Discussions on Contemporary Trends in the Diagnosis and Treatment of Low Back Pain

[vc_row][vc_column][vc_column_text]In February 2008, Brook Martin, MPH, and colleagues published an article in the Journal of the American Medical Association titled

Expenditures and Health Status Among Adults With Back and Neck Problems

This article evaluated the inpatient, outpatient, emergency department, and pharmacy expenditures related to back and neck problems in the United States from 1997 through 2005 and to examine associated trends in health status. In 1997, the mean age- and sex-adjusted medical costs for respondents with spine problems was $4,695 compared with $2,731 among those without spine problems (inflation-adjusted to 2005 dollars). This represents an increase of $1,964 per person per year. In 2005, the mean age- and sex- adjusted medical expenditure among respondents with spine problems was $6,096, compared with $3,516 among those without spine problems. This represents an increase of $2,580 per person per year. This indicates that the total expenditures among respondents with spine problems increased 65% (adjusted for inflation) from 1997 to 2005.

These authors state:

“Rates of imaging, injections, opiate use, and surgery for spine problems have increased substantially over the past decade.”

There was a “423% increase in the expenditure for spine-related narcotic analgesics from 1997 to 2004.”

“Despite rapidly increasing medical expenditures from 1997 to 2005, there was no improvement over this period in self-assessed health status, functional disability, work limitations, or social functioning among respondents with spine problems.”

“Inflation-adjusted health care expenditures related to spine problems increased 65% between 1997 and 2005.”

“The greatest relative increase among expenditure categories was observed for medications.”

“Across all years, the average expenditure for respondents reporting spine problems was 73% greater than that of those without spine problems.”

The total estimated cost for treating spine problems in 2005 was $85.9 billion.

Importantly, this study data did not include the costs from over-the-counter drugs used in the treatment of spinal problems.

This study shows that the cost of treating back problems is rising faster than other medical costs, and yet patients are not fairing any better. This study clearly indicates that increasing the amounts of drugs to treat back problems is not the answer, because it is clearly not working.

•••••[/vc_column_text][vc_column_text]In January 2009, physician Richard Deyo, from the Department of Medicine, Oregon Health and Science University in Portland, Oregon, and colleagues, published a study in The Journal of the American Board of Family Medicine titled:

Overtreating Chronic Back Pain: Time to Back Off?

In this article, Dr. Deyo and colleagues state:

“Pain complaints are a leading reason for medical visits. The most common pain complaints are musculoskeletal, and back pain is the most common of these.”

“The prevalence and impact of back pain have led to an expanding array of tests and treatments, including injections, surgical procedures, implantable devices, and medications. Each is valuable for some patients, but use may be expanding beyond scientifically validated indications, driven by professional concern, patient advocacy, marketing, and the media.”

“Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses.”

These authors list recent increases in Medicare expenditures associated with low back pain as follows:

1. A 629% increase for epidural steroid injections.
2. A 423% increase in expenditures for opioids for back pain.
3. A 307% increase in the number of lumbar magnetic resonance images.
4. A 231% increase in facet joint injections.
5. A 220% increase in spinal fusion surgery rates.

Sadly, these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. Expanded testing and treatment for back pain have not improved outcomes, but have increased complications, including deaths.

These authors estimate that 33 – 66% of spinal computed tomography (CT) imaging and MRI are inappropriate. Because positive imaging findings, such as herniated disks, are common in asymptomatic people, inappropriate imaging may result in inappropriate treatment. Positive imaging findings result in more surgery and higher costs than those receiving plain x-rays, but the clinical outcomes are no better, including subsequent pain, function, quality of life, or overall improvement.

Additionally, these authors state:

“Despite concerns surrounding the use of opioids for long-term management of chronic [low back pain], there remain few high-quality trials assessing their efficacy… Based on our results, the benefit of opioids in clinical practice for the long-term management of chronic [low back pain] remains questionable.”

“Many patients receiving opioids for noncancer pain have persistent high levels of pain and poor quality of life.”

Ironically, “opioid use may paradoxically increase sensitivity to pain.”

•••

“The efficacy of spinal injections is limited. Epidural corticosteroid injections may offer temporary relief of sciatica, but both European and American guidelines, based on systematic reviews, conclude they do not reduce the rate of subsequent surgery.”

“Facet joint injections with corticosteroids seem no more effective than saline injections.”

“For patients with axial back pain without sciatica there is no evidence of benefit from spinal injections; however, many injections given to patients in the Medicare population seemed to be for axial back pain alone.”

•••

Spine fusion surgery is limited when treating degenerative discs with back pain with no sciatica, yet they have increased 220% from 1990 to 2001 in the United States.

“Higher spine surgery rates are sometimes associated with worse outcomes.”

•••••

“Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain.”

“There are no ‘magic bullets’ for chronic back pain, and expecting a cure from a drug, injection, or operation is generally wishful thinking.”

•••••

[/vc_column_text][vc_column_text]There are a number of studies that show that chiropractic spinal adjusting is highly effective, safe, cost effective, and results in long-termed stable outcomes in the treatment of chronic low back pain.

In 1985, Professor Emeritus of Orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada, Dr. W. H. Kirkaldy-Willis and his colleague Dr. J. D. Cassidy, presented the results of chiropractic spinal manipulation in 283 patients with chronic, disabling, treatment resistant low back pain. Their study was published in the journal Canadian Family Physician, and titled:

Spinal Manipulation in the Treatment of Low back Pain

These authors state:

“Spinal manipulation, one of the oldest forms of therapy for back pain, has mostly been practiced outside of the medical profession.”

“Over the past decade, there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.”

“Most family practitioners have neither the time nor inclination to master the art of manipulation and will wish to refer their patients to a skilled practitioner of this therapy.”

“The physician who makes use of this resource will provide relief for many patients.”

Drs. Kirkaldy-Willis and Cassidy note that less than 10% of low back pain is due to herniation of the intervertebral disc or entrapment of spinal nerves by degenerative disc disease. They also explain the physiology of spinal manipulation by claiming that it improves the physiology of pain transmission using Melzack and Wall’s 1965 Gate Theory of Pain. Segmental spinal adjusting (manipulation) improves segmental motion, resulting in a neurophysiological sequence of events that closes the pain gait, inhibiting muscle spasm and pain. They state:

“The central transmission of pain can be blocked by increased proprioceptive input.” Pain is facilitated by “lack of proprioceptive input.” This is why it is important for “early mobilization to control pain after musculoskeletal injury.”

These authors present the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled (“Constant severe pain; disability unaffected by treatment.”) These patients were given a “two or three week regimen of daily spinal manipulations by an experienced chiropractor.”

These authors considered a good result from manipulation to be:

1. “Symptom-free with no restrictions for work or other activities.”
2. “Mild intermittent pain with no restrictions for work or other activities.”

81% of the patients with referred pain syndromes subsequent to joint dysfunctions achieved the “good” result.

48% of the patients with nerve compression syndromes, primarily subsequent to disc lesions and/or central canal spinal stenosis, achieved the “good” result.

•••••

[/vc_column_text][vc_column_text]In 1990, Dr. T W Meade and colleagues published a study in the British Medical Journal titled:

Low back pain of mechanical origin:
Randomized comparison of chiropractic and hospital outpatient treatment

This study involved 741 patients aged 18-65. The patients were treated by chiropractors, who used chiropractic manipulation in most patients, or by the hospital staff who most commonly used Maitland mobilization or manipulation, or both. The outcomes were assessed by noting changes in the score on the Oswestry pain disability questionnaire and in the results of tests of straight leg raising and lumbar flexion. These authors state:

“Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.”

“A benefit of about 7 percentage points on the Oswestry scale was seen at two years.”

“The benefit of chiropractic treatment became more evident throughout the follow up period.”

“Secondary outcome measures also showed that chiropractic was more beneficial.”

“For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management.”

“The benefit is seen mainly in those with chronic or severe pain.”

If all back pain patients without manipulation contraindications were referred for chiropractic instead of hospital treatment, there would be significant annual treatment cost reductions, a significant reduction in sickness days during two years, and a significant savings in social security payments.

“There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic.”

“The results leave little doubt that chiropractic is more effective than conventional hospital outpatient treatment.”

“The effects of chiropractic seem to be long term, as there was no consistent evidence of a return to pretreatment Oswestry scores during the two years of follow up, whereas those treated in hospital may have begun to deteriorate after six months or a year.”

“Chiropractic was particularly effective in those with fairly intractable pain-that is, those with a history of severe pain.”

“Whatever the explanation for the difference between the two approaches, however, this pragmatic comparison of two types of treatment used in day to day practice shows that patients treated by chiropractors were not only no worse off than those treated in hospital but almost certainly fared considerably better and that they maintained their improvement for at least two years.”

The editors of journal The Lancet reviewed the June 2nd 1990 British Medical Journal article by Meade [immediately above], and noted:

The article “showed a strong and clear advantage for patients with chiropractic.”

The advantage for chiropractic over conventional hospital treatment was “not a trivial amount” and “reflects the difference between having mild pain, the ability to lift heavy weights without extra pain, and the ability to sit for more than one hour, compared with moderate pain, the ability to lift heavy weights only if they are conveniently positioned, and being unable to sit for more than 30 minutes.”

“This highly significant difference occurred not only at 6 weeks, but also for 1, 2, and even (in 113 patients followed so far) 3 years after treatment.”

“Surprisingly, the difference was seen most strongly in patients with chronic symptoms.”

“The trial was not simply a trial of manipulation but of management” as 84% of the hospital-managed patients had [physiotherapy] manipulations.

“Chiropractic treatment should be taken seriously by conventional medicine, which means both doctors and physiotherapists.”

“Physiotherapists need to shake off years of prejudice and take on board the skills that the chiropractors have developed so successfully.”

•••••

[/vc_column_text][vc_column_text]The journal Spine is the top ranked orthopedic journal and the official journal for publication by the world’s top 14 orthopedic societies. In 2003, Lynton Giles and Reinhold Muller published a study titled:

Chronic Spinal Pain:
A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation

This was a 9-week clinical trial involving 115 patients with chronic neck and/or back pain. The drugs used in this study were either Celebrex or Vioxx, cox-2 inhibitors. The spinal manipulation was specific adjustments delivered by a chiropractor. All patients were evaluated using standard measurement outcomes, including the Oswestry Back Pain Disability Index (Oswestry), the Neck Disability Index (NDI), the Short-Form-36 Health Survey questionnaire (SF-36), visual analog scales (VAS) of pain intensity and ranges of movement. These authors state:

“The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).”

“Manipulation achieved the best overall results, with improvements of 50% on the Oswestry scale, 38% on the NDI, 47% on the SF-36, 50% on the VAS for back pain, 38% for lumbar standing flexion, 20% for lumbar sitting flexion, 25% for cervical sitting flexion, and 18% for cervical sitting extension.”

There is “insufficient evidence for the use of NSAIDs to manage chronic low back pain, although they may be somewhat effective for short-term symptomatic relief.”

“The results of this efficacy study suggest that spinal manipulation, if not contraindicated, may be superior to needle acupuncture or medication for the successful treatment of patients with chronic spinal pain syndrome.”

“In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

In January 2005, these same authors published the data on the 12-month follow-up status of these patients. These results were published in the Journal of Manipulative and Physiological Therapeutics, and titled:

Long-Term Follow-up of a Randomized Clinical Trial Assessing
the Efficacy of Medication, Acupuncture, and Spinal Manipulation
for Chronic Mechanical Spinal Pain Syndromes

This follow-up study on these patients involved reapplying the same instruments (ie, Oswestry Back Pain Index, Neck Disability Index, Short-Form-36, and Visual Analogue Scales). These authors state:

“Comparisons of initial and extended follow-up questionnaires to assess absolute efficacy showed that only the application of spinal manipulation revealed broad-based long-term benefit: 5 of the 7 main outcome measures showed significant improvements compared with only 1 item in each of the acupuncture and the medication groups.”

“In patients with chronic spinal pain syndromes, spinal manipulation, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.”

Both the 9-week findings and the extended follow-up results are consistent with others who conclude that “those treated by chiropractic derived more short-term and long-term benefit and satisfaction than those treated by hospital therapists.”

•••••

[/vc_column_text][vc_column_text]The most recent, comprehensive, and authoritative

Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain

were published in the October 2007 issue of the journal Annals of Internal Medicine. An extensive panel of qualified experts constructed these clinical practice guidelines. These experts performed a review of the literature on the topic and then graded the validity of each study. The literature search for this guideline included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. This article has 131 references, and lists 7 recommendations, as follows:

Recommendation 1:

Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories:

1. Nonspecific low back pain
2. Back pain potentially associated with radiculopathy or spinal stenosis
3. Back pain potentially associated with another specific spinal cause

The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.

Recommendation 2:

Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain.

Recommendation 3:

Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.

Recommendation 4:

Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy).

Recommendation 5:

Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options.

Recommendation 6:

For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care.

Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy.

For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

Recommendation 7:

For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation.

For chronic or sub-acute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

It is noted that when medication and self-care is inadequate for back pain that clinicians should “consider the addition of nonpharmacologic therapy with proven benefits.” For acute, sub-acute and chronic low back pain, spinal manipulation is listed.

Following these Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain, an article reviewing the evidence for nonpharmacologic therapies for the treatment of back pain was presented, and titled:

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

This article, also published in the Annals of Internal Medicine, October 2007, is probably the most comprehensive review of the literature concerning non-drug therapies used in the treatment of low back pain, citing 188 references.

These authors note that there are many nonpharmacologic therapies available for treatment of low back pain. They therefore assessed the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).

In this review, the only non-drug treatment that has proven evidence to benefit acute, subacute, and chronic back pain is spinal manipulation. Manipulation was defined as “Manual therapy in which loads are applied to the spine using short- or long-lever methods. High-velocity thrusts are applied to a spinal joint beyond its restricted range of movement.”

Below is a summary chart of the treatments assessed and their efficacy. The bottom line is that there exists substantial evidence that chiropractic spinal manipulation is safe, effective, cost effective and offers long-term clinical benefits to those suffering from acute an chronic low back pain syndromes.[/vc_column_text][vc_column_text]The Following Chart Summarizes The
Treatment Benefit For Low Back Pain

	Acute	Subacute	Chronic
Manipulation	yes	yes	yes
Massage	insufficient	insufficient	yes
Acupuncture	no	no	yes
Exercise Therapy	no	no	yes
Yoga	no	no	yes
Back Schools	no	no	no
Psychological Therapies	no	no	no
Interdisciplinary Rehabilitation	no	no	yes
Interferential Therapy	no	no	no
Low-Level Laser Therapy	no	no	yes
Lumbar Supports	no	no	no
Shortwave Diathermy	no	no	no
Superficial Heat	yes	no	no
Traction	no	no	no
TENS	no	no	no
Ultrasound	no	no	no

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References

1. Brook I. Martin, MPH, Richard A. Deyo, MD, MPH, Sohail K. Mirza, MD, MPH, Judith A. Turner, PhD, Bryan A. Comstock, MS, William Hollingworth, PhD Sean D. Sullivan, PhD; Expenditures and Health Status Among Adults With Back and Neck Problems; Journal of the American Medical Association; February 13, 2008, Vol. 299, No. 6, pp. 656-664.
2. Richard A. Deyo, MD, MPH, Sohail K. Mirza, MD, MPH, Judith A. Turner, PhD and Brook I. Martin, MPH; Overtreating Chronic Back Pain: Time to Back Off?; The Journal of the American Board of Family Medicine; Volume 22 Number 1, January 2009, pp. 62-68.
3. W. H. Kirkaldy-Willis and J. D. Cassidy; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
4. T W Meade, Sandra Dyer, Wendy Browne, Joy Townsend, A 0 Frank; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300, June 2, 1990, pp. 1431-7.
5. Chiropractors and Low Back Pain; The Lancet; July 28, 1990, p. 220.
6. Lynton G. F. Giles, DC, PhD; Reinhold Muller, PhD; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; 28(14):1490-1502.
7. Reinhold Muller, PhD, Lynton G.F. Giles, DC, PhD; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005, Volume 28, Number 1.
8. Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS; 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; Volume 147, Number 7, October 2007, pp. 478-491.
9. Roger Chou, MD, and Laurie Hoyt Huffman, MS; 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.

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