Low Back Pain and Chiropractic

Changing Attitudes

The RAND corporation is a well-known independent research organization located in Santa Monica, CA. The September-October 2017 issue of the Rand Review has an article titled Well-Adjusted (1). The article states:

“Researchers led by Paul Shekelle, co-director of the Southern California Evidence-Based Practice Center at RAND, aggregated the results of more than two dozen prior studies on spinal manipulation.”

“The study was published in the April issue of the Journal of the American Medical Association. An accompanying editorial noted that its findings suggest that spinal manipulation could be an effective treatment for patients with uncomplicated lower-back pain.”

“Spinal manipulation—the back popping most associated with chiropractors—is about as effective at treating short-term back pain as over-the-counter drugs like ibuprofen, a recent study found.”

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The October 2017 issue of Scientific American has a section titled The Science Of Health, with an article titled Back to Basics (2). The article notes:

“The US spends more on lower back and neck pain than almost any other health condition, …topping $87 billion in 2013.”

“In three separate large analysis published between 2015 and this year [2017], researchers at the University of Sydney and their colleagues compared evidence from dozens of studies to determine how well various pharmaceutical options assuage back pain and found all the drugs to be lacking.”

“The fact that opioids are the most commonly prescribed back pain medication has put added pressure on the medical community to find different solutions.”

They found “evidence supporting the use of techniques such as acupuncture and spinal manipulation for acute and chronic [back] pain.”

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The October 9, 2017 issue of celebrity magazine People profiled actor Stephen Moyer. The interviewer asked him about his “last injury” and he responded by talking about the management of his musculoskeletal problems by his “amazing chiropractor.” (3) This type of unsolicited celebrity endorsement of chiropractic for musculoskeletal problems is increasingly common, increasingly accepted by the public at large, and increasingly being expressed in a cross section of media.

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In healthcare, attitudes and procedures are slow to change. As stated by Gregory Grieve, “introductory knowledge becomes inflexibly hardened.” (4). Spinal manipulation has been used successfully to treat back pain for hundreds of years, and perhaps for millennia (5). Studies assessing and advocating the use of spinal manipulation for back pain began to appear in the scientific journals and medical reference texts in the mid twentieth century:

1954 (#6)
“Conservative Treatment of Intervertebral Disk Lesions”
American Academy of Orthopedic Surgeons, Instructional Course Lectures

1969 (#7)
“Reduction of Lumbar Disc Prolapse by Manipulation”
British Medical Journal

1969 (#8)
“Low Back Pain and Pain Resulting from Lumbar Spine Conditions:
A Comparison of Treatment Results”
Australian Journal of Physiotherapy

1977 (#9)
“Ruptured Intervertebral Disc”
“Treatment”
“Manipulation”
Orthopaedics, Principles and Their Applications

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The study referenced by RAND Corporation above (1) was published in the Journal of the American Medical Association, April 2017, and titled (10):

Association of Spinal Manipulative Therapy
With Clinical Benefit and Harm for Acute Low Back Pain:
Systematic Review and Meta-analysis

The objective of this study was to systematically review studies of the effectiveness and harms of spinal manipulative therapy for acute (less than 6 weeks duration) low back pain. The authors found 26 eligible randomized clinical trials for their review.

The spinal manipulative therapy was provided by physical therapists in 13 studies, chiropractors in 7 studies, medical doctors in 5 studies, and osteopathic doctors in 3 studies. The studies reviewed provided moderate-quality evidence that spinal manipulative therapy has a statistically significant association with improvements in back pain and in function.

The authors also noted that none of the clinical trials reviewed reported any serious adverse event from spinal manipulative therapy. Minor transient adverse events such as increased pain and muscle stiffness were reported, but again these symptoms were not serious and they were transient.

This study concluded:

“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.”

“Thrust-type manipulation may be more effective than nonthrust-type manipulation.”

This article generated an editorial titled (11):

The Role of Spinal Manipulation in the Treatment of Low Back Pain

The author of the editorial was Richard Deyo, MD, MPH, from the Department of Family Medicine, Oregon Health and Science University, Portland, OR. Dr. Deyo is a global leading authority and expert on the management of back pain. A search of the National Library of Medicine (11/8/2017) found 403 articles that he had authored or co-wrote.

In his editorial, Dr. Deyo notes that there are approximately 200 treatment options available to treat low back pain. Yet, in the majority of acute low back pain cases, a “precise pathoanatomical cause of the pain cannot be identified.”

Dr. Deyo notes that none of the trials in the study by Paige and colleagues (10) suggested that spinal manipulative therapy was less effective than conventional drug care for low back pain patients. Pertaining to chiropractic treatment for low back pain, Dr. Deyo states:

“Spinal manipulative therapy is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors.”

“Chiropractic care is popular today with the US public. According to a 2012 report, among patients with back or neck pain, approximately 30% sought care from a chiropractor.”

“In a 2013 survey by Consumer Reports magazine involving 14,000 subscribers with low back pain, chiropractic care had the largest proportion of ‘highly satisfied’ patients.”

“It appears that spinal manipulative therapy is a reasonable treatment option for some patients with low back pain. The systematic review by Paige et al suggests a treatment effect similar in magnitude to nonsteroidal anti-inflammatory drugs.”

In this editorial, Dr. Deyo explains the scientific physiological mechanisms by which spinal manipulation helps people with back pain. He also offers that chiropractic and spinal manipulation have other therapeutic physiologic benefits, including:

The hands-on, high-touch nature of treatment
An ongoing patient-clinician relationship through repeated visits
An expectation of change
A feeling of empowerment
Clinician enthusiasm, reassurance, and conviction

In contrast, Dr. Deyo notes the urgency for non-pharmacological approaches to the treatment of low back pain, stating:

“Renal and gastrointestinal adverse effects of nonsteroidal anti-inflammatory drugs are common.”

“Among patients taking nonsteroidal antiinflammatory drugs, renal function abnormalities occur in approximately 1% of patients, and superficial gastric erosions or asymptomatic ulcers may occur in up to 5% to 20% of users.”

“Low back pain is among the most common reasons for prescribing opioids in the United States. Among patients initiating opioid therapy, about 5% become long-term opioid users, with associated risks of dependency, addiction, and overdose.”

“The US societal cost of prescription opioid abuse in 2007 was estimated at $55.7 billion.”

Dr. Deyo notes that even though spinal manipulative therapy typically involves multiple visits, “the cost of caring for complications from pharmacologic therapies may exceed the costs of spinal manipulative therapy.” He also notes that the conclusions of the systematic review by Paige et al are generally consistent with another recently completed systematic review and clinical guideline from the American College of Physicians (12).

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Last year (2016), a study from the University of Montreal, Laval University, and the University of Toronto, quantified the health care provider that occupational back injured workers would consult. The study was published in the journal BMC Musculoskeletal Disorders, and titled (13):

Workers’ Characteristics Associated with the
Type of Healthcare Provider First Seen for Occupational Back Pain

This is an injured worker study from Ontario, CAN, where injured workers can go directly (without referrals from other professionals) to a physician or a chiropractor or physiotherapist. The study used 5,520 low back-injured workers. This is the first study to compare the factors that drive patient’s decision to choose a chiropractor, physician or physiotherapist as their first healthcare provider for occupational back pain.

The authors note that low back pain is a huge societal issue, with a point prevalence of 9.4% and a lifetime prevalence of approximately 85%.

About one-third of low back pain is attributed to occupation. Occupational low back pain represents one-third of all disabilities related to occupational factors. For many jurisdictions, low back pain is the most common occupational injury and reason for Worker’s compensation.

Low back pain is “often recurrent or chronic.” Back pain is 6th among the health problems that generate the most direct medical costs in North America. Back pain is a leading cause of disability worldwide.

Of the 5,520 analyzed claims in this study:

85.3% of the patients saw a medical physician
11.4% saw a chiropractor
3.2% saw a physiotherapist

The authors found that as a rule, those with more severe injuries did not primarily seek treatment from a medical physician. They also found that a worker’s choice of back care provider was often significantly influenced by the attitude and bias of the employer. They state:

“Our results suggest that workers suffering from more severe conditions are more likely to seek physiotherapy and chiropractic care than medical care.”

Back-injured workers who chose to see chiropractors often did so because they had suffered previous similar injuries that were successfully treated chiropractically. This suggests that these injured workers had a high level of satisfaction with prior chiropractic treatment, stating:

“We found that workers who reported a previous similar injury were more likely to seek physiotherapy and chiropractic care.”

“It is reasonable to think that workers will seek care that they perceived as effective for a similar condition, compensated or not, in the past.”

“Back pain patients are more likely to seek the type of care they previously sought, and this association was particularly strong for chiropractic care.”

The authors claim that one of the reasons chiropractic care is not more frequently used is because there are too few chiropractors available to serve the community. They found that in communities that had greater numbers of chiropractors a higher percentage of injured workers chose chiropractic to treat their back injuries.

An important finding pertaining to chiropractic effectiveness and cost effectiveness is complimentary to chiropractic:

“Chiropractic care was associated with lower use of medication, radiographic investigation, and surgery.”

This study presents several lines of evidence suggesting there is an employer bias against chiropractors, and that there should not be. Chiropractic patients are happy with their prior back injury outcomes with chiropractic care.

This study shows that even those with severe injury seek non-medical care, specifically chiropractic and/or physical therapy care.

This study suggests that an explanation for fewer visits to a chiropractor is because there are fewer chiropractors available in the community.

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A 2013 study emphasizing the importance of chiropractic care for back-injured workers appeared in the journal Spine, titled (14):

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury:
 Results from a Prospective Study of Workers in Washington State

The authors are from Dartmouth Medical School, University of Washington School of Public Health, University of Washington School of Medicine, and Ohio State University College of Public Health. This is a prospective population-based cohort study whose objective is to identify early predictors of lumbar spine surgery within 3 years after occupational back injury.

The authors note that back injuries are the most prevalent occupational injury in the United States, stating:

“Back pain is the most costly and prevalent occupational health condition among the U.S. working population.”

The authors note that the incidence of back surgery has increased dramatically in the past several decades “with little evidence for improved population outcomes.” They state:

“Reducing unnecessary spine surgeries is important for improving patient safety and outcomes and reducing surgery complications and health care costs.”

This study assessed 1,885 back-injured workers. The primary measurement outcome used was the Roland Morris Disability Questionnaire. They note:

“The Roland Morris Disability Questionnaire has been shown to be predictive of chronic work disability, longer duration of sick leave, chronic pain, and other measures of function.”

The authors found that a significant predictor of having back surgery in the following 3 years was determined by the first provider seen for their back injury. The highest risk for a future back surgery occurred when the first provider was a surgeon. The lowest predictor for a future back surgery was when the first provider was a chiropractor. The authors stated:

“In Washington State worker’s compensation, injured workers may choose their medical provider. Even after controlling for injury severity and other measures, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, whereas workers whose first visit was to a chiropractor had significantly lower odds of surgery.”

“Those whose first provider seen for the injury was a surgeon had significantly higher odds of surgery, after adjusting for all other variables.”

“Factors associated with significantly reduced odds of surgery included…  chiropractor as first provider seen for the injury.”

“42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.”

“There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.”

It is possible that these findings indicate that “who you see is what you get.”

“Approximately 43% of workers who saw a surgeon had surgery within 3 years, in contrast to only 1.5% of those who  saw a chiropractor.”

These authors comment that previous studies have shown:

Those with occupational back injuries who first saw a chiropractor had lower odds of chronic work disability.

Those seeing chiropractors for occupational back pain had “higher rates of satisfaction with back care.”

They also noted that no measures in the employment-related behavior, health behavior, or psychological findings were significant in predicting the outcomes in these patients.

These authors suggest that it is wise to use a “gatekeeper” for patients who suffer occupational back injury. This article presents substantial reason for why such a gatekeeper should be a chiropractor. The reduction of back surgeries in those consulting chiropractors for back pain represents a substantial costs savings, and also the highest levels of back care satisfaction.

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The November 2017 Harvard Health Letter has an important article titled (15):

Where to Turn for Back Pain Relief

“In Most Cases, a Primary Care Doctor or Chiropractor
Can Help You Resolve the Problem”

This article makes these points:

• “Low back pain is one of the most common complaints on the planet.”
  
• Once low back pain starts, “Take heart. ‘In most cases, you won’t need a specialist,’ says Robert Shmerling, a rheumatologist at Harvard-affiliated Beth Israel Deaconess Medical Center.”
  
• When pain strikes: “You should not try to diagnose your own back pain.”; “Make that initial call if back pain is interfering with your day.”; Make your first call to a professional, such as a “primary care physician or a chiropractor.”; “35% to 42% of people with their first episode of back pain will consult an chiropractor.”
  
• Referral to a specialist makes sense “when conservative measures have failed to address your back pain, symptoms aren’t improving or are getting worse, or there’s a suspicion that surgery might be needed.”
  
• “Chiropractors use posture exercises and hands-on spinal manipulation to relieve back pain, improve function, and help the body heal itself.”
  
• Chiropractors “often work in conjunction with other doctors, and they can prescribe diet, exercise, and stretching programs.”
  
• “A well-trained chiropractor will sort out whether you should be in their care or the care of a physical therapist or medical doctor.”
  
• “For back sprains, strains, and herniated discs, a visit to your primary care physician or chiropractor may be all it takes to feel better.”
  
• Keep in mind that “it may take several types of tests, such as x-rays, MRIs, and blood tests to determine the exact cause of your back pain.”
  

This article emphasizes that a modern well-trained chiropractor is a preferred portal-of-entry provider for back pain. It notes that such a chiropractor will be able to determine if a referral to a specialist, such as a surgeon, is necessary for a back complaint. It also notes that a chiropractor is trained not only in diagnosing back problems, but also in treating both soft tissue problems such as sprains and/or strains, and also disc herniations.

Other pertinent comments include that improved back pain diagnostics includes special imaging (like MRI), but also x-rays, which are commonly provided by chiropractors. “Chiropractors use posture exercises and hands-on spinal manipulation to relieve back pain, improve function, and help the body heal itself.” In addition, chiropractors often prescribe diet, exercise, and stretching programs. Chiropractors work well with other healthcare providers and doctors.

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When it comes to treating and managing back pain, several themes are apparent:

Back pain is epidemic in the modern society. The majority of Americans will experience back pain within their lives.
Back pain is the major cause of worker’s injuries, and the primary cause of worker’s disability, worker’s healthcare costs, and financial costs to the employers.
Even with successful treatment, back pain tends to become chronic and recurrent.
Neither drugs nor surgery for the treatment of back pain are very successful, and both approaches are saddled with steep costs and high complication rates.
Chiropractic offers a viable approach for the management of back pain, especially as the first consulted provider. Studies show that chiropractic for back pain is safe, outcome effective, cost effective, and has high patient satisfaction levels. Chiropractors are excellent diagnosticians, work well with other doctors and healthcare providers, and make referrals to these other providers when appropriate. 

  REFERENCES

1. Rand Review; Well-Adjusted; September-October 2017; p. 3.
2. Yuhas D; Back to Basics; Scientific American; titled The Science Of Health; October 2017; pp. 28-29.
3. Jordan J; People; onelastthing; Stephen Moyer, October 9, 2017; p. 110.
4. Grieve G; Common Vertebral Joint Problems; Second Edition; Churchill Livingstone; 1988.
5. Cyriax J; Textbook of Orthopedic Medicine; Volume One, Diagnosis of Soft Tissue Lesions; Bailliere Tindall, 1982.
6. Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons, Instructional Course Lectures; Volume 11, 1954, pp. 118-120.
7. Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969; No. 3, pp. 696-697.
8. 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.
9. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
10. Paige NM, Miake-Lye IM, 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.
11. Deyo RA; The Role of Spinal Manipulation in the Treatment of Low Back Pain; Journal of the American Medical Association; April 11, 2017; Vol. 317; No, 14; pp. 1418-1419.
12. Chou R, Huffman LH; Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society and American College of Physicians Clinical Practice Guideline; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.
13. Blanchette MA, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I; Workers’ Characteristics Associated with the Type of Healthcare Provider: First Seen for Occupational Back Pain; BMC Musculoskeletal Disorders; October 2016; Vol. 17; No. 1; 428.
14. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KCG, Franklin GM; Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State; Spine; May 15, 2013; Vol. 38; No. 11; pp. 953-964.
15. Harvard Health Letter; November 2017.