Non-Specific Low Back Pain
The United States National Library of Medicine (NLM) is the world’s largest biomedical library and the leader in research in computational health informatics (1):
- “NLM is part of the National Institutes of Health (NIH), U.S. Department of Health and Human Services, and located in Bethesda, Maryland.”
- “NLM plays a pivotal role in translating biomedical research into practice.
- “NLM’s research and information services support scientific discovery, health care, and public health.”
- “NLM enables researchers, clinicians, and the public to use the vast wealth of biomedical data to improve health.”
- “Every day, millions of scientists, health professionals, and members of the public from around the world use NLM’s online information resources to translate research results into new treatments, develop new products, inform clinical decision making, and improve public health.”
- “NLM’s advanced biomedical information services are among the most visited websites in the Federal Government.”
- The NLM provides free online access to scholarly biomedical literature from around the world.
Important events in NLM history include:
- 1836 - National Library of Medicine established.
- 1964 - Medical Literature Analysis and Retrieval System (MEDLARS), a computer-based system for medical professionals to retrieve biomedical information, became operational at NLM.
- 1997 - Access to NLM’s MEDLINE/PubMed database became free via the World Wide Web.
There are roughly 30,000 medical journals published worldwide. The National Library of Medicine (NLM) maintains an online database of these journals and their publications called PubMed (www.pubmed.gov). PubMed allows anyone to search for studies in these publications (2). Currently, PubMed contains more than 38 million citations, abstracts, and book chapters of biomedical and life sciences literature (3).
The (approximately) 30,000 journals that are indexed by PubMed have a ranking, a pecking order, this is sometimes referred to as an “impact factor.” The ranking formula is complex, but essentially is based on the number of times other indexed journals reference a study published in one’s journal.
The New England Journal of Medicine (NEJM) is consistently ranked as one of the most prestigious and influential medical journals globally, often considered the top general medical journal, with a high impact factor and a strong reputation.
The New England Journal of Medicine (NEJM) is a weekly medical journal that is published by the Massachusetts Medical Society. It was founded in 1812. The NEJM is among the most prestigious peer-reviewed medical journals, currently ranking at number 2 (4). Currently, the editorial staff for the NEJM is located on the top floor of the Medical School Library at Harvard University (5).
••••
The largest modern review of the chiropractic profession was published in the journal Spine on December 1, 2017, titled (6):
The Prevalence, Patterns, and Predictors
of Chiropractic Use Among US Adults
The authors of this study note that there are more than 70,000 practicing chiropractors in the United States. Chiropractors use manual therapy to treat musculoskeletal and neurological disorders. The authors state:
“Chiropractic is one of the largest manual therapy professions in the United States and internationally.”
“Chiropractic is one of the commonly used complementary health approaches in the United States and internationally.”
“There is a growing trend of chiropractic use among US adults from 2002 to 2012.”
“Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being.”
“Our analyses show that, among the US adult population, spinal pain and problems - specifically for back pain and neck pain - have positive associations with the use of chiropractic.”
“The most common complaints encountered by a chiropractor are back pain and neck pain and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain.”
This study is consistent with decades of publication supporting the use of spinal manipulation for the treatment of low back pain.
•••
In 1958, WB Parsons, MD and JDA Cumming, MD published a study to “describe a method of manipulation that for 20 years has brought gratifying results with none of the disasters that so many predict.” This article was published in the Canadian Medical Association Journal, titled (7):
Manipulation in Back Pain
The authors made these statements:
“The standard medical treatment for lumbago and other acute backache is bed rest and sedation, counter-irritation and heat, possibly supplemented by massage and injections of procaine.”
Yet, “patients soon find that in the majority of instances they can get rapid relief [from spinal manipulation] without the loss of time.”
“The reason we took up manipulation was an interest in backache, with the early discovery that many patients who failed to respond to routine medical treatment went to a manipulator and received immediate relief.”
“Manipulation as an art is as old as medicine.”
“That manipulation will relieve back pain in many instances, few will argue. Those who manipulate swear by it.”
“That manipulation can bring comfort to mankind there can be no doubt.”
“Since the majority of backaches will respond to manipulation, it is probable that the origin of the pain lies in relationship to one of the joints, either the zygapophysial joint or the intervertebral disc.”
“Pain so severe as to keep the patient in bed is no contraindication to manipulation. We see many patients who are afraid to make an effort to get out of bed but who, following manipulation, get up and move with ease.”
“It is our belief, based on long experience, that manipulation is no more beset by hazards than many other recognized procedures in therapy, while its results are often more dramatic and sure.”
“In our hands this approach to backache has proved most gratifying and, more important, has brought comfort to a large group of patients who have not been able to achieve it before.”
•••
In 1969, Brian C. Edwards, MAPA (Medical Affairs Professionals of Australia), published a study in the Australian Journal of Physiotherapy, titled (8):
Low Back Pain and Pain
Resulting from Lumbar Spine Conditions:
A Comparison of Treatment Results
This was the first study to compare the results of the effectiveness for low back and leg pain treated with mobilization/manipulation compared to those treated with heat, massage, and exercise. The study used 184 subjects, half were treated with heat/massage/exercise and half were treated with mobilization/manipulation. The authors made these statements:
“The difference in the number of patients with ‘acceptable’ results by each method of treatment, in the third [pain radiation down thigh to knee] and fourth [pain radiation down leg to foot] groups are statistically significant.”
“[The results] indicate that treatment of low back pain and pain resulting from low back conditions by passive movement techniques of mobilization and manipulation is a more satisfactory method than by standard physiotherapy of heat massage and exercise, in regards to both results and number of treatments required.”
“The survey also indicated that by using techniques of mobilization good results can be obtained with patients even if neurological signs are present.”
This study (8) was reviewed in the 1990 reference text, White and Panjabi’s Clinical Biomechanics of the Spine. This learned treatise notes (9):
“A well-designed, well executed, and well-analyzed study.”
In the group with central low back pain only, “the results were acceptable in 83% for both treatments. However, they were achieved with spinal manipulation using about one-half the number of treatments that were needed for heat, massage, and exercise.”
In the group with pain radiating into the buttock, “the results were slightly better with manipulation, and again they were achieved with about half as many treatments.”
In the groups with pain radiation to the knee and/or to the foot, “the manipulation therapy was statistically significantly better,” and in the group with pain radiating to the foot, “the manipulative therapy is significantly better.”
“This study certainly supports the efficacy of spinal manipulative therapy in comparison with heat, massage, and exercise. The results (80 – 95% satisfactory) are impressive in comparison with anyform of therapy.”
•••
In 1985, W. H. Kirkaldy-Willis, MD, and J. D. Cassidy, DC, published a study in the journal Canadian Family Physician, titled (10):
Spinal Manipulation in the Treatment of Low back Pain
Dr. Kirkaldy-Willis was a Professor Emeritus of Orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada.
The authors note that spinal manipulation is one of the oldest forms of therapy for back pain, yet it has mostly been practiced outside of the medical profession. They also note that “there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.”
These authors presented the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled (“constant severe pain; disability unaffected by treatment”). These patients were given a “two or three week regimen of daily spinal manipulations by an experienced chiropractor.” Eighty-one percent of the patients achieved a good clinical outcome (“symptom-free with no restrictions for work or other activities;” “mild intermittent pain with no restrictions for work or other activities”).
The authors made these statements:
“In most cases of chronic low back pain, there is an initial increase in symptoms after the first few manipulations. In almost all cases, however, this increase in pain is temporary and can be easily controlled by local application of ice.”
“No patients were made worse by the manipulation, yet many experienced an increase in pain during the first week of treatment. Patients undergoing manipulative treatment must therefore be reassured that the initial discomfort is only temporary.”
“Most family practitioners have neither the time nor inclination to master the art of manipulation and will wish to refer their patients to a skilled practitioner of this therapy.”
“The physician who makes use of this [manipulation] resource will provide relief for many back pain patients.”
•••
In 1990, epidemiologist TW Meade assembled a team that published a study in the British Medical Journal, titled (11):
Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment
The objective of this study was to compare chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin. It is a randomized controlled trial that involved 741 patients. Each patient was re-evaluated at weekly intervals for six weeks, at six months, and at one and two years after entry. The authors stated:
“Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.”
“For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management.”
“The results were also analyzed according to length of the current episode of pain. Those treated by chiropractors improved more than those treated in hospital.”
“The results leave little doubt that chiropractic is more effective than conventional hospital outpatient treatment.”
“The effects of chiropractic seem to be long term, as there was no consistent evidence of a return to pretreatment Oswestry scores during the two years of follow up, whereas those treated in hospital may have begun to deteriorate after six months or a year.”
“Chiropractic was particularly effective in those with fairly intractable pain-that is, those with a history of severe pain.”
“The results from the secondary outcome measures suggest that the advantage of chiropractic starts soon after treatment begins.”
“Patients treated by chiropractors were not only no worse off than those treated in hospital but almost certainly fared considerably better and that they maintained their improvement for at least two years.”
“There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic.”
•••
This significant article generated an editorial comment in a different United Kingdom medical journal, The Lancet, titled (12):
Chiropractors and Low Back Pain
The editors of The Lancet note:
“[The article] showed a strong and clear advantage for patients with chiropractic.”
“The highly significant difference occurred not only at 6 weeks, but also for 1, 2, and even (in 113 patients followed so far) 3 years after treatment.”
“Surprisingly, the difference was seen most strongly in patients with chronic symptoms.”
•••
In this study (11), the follow-up period was up to 2 years. In 1995, the same authors published a 3-year follow-up on the same group of subjects. It was also published in the British Medical Journal, and titled (13):
Randomised Comparison of Chiropractic
and Hospital Outpatient Management for Low Back Pain:
Results from Extended Follow Up
In 1990, the authors “reported greater improvement in patients with low back pain treated by chiropractic compared with those receiving hospital outpatient management.” The authors further stated:
“The beneficial effect of chiropractic on pain was particularly clear.”
“At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long-term satisfaction than those treated by hospitals.”
“The substantial benefit of chiropractic on intensity of pain is evident early on and then persists.”
“The results of our trial show that chiropractic has a valuable part to play in the management of low back pain.”
•••
In 2003, Lynton Giles, DC, PhD and Reinhold Muller, PhD published a study in the journal Spine, titled (14):
Chronic Spinal Pain: A Randomized Clinical Trial
Comparing Medication, Acupuncture, and Spinal Manipulation
The objective of this study was to compare pain medications, needle acupuncture, and chiropractic spinal manipulation for management of chronic spinal pain. It was a randomized controlled clinical trial. Patients were assessed before treatment, and again at 2, 5, and 9 weeks after the beginning of treatment.
In this study, chiropractic manipulation achieved the best overall results. The authors stated:
“High-velocity, low-amplitude thrust spinal manipulation to a joint was performed by a chiropractor at the spinal level of involvement to mobilize the spinal joints.”
“The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).”
“The results of this efficacy study suggest that spinal manipulation, ... may be superior to needle acupuncture or medication for the successful treatment of patients with chronic spinal pain syndrome.”
“The significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”
•••
In 2005, these same authors (14) published a 12-month follow-up status of these patients in the Journal of Manipulative and Physiological Therapeutics, titled (15):
Long-Term Follow-up of
a Randomized Clinical Trial
Assessing the Efficacy of Medication,
Acupuncture, and Spinal Manipulation
for Chronic Mechanical Spinal Pain Syndromes
In this 1-year follow up, the authors assess the long-term benefits of medication, needle acupuncture, and spinal manipulation in patients with chronic spinal pain syndromes. The authors stated:
“In patients with chronic spinal pain syndromes, spinal manipulation may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.”
“The overall results of this extended follow-up efficacy study appears to favor the application of manipulation” which successfully achieved long-term benefits in chronic spinal pain syndrome patients.
“No such benefit could be observed for medication.”
“Spinal manipulation appeared to provide the highest satisfaction.”
“Patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes.”
•••
In 2017, Neil Paige, MD, and colleagues, published a study in the Journal of the American Medical Association, titled (16):
Association of Spinal Manipulative Therapy
with Clinical Benefit and Harm for Acute Low Back Pain
Systematic Review and Meta-analysis
The objective of this article was to systematically review studies of the effectiveness and harms of spinal manipulative therapy for acute low back pain. The authors stated:
“In this systematic review and meta-analysis of 26 randomized clinical trials, spinal manipulative therapy was associated with statistically significant benefits in both pain and function.”
•••
In 2023, Emmanuel Wong and colleagues published a study in the Journal of Orthopedics and Sports Medicine, titled (17):
Comparison of Effectiveness of Chiropractic Spinal Manipulation
and Conservative Therapy for Low Back Pain
The objective of this study was to describe the evidence for the effectiveness of chiropractic spinal manipulation (SMT) in comparison to the conservative intervention on low back pain (LBP). It is a meta-analysis of eight randomized clinical trials (RCTs). The authors stated:
“SMT which is delivered by chiropractors, is a regularly utilized treatment that has consistently excellent effects in terms of pain intensity and functionality.”
“Clinical practice recommendations for patients with acute, subacute, and chronic LBP suggest chiropractic therapy or spinal manipulation as a scientific proof, cost-effective, conservative treatment approach.”
“Spinal manipulation or mobilization is recommended as an effective therapy for acute, subacute, and chronic LBP by four guidelines in total which include National Institute for Health and Care Excellence (NICE), The American College of Physicians Pain Society, European guidelines for chronic LBP, and European guidelines for acute LBP.”
“RCTs have demonstrated that chiropractic care and its signature treatment, spinal manipulation, is an effective conservative care option for patients with LBP.”
“Chiropractic care seems to be more effective than conservative intervention for LBP in reducing pain, increasing range of motion in lumbar spine, improving disability status, and enhancing general health.”
•••
In 2024, Carlos Gevers-Montoro, PhD, and colleagues published a study in the Journal of Pain, titled (18):
Reduction of Chronic Primary Low Back Pain
by Spinal Manipulative Therapy
is Accompanied by Decreases in Segmental Mechanical
Hyperalgesia and Pain Catastrophizing:
The objective of this study was to investigate the efficacy of spinal manipulative therapy to improve chronic low back pain. It involved 49 individuals with chronic low back pain and 49 controls (placebo group). The authors stated:
“Most clinical practice guidelines recommend spinal manipulative therapy for the management of chronic low back pain.”
“The present study shows that spinal manipulative therapy produces greater pain relief compared with a control intervention that was undistinguishable from spinal manipulative therapy.”
“The present results indicate that spinal manipulative therapy produced a clinically significant reduction of chronic low back pain.”
•••
As noted above, The New England Journal of Medicine is the most prestigious of medical publications. In 2022, in this journal, Alessandro Chiarotto, PT, PhD, and Bart W. Koes, PhD, published a study titled (19):
Nonspecific Low Back Pain
The authors define specific low back pain as pain that can be attributed to a specific identifiable and verifiable lesion. Examples of such specific lesions include fracture, tumor, infection, etc. Yet, only about 15% of low back pain is actually specific.
In contrast, nonspecific low back pain arises from structures such as muscles, joints, or disks (or a combination of these). However, these causes of low back pain are “not readily identified by means of history taking and physical examination.” Nonspecific low back pain “accounts for approximately 80 to 90% of all cases of low back pain.”
It is proposed that chiropractic care is most suited to nonspecific low back pain patients. The diagnostic impression that a patient is suffering from nonspecific back pain is made after history and examination rules out other potential explanations. As examples:
- Fracture will have a history of injury or of long-term use of glucocorticoid drugs
- Fever might indicate infection
- Unexplained weight loss might indicate cancer
Chiropractic education and clinical practice emphasize the importance of history and examination to arrive at a diagnosis prior to initiating treatment (usually spinal adjusting) for low back pain. Yet, this study, from a top medical publication, reminds us that in about 85% (“80% to 90% of all cases of low back pain”) of low back pain cases, a definitive diagnosis is not possible despite a thorough history and examination. As such, chiropractors concentrate on mechanical problems and monitor the patient’s progress. The benefits of chiropractic care for such patients has been documented for decades.
REFERENCES:
- https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-library-medicine-nlm; Accessed April 8, 2025.
- https://pmc.ncbi.nlm.nih.gov/articles/PMC10024814/; Accessed April 8, 2025.
- https://www.nlm.nih.gov/oet/ed/pubmed/mesh/mod00/01-000.html; Accessed April 8, 2025.
- https://www.nejm.org/about-nejm/about-nejm; Accessed April 8, 2025.
- Abramson J; Sickening: How Big Pharma Broke Health Care and How We Can Repair It; Mariner Books; 2022.
- Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
- Parsons WB, Cumming JDA; Manipulation in Back Pain; Canadian Medical Association Journal; July 15, 1958; Vol. 79; pp. 013-109.
- Edwards BC; Low Back Pain and Pain Resulting from Lumbar Spine Conditions: A Comparison of Treatment Results; Australian Journal of Physiotherapy; September 1969; Vol. 15; No. 3; pp. 104-110.
- White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition; JB Lippincott Company; 1990.
- Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
- Meade TW, Dyer S, Browne W, Townsend J, Frank OA; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300; June 2, 1990; pp. 1431-7.
- _____; Chiropractors and Low Back Pain; Lancet; July 28, 1990; Vol. 336; p. 220.
- Meade TW, Dyer S, Browne W, Frank OA; Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow Up; British Medical Journal; August 5, 1995; Vol. 311; No. 11; pp. 349-353.
- Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
- Muller R, Lynton G.F. Giles LGF, DC, PhD; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005; Vol. 28; No. 1; pp. 3-11.
- Paige NM, Miake-Lye IM, Suttorp Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG; Association of Spinal Manipulative Therapy with Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis; Journal of the American Medical Association; April 11, 2017; Vol. 317; No. 14; pp. 1451-1460.
- Wong E, Lee WT, Chau C, Cheng HY, Kwok R; Comparison of Effectiveness of Chiropractic Spinal Manipulation and Conservative Therapy for Low Back Pain; Journal of Orthopedics and Sports Medicine; January 3, 2023; Vol. 5; No. 1; pp. 1-8.
- Gevers-Montoro C, Romero-Santiago B, Medina-García I, Larranaga-Arzamendi B, Álvarez-Gálovich L, Ortega-De Mues A, Piché M; Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial; Journal of Pain; August 2024; Vol. 25; No. 8; Article 104500.
- Chiarotto A, Koes BW; Nonspecific Low Back Pain; The New England Journal of Medicine; May 5, 2022; Vol. 386; No. 18; pp. 1732-1740.
“Authored by Dan Murphy, D.C. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”