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):


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 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):


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):


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.