Low Back Pain…yeah we do that.

[originally published in KCN, January 2002]

It may come as a surprise, but after authoring some 46 Spinal Column articles over the past 5 years, I have yet to dedicate one to the condition that we chiropractors most often see — low back pain.  Sure, I’ve made reference to it many times, but I’ve never given it the spotlight.  Perhaps, that’s exactly what I have been afraid of — giving it the “spotlight.”  Much of the media and scientific journals have made lower back pain and chiropractic one and same.  And while we are grateful for the validation and coverage, many in our profession, and rightfully so, are afraid that we might get pigeon-holed into becoming known as “low back doctors” when chiropractic really has so much more to offer.

Having said that, when it comes to treating lower back pain, we really do a pretty decent job.  So much so, in fact, that more and more countries are releasing guidelines that recommend the type of treatment we chiropractors offer when it comes to low back pain.

Why?  Because lower back pain is a big issue in our society.  It is estimated that 80% of the adult population will experience back pain at some point in their lifetime.  National statistics indicate that during a given year, 15-20% of our population experiences this annoyance.  So much so that it is the second most common reason  patients pay a visit to their primary care physicians.  Speaking of paying, I probably don’t need to tell you, but  lumbago is expensive.  Not only are medical costs high, but even higher are the costs of time loss from work and disability  — together they can cost up to three times as much as any of the medical efforts.  It is estimated that the total annual societal cost of back pain in the U.S. ranges from $20 to $50 billion.  And then there are some things that one cannot attach a price tag to — like the impact that patients, and their families, feel because of their inability to function normally at work and other daily activities.

Yes, low back pain is a pain.  Which is precisely why the U.S. government decided to step in and figure out which form of treatments made the most sense.  In other words, what worked and was it cheap?

In 1994, the Government got its answer from the Agency for Health Care Policy and Research (AHCPR), an agency within the Department of Health and Human Services, when it unveiled its Clinical Practice Guideline for Acute Low Back Problems in Adults.  This was a pretty remarkable guideline in that it was composed by a 23-member panel (whittled down from more than 200 nominees) representing the fields of biomechanical and spine research, chiropractic care, emergency medicine, family medicine, internal medicine, neurology, neurosurgery, occupational health nursing, occupational medicine, occupational therapy, orthopedics, osteopathic medicine, physical and rehabilitation medicine, physical therapy, psychology, rheumatology, and radiology.  In all, this well-rounded panel, sifted through more then 10,000 research articles published since 1984, as well as a previous exhaustive literature search compiled by the Quebec Task Force on Spinal Disorders for publications prior to this date.  And if this wasn’t enough, the comprehensiveness of the panel’s review and their prevailing conclusions were overseen by a group of over 100 peer reviewers who had expertise in the care of low back problems.  In formulating their conclusions, the panel not only focused on what was working (ie. the efficacy of assessment and treatment methods), but they also factored in the risks of the different treatment methods and their relative costs.

Five years and a lot of reading later, the panel released their conclusions.  Among other things, they found that spinal manipulation (the type of care delivered primarily by chiropractors) to be a preferred  form of treatment for acute lower back pain.  The panel downplayed the use of prescription medications (eg. muscle relaxers and steroids) and bed rest — and was highly critical of surgery.

Two years later, in 1996 Great Britain, through the efforts of the Royal College of General Practitioners, took the baton and updated these low back guidelines to include the latest research.  As with the U.S. guidelines, manipulation of the spine was among the top treatment choices for lower back pain.

In 1998 Denmark came out with their own set of low back pain guidelines.  The 14-member multidisciplinary panel organized by the Danish Institute for Health Technology Assessment listed manual therapy (which included chiropractic) first under “treatments which can generally be recommended.”  The only other forms of treatment that shared the spot under this top heading were back school, ergonomics, exercise therapies, and pain relieving medication.

And let’s not forget the bold findings from our friends to the north.  Canada acknowledged chiropractic’s valuable role in the treatment of lower back pain back in 1993, when health economist Pran Manga, PhD., a professor of health economics at the University of Ottawa, released his report on The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain.  This report was funded by the Ontario Ministry of Health to aid them in their efforts to contain and reduce health care costs in their province.  After an exhaustive review of the scientific literature, Dr. Manga and his colleagues found that spinal adjustments given by chiropractors were more effective than other forms of treatment for low back pain.  In fact, they reported that “many medical therapies were of questionable validity or were clearly inadequate.”  They also found chiropractic care to be safer than medical management of low back pain, and that “an overwhelming body of evidence indicated that chiropractic management of low back pain was more cost-effective than medical management.”  In their recommendations to the government for reform, they stated that not only should “chiropractic services… be fully insured under the Ontario Health Insurance Plan,” but that “a very good case could be made for making chiropractors the gatekeepers for management of low-back pain in the workers’ compensation system in Ontario.”

Pretty compelling evidence.  And remember, these reports are reviewing countless scientific studies.  The ironic thing in all of this is that we chiropractors really don’t  treat lower back pain at all.  At the risk of oversimplifying what we do, we’re moving stuck bones in the back, which unpinches nerves, and subsequently allows everything to just,work better.  Work the way it’s supposed to — free of pain.

Sources used for this article:
Bigos, et. al.  Acute low back problems in adults.  Clinical practice guidelines no. 14. AHCPR Publication No. 95-0642.  Rockville, MD:  Agency for Health Care Policy and Research, Public Health Services, U.S. Department of Health and Human Services.  December 1994.
Denmark produced low back pain guidelines —  chiropractic recommended. Dynamic Chiropractic.  18(23). 1997.
Manga, et. al.  The effectiveness and cost-effectiveness of chiropractic management of low-back pain. Pran Manga and Associates.  Ottawa, Ontario, Canada.  1993
New British low back pain guidelines released:  Royal college of general practitioners update AHCPR guideline. Dynamic Chiropractic.  17(02).  1997.
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