By John-David Kato, DC, BSc, MSc, RCEP
This month (October 2007) there were some of articles published in the medical journal Annals of Internal Medicine1,2,3 that reviewed the scientific evidence on the diagnosis and treatment of low back pain (LBP), and presented a number of recommendations as guidelines for medical doctors and other clinicians to follow. In this article I wanted to highlight on some of the recommendations and comment based on my own experience and knowledge.
Are X-rays, MRI and CT scans necessary?
The article emphasized the importance of conducting a medial history and physical examination to identify any serious pathology. They emphasized that diagnostic imaging such as x-ray, MRI or computerized tomography (CT) scans were not necessary in the vast majority of LBP patients. Special studies such as x-rays add cost to the health care system, can often lead to further costly testing, unnecessary radiation and can have a slight negative impact on the outcome of care4. That being said there are circumstances when these studies are necessary and should be performed.
What does the research show is the best treatment?
After pathological causes for LBP are ruled out, the recommendations state a person seeking care for LBP should receive advice on self-care he/she can do on their own and should have a discussion about medications and non-drug therapy options. The recommendations concluded that the most effective non-drug intervention for acute (less than 4 weeks duration) LBP is spinal manipulation. Spinal manipulation is the therapy, which is done by hand, where a thrust is applied to the spine and is what chiropractors do best. Similarly, for subacute and chronic low back pain (pain of longer duration than 4 weeks), there is evidence for a number of therapies including spinal manipulation, exercise, massage and acupuncture.
Is acute low back pain self-limiting?
The guidelines state that LBP improves rapidly within a month. However there is conflicting evidence for this, which was not mentioned. For example authors of a similar scientific review article published last year wrote, “These clear contradictions led us to believe that the current view of acute LBP as benign and self-limiting should be reconsidered.”5 The guidelines published in the Annals of Internal Medicine synthesize the evidence into a clinical standard to help medical doctors and other clinicians make decisions on how to diagnose and care for those with LBP. They reinforce the recommendations that diagnostic imaging is not necessary in most cases. Evidence suggests that although many will improve within four weeks, many with LBP do not. And one could say that, based on these guidelines, the best non-medical therapy is spinal manipulation because it is the only therapy with evidence for being effective for acute, subacute and chronic LBP. Spinal manipulation is the main therapy used by chiropractors. They have the most education and training for it. Additionally all chiropractors are trained in the prescription of rehabilitative exercise, lifestyle advice and soft tissue therapies which will add to the effectiveness of manipulation to reduce pain and disability. In
- 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.
- Chou R, Huffman LH; American Pain Society; American College of Physicians. Nonpharmacologic therapies 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):492-504.
- 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.
- Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ 2001; 322:400-5.
- Refshauge KM, Maher CG. Low back pain investigations and prognosis: a review. Br J Sports Med. 2006 Jun;40(6):494-8.
