Another Low Back Pain Road Map

1076818_folded_map[originally published in KCN, January 2008]

In our ever changing healthcare environment, doctors are constantly learning  — so much so, that the treatments they hold fast to today, may be surpassed by another, more effective means tomorrow.  To not recognize this would be like freezing a physician in a time capsule with his dated professional diploma.  In an effort to stay abreast of the latest research regarding effective treatments for the myriad of conditions out there, doctors will often turn to the latest published practice guideline to assist them in their decision making process.  Why am I telling you all this?  Because a fresh set of guidelines just crossed my desk for Low Back Pain.  And chiropractic — as it has in guidelines past — has managed to find itself a comfortable spot in this set of recommendations, even if it was written for doctors of internal medicine.

Lower Back Pain is a huge deal in the United States.  It ranks as the 5th most common reason people visit their medical doctor.  Twenty-five percent of adults report having had a bout of lower back pain lasting at least one day in the past 3 months, and nearly 8% report having had at least one severe episode in the past year.  And it doesn’t come cheap either — ringing up more than $26 billion a year in direct health care costs in the U.S. alone.  With a problem like this, it makes sense that we treat the problem as effectively, and efficiently, as possible.

With the backing of the American Pain Society and the American College of Physicians— which together represent 100,000 internists — Roger Chou, MD, and his team of researchers hoped their set of guidelines would “help physicians to be more confident when suggesting therapies for low back pain,” he told Medical News Today, pointing out that the evidence available nowadays on lower back pain is much better than it was 5 or 10 years ago.

The guideline, which appeared in the October 2, 2007 edition of the Annals of Internal Medicine, relied on a multidisciplinary panel’s review and analysis of stacks of evidence related to the diagnosis and treatment of low back pain in the primary care setting.

In essence, the guideline (available at supported the importance of a focused history and physical examination to determine if the low back pain was attributable to a specific disease or spinal abnormality.  Since more than 85% of low back pain cases are what they classify as “nonspecific,” they discouraged the routine reliance on expensive imaging and diagnostic tests and showed that strong evidence exists to support the benefits of several therapies, either with, or without, medication.

An interesting thing about this guideline is that it didn’t take sides when it came to treatments involving medication vs. non-medication.  Instead, they attempted to lay out the options for doctors and patients to discuss — enabling informed decisions to be made.  In an interview with The Integrator — a proponent of the non-medication approach — Dr. Chou stated, “It has a lot to do with patient choice or preference.”  He indicated that the guideline did not place a higher value on one over the other, and that “patients who prefer not to take medication can benefit from non-drug treatments.”  However, he cautioned, “Just because some people prefer a non-pharmacologic approach doesn’t mean that everyone prefers a non-pharmacologic approach…  A person might want to take a pill instead of traipsing over to the chiropractor….”  surmising that for many it’s an issue of convenience.

On the medication side of the treatment spectrum, the guideline recommends that the medications used be appropriate for the amount of pain and impairment that the patient is experiencing.  “Several medications offer some benefits for low back pain, but they have risks, “ Chou was quoted in  Medical News Today.  Clinicians need to weigh these risks with the potential benefits and explain them, the guideline spells out.  “For example,” Chou continued, “acetaminophen is safe but not that effective, NSAIDS provide more relief but have gastrointestinal and cardiovascular side effects, and opioids can treat severe pain but pose risks for sedation and dependence over time.”

As for those looking for a non-pharmacologic approach, their first recommendation was to engage in a period of “self care.”  Self care included advice to remain active, read a back book, and to apply heat.  Once it was determined that this was not effective, recommendation of the following therapies with proven benefit was suggested.

For pain in the acute phase (ie. less than 4 weeks):  Spinal Manipulation (that’s medical talk for what we chiropractors do).  Nothing else was recommended for the acute phase.

Now if you’ve had pain for greater than 4 weeks — entering you into the sub-acute or chronic phase — your choices broaden.  Still on the list:  Spinal Manipulation (chiropractic scores again!).  But joining the list this time is exercise therapy, massage, acupuncture, yoga, cognitive-behavioral therapy, and progressive relaxation.  Something for everyone.

Is this guideline perfect?  In this chiropractor’s opinion, no.  But, I must admit, it’s pretty impressive when you consider who its intended audience is.  In a lot of ways, this guideline pushes the envelope.  I like that this guideline acknowledges  that patients have choices and encourages doctors and patients to discuss these choices. Whether or not this will actually happen remains to be seen.  As Dr. Chou told The Integrator, “A lot of people in the allopathic world will be kind of surprised by how much presence the non-pharmacological and alternative approaches have in the guideline.”

Sources used for this article:
American Pain Society and American College of Physicians release clinical practice guideline for low         back pain.  Medical News Today.  October 9, 2007.
Chou, et. al.  Diagnosis and treatment of low back pain:  a joint clinical practice guideline from the         American College of Physicians and the American Pain Society.  Annals of Internal Medicine.      October 2007; 147: 478-91.
Weeks.  Interview with internist Roger Chou, MD, lead author of ACP/APS “integrative” pain guideline.      The Integrator Blog.  November 8, 2007.
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