Submitted by Shawn Thistle, DC, RRS Education
Article: “Clinical Practice Guideline: Chiropractic Care for Low Back Pain”
Authors: Globe G, Farabaugh RJ, Hawk C, et al.
Publication Information: Journal of Manipulative & Physiological Therapeutics 2016; 39(1): 1-22. doi: 10.1016/j.jmpt.2015.10.006.
It is now well known that low back pain (LBP) is the leading cause of disability worldwide1 and that chiropractors can play a pivotal role in the management of this condition. However, the chiropractic profession can achieve wider acceptance and improved cultural authority, particularly within integrated health care delivery systems, by embracing and integrating current scientific research into our approach to evidence-based health care. It is in this context that this Clinical Practice Guideline (CPG) was developed.
The aim of this systematic review was to update and combine three previously published clinical guidelines,2-4 while answering this question: “What is the effectiveness of chiropractic care, including spinal manipulation (SMT), for nonspecific low back pain?”
Clinical Practice Guideline Summary
Literature Search Results:
The search yielded 270 articles. After screening for eligibility, 18 were included for review. Of these, 16 were retained as acceptable/high quality and two were excluded for being of unacceptable quality according to the the Scottish Intercollegiate Guideline Network Checklists (SIGN). Those papers with new, relevant information were summarized and provided to the Delphi panel. 51 seed statements were developed based on the background documents, revising the previous statements if it seemed advisable based on the literature. Panelists scored each statement on an ordinal scale of 1-9, with scores amalgamated as follows: ratings of 1-3 were deemed “inappropriate,” 4-6 as “uncertain” and 7-9 as “appropriate.”
Results of Literature Update & Delphi Panel Review – Chiropractic Care for LBP
- Most acute pain responds to a short course of conservative treatment. If effectively treated in this stage, patients generally recover with full resolution of pain and function, although recurrence is common.
- Delayed or inadequate early management may result in increased risk of chronicity and disability in LBP.
- Clinicians should remain vigilant for the presence of clinical red flags that may appear at any time during patient care. They should also identify and address biopsychosocial factors, also known as yellow flags, as early as possible to facilitate a comprehensive treatment approach.
- Chiropractors are competent at many approaches to functional assessment and treatment, and depending on clinical complexity, can function independently or as part of a multidisciplinary team.
- The overarching goal of chiropractic care is to improve the functional capacity of a patient while educating them to accept responsibility for their own health.
- Informed consent is the process of proactive communication between a patient and clinician that results in the patient's authorization or agreement to undergo a specific intervention.
- Informed consent should be obtained from the patient and performed within the local and/or regional standards of practice. This process should include clear explanation of the diagnosis, examination and proposed procedures (including material risks and other treatment options, including receiving no treatment).
- Patients’ questions should be addressed to ensure their capacity to make an informed decision about their health care choices.
Examination Procedures for LBP:
- Assessment should include, but is not limited to: health history (e.g., pain characteristics, systems and red flags screening, risk factors for chronicity), examination (e.g., ROM, orthopedic tests or neurological testing) and further diagnostics when needed (e.g., imaging or laboratory tests).
- ROM may be used as part of the physical examination to assess regional mobility, but evidence does not support its reliability for determining functional status.
- Routine imaging or diagnostic tests are not recommended in cases of nonspecific LBP.
- Further work-up is required in the presence of severe and/or progressive neurological deficits, or if serious pathology is suspected.
- Patients with persistent LBP accompanied by signs of radiculopathy or spinal stenosis should be evaluated by MRI (preferably).
- Imaging should also be considered in patients failing to respond to a reasonable course of conservative care, or if there is suspicion of underlying anatomical anomaly (i.e., spondylolisthesis, moderate to severe spondylosis or post-trauma with worsening symptomatology).
- Findings from any imaging study should be considered only in conjunction with careful correlation to history and physical examination findings.
Severity & Duration of Conditions:
- Acute = symptoms persisting for less than six weeks
- Subacute = symptoms persisting between six to 12 weeks
- Chronic = symptoms persisting for at least 12 weeks
- Recurrence/”flare-up” = return of symptoms perceived to be similar to those of the original injury/incident
Treatment Frequency & Duration:
- Most patients respond to care in an anticipated timeframe, but treatment frequency and duration may be influenced by individual patient factors (e.g., comorbidities and yellow flags).
- Therapeutic effects of care should be evaluated by subjective/objective means during and/or after each course of care. Examples include:
- A typical therapeutic trial of chiropractic care consists of 6-12 visits over two to four weeks.
Initial Course of Care for Low Back Disorders:
- The most robust research literature regarding manual therapy for low back disorders is based primarily on high-velocity, low-amplitude (HVLA) techniques, as well as mobilization (such as flexion-distraction).
- A typical initial course of chiropractic care includes one or more ‘passive’ modalities (i.e., SMT/mobs) and physiotherapeutic modalities for pain reduction, in addition to patient education designed to reassure and develop strategies for independent management.
- The evidence does not generally support the isolated use of therapeutic modalities (i.e., ultrasound, electric stim etc.), but their use in a multimodal approach may be warranted based on clinician judgement and patient preferences.
- There is scarce evidence on the use of lumbar supports (i.e, bracing/taping/orthoses) so their routine use cannot be recommended at this time (again, allowing for inclusion depending on clinician and patient preference).
- Exercise (or ‘active’ care methods) should be increasingly integrated into a plan of management.
Re-evaluation & Re-examination:
After the initial course of care, clinicians should determine the necessity for further treatment based on the patient’s response to date. If the patient has resolved or reached a plateau, further care should be tapered or discontinued. If complete resolution has been reached (i.e., maximum therapeutic benefit or MTB), the chiropractor should perform a final evaluation following a trial of therapeutic withdrawal, followed by relevant patient education moving forward. At this point, those interested in wellness care (also referred to as “maintenance care”) should be given this option (despite a general lack of evidence for or against the efficacy of such an approach).
Benefit vs. Risk:
Chiropractic care is considered quite safe and effective compared to common medical treatments or procedures. Serious adverse events are considered to occur in no more than one per million patient visits for lumbar SMT.5 Although the risk of major adverse events is low, mild to moderate, short-lived adverse events after treatment do occur, most often in the form of muscle stiffness or general soreness.
Contraindications & Cautions:
Chiropractors should be aware of contraindications to HVLA SMT (some of which may still allow for low-velocity, low amplitude technique or soft-tissue work, etc.):
- Conditions: severe osteoporosis, multiple myeloma, osteomyelitis, local primary bone tumors where osseous integrity is questionable, local metastatic bone tumors, Paget’s disease
- Neurological Conditions: progressive or sudden neurological deficit (including cauda equina syndrome) or spinal cord tumors demonstrating neurological compromise (care may be appropriate after specialist investigation and clearance)
- Inflammatory Conditions: rheumatoid arthritis in active systemic stage (or locally in the presence of inflammation or atlantoaxial instability), inflammatory phase of ankylosing spondylitis or psoriatic arthritis, or Reiter’s syndrome (reactive arthritis)
- Bleeding Disorders: congenital or acquired, unstable aortic aneurysm, etc.
- Other: structural instability, inadequate physical exam, or inadequate SMT training/skills
Other factors may contraindicate care to the affected area of the body, while still permitting care to other areas. Examples include local open wounds or burns, joint infection, recent/healing fracture, cancer, spinal/joint implants or surgical fixations.
Chronic Pain Management for Spinal Disorders:
Appropriate chronic pain management of spine-related conditions includes addressing issues such as physician dependence, somatization, illness behavior and secondary gain. Once documented as persistent or recurrent, these chronic presentations should not be categorized as “acute” or “uncomplicated.” Many factors can complicate a patient’s condition, recovery or response to treatment, including:
- nature of work requirements or ergonomics
- history of prior treatment
- lifestyle factors/habits
- psychological factors such as depression, anxiety, etc.
Clinical Application & Conclusions
The goal of this Clinical Practice Guideline was to build on prior guidelines in this area. The key changes and updates from existing CPGs reflected in this current update were as follows:
- A brief description of key elements that should be included during an informed consent discussion;
- The recommendation that routine radiographs, other imaging and other diagnostic tests are not recommended for patients with nonspecific LBP (along with recommendations for when these studies should be considered);
- The recommendation that the hierarchy of clinical methods used in patient care should generally correspond to the supporting level of existing evidence;
- Additional clarification regarding the limited use of therapeutic modalities and lumbar supports that reflects patient preferences with the intention of facilitating a shift from passive-to-active care while reducing dependency on passive modalities with limited evidence of efficacy;
- Recognition that although ROM testing may be clinically useful as a part of the physical examination to assess for regional mobility, the evidence does not support its reliability in determining functional status; and
- Inclusion of a brief summary of the evidence informing HVLA SMT risk vs. benefit assessment.
The authors conducted a systematic review between March and July of 2014. Their aim was to update the literature published since the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) guideline was developed. As such, their search included articles published between October 2009 through February 2014. The PubMed, Index to Chiropractic Literature, CINAHL and MANTIS databases were searched. Articles and abstracts were screened independently by two reviewers. Data were not further extracted at this point. To be eligible for inclusion in this guideline, studies had to fulfill the following criteria:
- Publication (in English) between October 2009 and February 2014;
- Study design had to be one of: randomized controlled trial (RCT), cohort, systematic review or meta-analysis;
- Involvement of human participants over the age of 17;
- Evaluation of spinal manipulation for low back pain > 3 months duration (chronic), with a non-manipulation comparison group; and
- Reporting of patient outcomes.
Studies were excluded from this guideline if they were:
- case reports or case series, commentaries, conference proceedings, in-patients or letters
- narrative and qualitative reviews
- non-peer-reviewed publications
- pilot studies
- inclusive of patients with pregnancy-related LBP
- secondary analyses or descriptive studies.
Studies were evaluated by at least two of the three investigators conducting the review using the Scottish Intercollegiate Guideline Network Checklists (SIGN) for randomized controlled trials, systematic reviews and meta-analyses. For guidelines, the AGREE 2013 instrument was used (“unacceptable” was considered a score < 4). If the two reviewers disagreed about a particular paper, a third reviewer was included to establish a majority.
Articles with new, relevant information were summarized and provided to the Delphi panel as background information in addition to the previous CCGPP guidelines. Delphi panelists who had served on prior consensus projects and represented a broad sampling of jurisdictions and practice experience related to LBP management were invited to participate. Thirty-seven panelists agreed to participate; 33 of whom were doctors of chiropractic (DCs). In addition, public comment was sought by posting the consensus statements on the CCGPP website. The RAND-UCLA methodology was used to reach formal consensus during this process. This methodology uses an ordinal scale of 1-9 (highly inappropriate to highly appropriate) to rate each seed statement. For scoring purposes, ratings of 1-3 were deemed “inappropriate,” 4-6 as “uncertain” and 7-9 as “appropriate”.
Study Strengths / Weaknesses
Overall, this guideline could have been a bit more concise. Further, they were unable (in most cases, due to a lack of pertinent research) to address a few important issues, including:
- Appropriate recommendations on limited rest;
- More specific guidelines on how clinicians should assess history findings that might require imaging; and
- Comparing the efficacy and appropriateness of various manipulative techniques.
The use of a Delphi panel was appropriate, described in detail and seemingly well-managed.
Dr. Thistle is a practicing chiropractor, educator, international speaker, knowledge-transfer leader, entrepreneur and medicolegal consultant. He is the founder and CEO of RRS Education, a continuing education company providing weekly research reviews, informative seminars and convenient online courses for chiropractors, physiotherapists and osteopaths around the world. He has lectured as a part-time faculty member at the Canadian Memorial Chiropractic College in the Orthopedics Department for 13 years. For questions, contact firstname.lastname@example.org or to learn more about RSS Education, visit www.rrseducation.com.
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