CHRONIC LOWER-BACK PAIN. For chiropractors it’s an area in which our services shine and that contributes to our strong rates of patient satisfaction. Chronic lower-back pain is one condition that can open doors for chiropractic physicians within the medical community, as it is lacking conservative care treatment options.
Guidelines have been established to manage nonspecific chronic back pain with a focus on medication as a first choice option.1,2 Some of these guidelines are based on traditional standards of care and reasonableness, concluding that they may have an impact on pain for the better, but often lack scientific evidence to support this claim. The recent Lancet study on the lack of efficacy of paracetamol, discussed below, provides a perfect example.
While chiropractic manipulation is commonly listed as a reasonable course of care and suggested in the Journal of the American Medical Association’s (JAMA) patient handout as a valid treatment option,3 it is still highly underutilized. Most MDs continue to focus on prescription medications as the starting point of pain management, with limited consideration of chiropractic referrals.
In an effort to help increase patient access to chiropractic services and improve understanding of where chiropractic can be utilized alongside of, or in place of medication, the following review provides some talking points for your next conversation with an MD.
Common Pharmaceutical Interventions PARACETAMOL: The most recently published data for paracetamol considered acute back pain, finding that paracetamol made no impact on pain, disability and several other outcomes compared with placebo.4 Thus, the authors have called into question the reasonableness of prescribing paracetamol for acute back pain. Findings are scarce for paracetamol use on its own to treat chronic pain.
NSAIDS: A 2008 Cochrane systematic review of nonsteroidal anti-inflammatory drugs (NSAIDs) for back pain indicated that NSAIDs performed only marginally better than paracetamol for controlling back pain but had significantly more side effects.5 In 2007, the American Heart Association published a scientific statement warning against chronic use of NSAIDs for pain in patients with, or at risk of, cardiovascular conditions.6 A 2010 Danish study supported these findings,7 and this warning has now encompassed over-the-counter versions as well. Thus, limiting the reliance on these medications is of clinical concern.
Studies that compared manipulation with NSAIDs or featured NSAIDs and manipulation as primary treatments often show a benefit in favor of manipulation without the risk of adverse symptoms. Manipulation instead of, or alongside, NSAIDs could help limit the need and reliance upon NSAIDs.
MUSCLE RELAXANTS: A 2007 systematic review of medications found muscle relaxants useful for acute lower-back pain in the short term.8 A 2003 Cochrane review concluded: “Muscle relaxants are effective in the management of nonspecific low-back pain, but the adverse effects require that they be used with caution.”9 There are multiple chiropractic therapies and strategies for managing the muscular aspects of back pain.
OPIOIDS: It’s postulated that restrictions in health care benefits, the FDA’s 2007 decision to deny marketing approval for the COX-2 inhibitor etoricoxib and reduced access for non-pharmacological treatments helped contribute to an alarming rise in opioid prescriptions. The growing documentation in lawsuits against the pharmaceutical companies marketing these medications argue the benefits have been overstated, while serious risks have been minimized, and that opioids are not approved for general pain management for common non-cancer chronic pain like back pain, arthritis and headaches.10,11 Specialists conclude that because much pain management takes place in MDs’ primary care offices where a significant rise in opioid prescriptions has been noted, more education is needed to properly advise these physicians on the safety and proper use of opioids.12
Simply stated, opioids are not conservative care. It would make sense to provide a short-term trial of manipulation prior to opioid prescriptions.
Conversing with MDs on safety and the side effects of medications will likely lead to a similar discussion on manipulation. The American Pain Society’s Clinical Guideline for the Evaluation and Management of Low Back Pain states that for manipulation, “including data from observational studies, the estimated risk for serious adverse events was lower than one per 1 million patient visits.”13
Finally, many surgical specialists remark that a majority of presenting patients are not surgical candidates nor have they had adequate courses of conservative care. It’s interesting to note that health plans such as the one for the University of Pittsburgh Medical School now mandate a course of manipulation for back pain prior to the authorization of surgical intervention.14
The causes of back pain are multifactorial, and there are opportunities to pursue other approaches as shown in a Cochrane review on low-back pain,15 but chiropractors are certainly a sensible starting point for conservative care. It will take proper collaboration and sound clinical advances among conservative care algorithms that must include spinal manipulation if we wish to see a positive change in the outcomes associated with nonspecific back pain.
1. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91. Erratum in: Ann Intern Med. 2008 Feb 5;148(3):247-8.
2. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010 Dec;19(12):2075-94. doi:10.1007/s00586- 010-1502-y. Epub 2010 Jul 3. Review.
3. Goodman DM, Burke AE, Livingston EH. Low Back Pain. JAMA. 2013;309(16):1738. doi:10.1001/jama.2013.3046.
4. Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, Lin CW. Efficacy of paracetamol for acute lowback pain: a double-blind, randomized controlled trial. Lancet. 2014 Jul 23. pii: S0140-6736(14)60805-9. doi:10.1016/ S0140-6736(14)60805-9. (Epub ahead of print).
5. Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine (Phila Pa 1976). 2008 Jul 15;33(16):1766-74. doi: 10.1097/ BRS.0b013e31817e69d3.
6. Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA; American Heart Association. Use of nonsteroidal anti-inflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007 Mar 27;115(12):1634-42. Epub 2007 Feb 26. Review.
7. Fosb.l EL, Folke F, Jacobsen S, Rasmussen JN, S.rensen R, Schramm TK, Andersen SS, Rasmussen S, Poulsen HE, K.ber L, Torp-Pedersen C, Gislason GH. Cause-specific cardiovascular risk associated with nonsteroidal anti-inflammatory drugs among healthy individuals. Circ Cardiovasc Qual Outcomes. 2010 Jul;3(4):395-405. doi: 10.1161/CIRCOUTCOMES. 109.861104. Epub 2010 Jun 8.
8. Chou R, Huffman LH; American Pain Society; American College of Physicians. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):505-14. Review. Erratum in: Ann Intern Med. 2008 Feb 5;148(3):247-8.
9. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM; Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the Cochrane collaboration. Spine (Phila Pa 1976). 2003 Sep 1;28(17):1978-92.
10. City of Chicago: City of Chicago Sues Big Pharma for Deceptively Marketing Highly Addictive Prescription Painkillers Drug Manufacturers; Knowingly Downplayed Serious Risks, Promoted Unfounded Benefits Associated With Highly Addictive Painkillers Mayor’s Press Office, Jun 3 2014.
11. Law 360.com Calif. Counties Claim Pharma Cos. Lied About Opioid Safety. May 22, 2014
12. American Academy of Pain Physicians. 2014 Annual Meeting Poster Presentation Impacting Opioids Prescribing Practices of Primary Care Providers Through Innovative Use of Tele-Health Technology.
13. Chou R, Huffman LH. Guideline for the Evaluation and Management of Back Pain. American Pain Society.
15. Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev. 2012 Sep 12;9:CD008880. doi: 10.1002/14651858. CD008880.pub2.
Dr. Acampora is the author of Marketing Chiropractic to Medical Practices and the founder of Aligned Methods, a company specializing in helping DCs establish informed working relationships with medical physicians.