and Response to Chiropractic Care in Older Adults with Back-related Disability: a secondary analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-12 19:44:23","doi":"10.21203/rs.3.rs-4669429/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-27T07:16:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-24T18:27:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-16T06:59:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37900793901661193100249886562807334701","date":"2024-08-02T10:31:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150954083906270908082597717458760889847","date":"2024-07-26T00:38:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-25T00:11:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-17T12:23:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-17T12:23:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Chiropractic \u0026 Manual Therapies","date":"2024-07-01T16:33:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"chiropractic-and-manual-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chmt","sideBox":"Learn more about [Chiropractic \u0026 Manual Therapies](http://chiromt.biomedcentral.com/)","snPcode":"12998","submissionUrl":"https://submission.springernature.com/new-submission/12998/3","title":"Chiropractic \u0026 Manual Therapies","twitterHandle":"@ChiroManTher","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb6a80f1-ce6b-4ec1-9744-cf8df60f4661","owner":[],"postedDate":"August 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T16:01:35+00:00","versionOfRecord":{"articleIdentity":"rs-4669429","link":"https://doi.org/10.1186/s12998-024-00566-9","journal":{"identity":"chiropractic-and-manual-therapies","isVorOnly":false,"title":"Chiropractic \u0026 Manual Therapies"},"publishedOn":"2025-01-07 15:56:56","publishedOnDateReadable":"January 7th, 2025"},"versionCreatedAt":"2024-08-12 19:44:23","video":"","vorDoi":"10.1186/s12998-024-00566-9","vorDoiUrl":"https://doi.org/10.1186/s12998-024-00566-9","workflowStages":[]},"version":"v1","identity":"rs-4669429","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4669429","identity":"rs-4669429","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}