Decades of Low Back Pain

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There are many people for whom low back pain is a considerable daily issue. You may even be reading this essay because you have back pain and are looking for help. From my point of view as a Chiropractor it is without a doubt a frequent reason why people attend this Chiropractic office. 

Yet there remains many questions among the public and professional healthcare groups as to what is the best form of care for people with low back pain (LBP). So lets sift through the decades of research-evidence and encouragement of those individuals who have taken the time to highlight if Chiropractic can help people with LBP.

According to the world health organisation, in 2020, LBP touched the lives of 619 million people worldwide and LBP is the single leading cause of disability on the planet. Non-specific LBP is the most common presentation of LBP accounting for approximately 90% of cases.(1)

Acute LBP lasts less than 12-weeks and chronic LBP is ongoing LBP persisting for at least 12-weeks. Another classification that arises is thus, nonspecific chronic LBP is the LBP that is not attributable to a “Identifiable”, known specific pathology like: infection, tumour, osteoporosis, fracture, structural deformity, radicular syndrome, cauda equine syndrome, or inflammatory disorders like ankylosing spondylitis,.(2)

Fersum(3) states, in spite of a large number of pathological conditions being capable of causing low back pain (LBP), a definitive diagnosis is not possible in up to 85% of cases. As a result there is considerable uncertainty in the treatment of this group people.

Therefore, as a Chiropractor who sees many people in the above categories it does seem important to get the facts assembled about LBP. Questions that you and I must ask: Are Chiropractors able to help? Are there alternatives to Chiropractic? How long might it take to resolve low back pain? 

Let’s  attempt to answer to these question in a evidence informed and logical manner.

In 1990 the British Medical Journal published an article(4) from a randomised control trial (RCT) that  compared how people with low back pain responded to care provided over 6-weeks in a hospital setting vs in a Chiropractic setting.

The answers to this question was, Chiropractic care was more effective than hospital outpatient management [drugs and physiotherapy], mainly for patients with chronic or severe back pain. Furthermore, long term benefits of people’s functional disabilities, when checked at two years, showed the benefit of Chiropractic adjustments had become more evident throughout the follow up period.(4)

In 1993 Canada’s, Ontario Ministry of Health funded an investigation into the effectiveness and cost effectiveness of chiropractic management of low back pain.(5) The authors of this endeavour came to many interesting conclusions of which point to the necessity for Chiropractors to provide care to people with low back pain. It was stated, on this evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP. Often medical therapies are of debatable validity or are inadequate.

Then toward the end of the 90’s this same lead author was again asked to provide more information. Manga again concluded “We have presented much evidence that neuromuscular-skeletal disorders and injuries are very prevalent and costly. They cause a disproportionate amount of chronic illness and disability. We then presented sophisticated studies and analyses, especially those by Stano and Smith, demonstrating that chiropractic care is significantly more cost-effective than medical care within a common scope of practice. We also cited evidence favouring chiropractic in terms of safety and patient preference.”(6)

In 2008 The Spine Journal(7) printed an article covering the effectiveness between spinal manipulation therapy (SMT) and mobilisation (MOB) for Chronic Low Back Pain (CLBP) in comparison therapies: acupuncture, back school, bed rest, corset, diathermy, education advice, electrical modalities, exercise, heat, injections, massage and trigger point therapy, medication, no treatment, placebo, physical therapy, sham SMT, and ultrasound.

  • In general, the recommended indication for SMT or MOB is nonspecific mechanical CLBP.
  • Contraindications for SMT include ‘‘red flags’’ as described: fever, unrelenting night pain or pain at rest, pain with below knee numbness or weakness, leg weakness, loss of bowel or bladder control, progressive neurological deficit, direct trauma, unexplained weight loss, and history of cancer.
  • In addition, SMT or MOB may not be the best choice for patients who cannot increase activity/workplace duties, are physically deconditioned, and have psychosocial barriers to recovery 
  • The UK BEAM trial is the largest study with a pre-specified comprehensive cost-effectiveness design, and the authors concluded that SMT is a cost-effective addition to ‘‘best care’’ for back pain in general practice. 
  • SMT alone probably gives better value for money than SMT followed by exercise.
  • Estimated very low risk of serious adverse events support SMT and MOB as viable options for the treatment of CLBP. SMT and MOB are at least as effective as other efficacious and commonly used interventions.

As a side note, and perhaps also significant are the remarks again published in The British Medical Journal in 2019(8) showing via a retrospective study for acute low back pain and to minimise the use of short and long term use of opioids it was likely that early intervention by a Chiropractor would be beneficial compared over initially receiving usual treatments from primary care physicians.

Thus the question arises, if you do decide to employ a Doctor of Chiropractic to help you, how long will your healing and recovery take?

The first RCT mention by Meade(4) during the 1990”s happened over the duration of 6-weeks and as noted, there was favourable results within this time period and 2-years following the chiropractic group continued to respond positively. 

Subsequently in 2009 Maltby tried to clarify the issue regarding what time period is necessary for SMT to be effective. Finally stating, there is no support for the claim of resolution of low back pain in 6-12 visits of Chiropractic SMT care from randomised clinical trials. In fact, the average improvement in 65 RCT’s on low back pain with SMT and/or Mobilisation as the treatment, was less than 43%. For a program of treatment sessions in studies with Chiropractors as the treating doctors, it was estimated that 28 visits were needed to resolve low back pain.(9)

Information conducted during an RCT by Senna and Machaly(3) also parallels the above statement. The statements below come from their study in which chronic, non-specific LBP patients were randomised to 12 SMT sessions over 1 month, 12 sham manipulation sessions over 1 month, or 12 SMT sessions over 1 month followed by 10 months of twice monthly maintenance SM.

  • Patients in the 1-month SMT only and 1-month SMT + maintained SMT for 10-month groups experienced significantly lower pain and disability scores compared with group 1 after the first phase of treatments, that is, after 1-month period. 
  • By the end of second phase of treatment (after 10-month period), patients with maintained SMT had significantly lower pain and disability scores compared with the patients of the non-maintained SMT group.
  • The disability score difference (>14 points) observed after 10 months in current study between the maintained SMT group and non-maintained SMT group is statistically significant and clinically important.

The conclusion from the above study(3) was, SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SMT after the initial intensive manipulative.

In summary of this review, I think we may now answer the questions proposed earlier and throughout this essay. Based on the above evidence provided Chiropractors are able to help people with acute and chronic low back pain. There are alternatives to chiropractic like usual medical care including physical therapy and acupuncture however Chiropractic fairs well in comparison. How long it will to take a person to improve is about 1-month. To continue to gain good results in your spinal health, continued care after the initially block of appointments is appropriate and clinical important. 

In healthcare science there is more to be studied and answered and overtime we’ll get there. There is now a remark this author and Chiropractor would like to make. In this office real world interactions are sometimes vastly different or may be carbon copies of the evidence provided. Each person who walks through the doors of my office is first seen as a unique human being and secondly rules of practice and evidence are applied within reason of time, and available energy. Therefore, the above information has been provided as evidence for you and I to make informed decisions. 

Chiropractic is hands on care of the spine and nerve system. We take care of people and we love to help, especially helping people most in need. When you’re ready, you can schedule an appointment with your local Faversham Chiropractor and discuss if the care provided here is a good fit for you and your family.

Please feel free to contact The Healthpraxis – Faversham Chiropractic via email: care@thehealthpraxis.com or call 01795 360123

References 

  1. https://www.who.int/news-room/fact-sheets/detail/low-back-pain
  2. Senna & Machaly, 2011, Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome? SPINE 36 (18) 1427-37
  3. Fersum, 2006, Spinal manipulation and exercise was better than ultrasound and exercise for patients with chronic low back pain, Australian Journal of Physiotherapy 2006 Vol. 52
  4. Meade, T.W. et al. 1990, Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 300; 1431-1437
  5. Manga, 1993, THE EFFECTIVENESS AND COST-EFFECTIVENESS OF CHIROPRACTIC MANAGEMENT OF LOW BACK-PAIN, Funded by the Ontario Ministry of Health
  6. Manga & Angus, 1998, Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs, Attaining Better Outcomes and Achieving Equitable Access to Health Services. (An Independent Report Commissioned by the Ontario Chiropractic Association)
  7. Bronfort, 2008, Evidence-informed management of chronic low back pain with spinal manipulation and mobilisation, The Spine Journal
  8. Kazis LE, et al. BMJ Open 2019;9:e028633. doi:10.1136/bmjopen-2018-028633 
  9. Maltby, 2009, Program of Care Derived from Pain Data Reported in RCTs on Low Back Pain, J. Vertebral Subluxation Res

Special thanks to James Chestnut Doctor of Chiropractic for providing a signpost to these articles and many more like it.