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Chiropractic Care For Low Back Pain – What Does the Research Say?

There has been a debate for years regarding the use of spinal manipulation and its benefits in the treatment of low back pain. Since the founding of chiropractic in 1895, the initial reaction against the early pioneer chiropractors resulted in doctors of chiropractic (DC’s) being incarcerated for “…practicing medicine without a license.” But chiropractors kept forging ahead and because of obtaining good results and helping millions of people, by 1971, Medicare adopted coverage for chiropractic – a first in chiropractic’s history. In 1975, the US Department of Health, Education, and Welfare invited an international group of health care provider types (MD’s, DC’s, DO’s, etc.), to share with each other at the National Institute of Health, and determine what the “current” research status of spinal manipulative therapy was at that time. Recommendations for future needed research resulted and the proceedings were published in: The DHEW Publication No. (NIH) 76-998 “The Research Status of Spinal Manipulative Therapy.” That landmark gathering stimulated a plethora of research that was to follow over the course of the next 30+ years and continues today. Due to the overwhelming positive benefits of chiropractic published in many research studies, by the late 1980’s, most insurance companies included coverage for chiropractic care. Today, many chiropractors practice in multidiscipline health care centers that include DC’s, MD’s, and PT’s others. The following list of research studies has had a significant impact in vaulting chiropractic to its current accepted status in the health care system (the URL is included for further study):

  1. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. British Medical Journal 1990 (Jun 2); 300 (6737):1431-1437. http://www.chiro.org/LINKS/ABSTRACTS/LBP_of_Mechanical_Origin.shtml
  2. Manga P, Angus DE, Papadopoulos C, Swan WR. A Study to Examine the Effectiveness and Cost-effectiveness of Chiropractic Management of Low-Back Pain. 8/1993; Ontario, Canada.http://www.chiro.org/LINKS/GUIDELINES/Manga_93.shtml
  3. Bigos S, et. al., 1994, Agency for Health Care Policy and Research (AHCPR).http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.25870
  4. Meade TW, Dyer S, Browne W, Frank AO. Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow up. British Medical Journal 1995 (Aug 5); 311 (7001): 349–351http://www.chiro.org/LINKS/ABSTRACTS/Chiropractic_and_Hospital_Outpatient.shtml
  5. Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Estimates and Patterns of Direct Health Care Expenditures Among Individuals With Back Pain in the United States. Spine 2004 (Jan 1); 29 (1): 79–86. http://www.ncbi.nlm.nih.gov/pubmed/14699281

Does Chiropractic Work? – What Do Insurance Companies Say?

If chiropractic care helps patients get better faster and costs the patient and/or insurance company less, shouldn’t EVERY low back pain patient FIRST see a chiropractor before any other type of doctor? That is in fact, what should be done, based on a recent report!

On October 20, 2009, a report was delivered on the impact on population, health and total health care spending. It was found the addition of chiropractic care for the treatment of neck and low back pain “…will likely increase value-for-dollar in US employer-sponsored health benefit plans.” Authored by an MD and an MD/PhD, and commissioned by the Foundation for Chiropractic Progress, the findings are clear; chiropractic care achieves higher satisfaction and superior outcomes for both neck and low back pain in a manner more cost effective than other commonly utilized approaches.

The study reviews the fact that low back and neck pain are extremely common conditions consuming large amounts of health care dollars. In 2002, 26% of surveyed US adults reported having back pain in the prior 3 months, 14% had neck pain and the lifetime prevalence of back pain was estimated at 85%. LBP accounts for 2% of all physician office visits where only routine examinations, hypertension, and diabetes result in more. Annual national spending is estimated at $85 billion in the US with an inflation-adjusted increase of 65% compared to 1997. Treatment options are diverse ranging from rest to surgery, including many various types of medications. Chiropractic care, including spinal manipulation and mobilization, is reportedly also widely utilized with almost half of all patients with persisting back pain seeking chiropractic treatment.

In review of the scientific literature, it is noted that 1) chiropractic care is at least as effective as other widely used therapies for low back pain; 2) Chiropractic care, when combined with other modalities such as exercise, appears to be more effective than other treatments for patients with neck pain. Other studies reviewed reported patients who had chiropractic coverage included in their insurance benefits found lower costs, reduced imaging studies, less hospitalizations, and surgical procedures compared to those with no chiropractic coverage. They then utilized a method to compare medical physician care, chiropractic physician care, physiotherapy-led exercise and, manipulation plus physiotherapy-led exercise for low back pain care. They found adding chiropractic physician care is associated with better outcomes at “…equivalent to an incremental cost-effectiveness ratio of $1837 per QALY (Quality-adjusted Life Year).”

When combined with exercise, chiropractic physician care was also found to be very cost- effective when compared to exercise alone. This combined approach would achieve improved health outcomes at a cost of $152 per patient, equivalent to an “incremental cost-effectiveness ratio of $4591 per QALY.” When comparing the cost effectiveness of chiropractic care with or without exercise even at 5 times the cost of the care they utilized in their analysis, it was still found to be “substantially more cost-effective” compared to the other approaches. It will be interesting given these findings if insurance companies and future treatment guidelines start to MANDATE the use of chiropractic FIRST – it would be in everyone’s best interest!

Low Back Pain and Balance Exercises

You may recall last month, we talked about the relationship between low back pain and balance, particularly our unfortunate increased tendency to fall as we “mature.” This month, we’re going to look at ways to improve our balance by learning specific exercises that utilize the parts of our nervous system that regulate balance or, proprioception. Particularly, our cerebellum (back of the brain that regulates coordination), the vestibular system (the inner ear where the semi-circular canals are located), the ascending tracts in our spinal cord (the “highways” that bring information to the brain from our feet and the rest of our body), and the small “mechano-receptors” located in our joints that pick up our movements as we walk and run and sends that information through our nerves, up the spinal cord tracts to the brain. Here are some very practical exercises to do, “…for the rest of our lives.” Start with the easy ones!

  1. Easy (Level 1): Standing eyes open/closed – Start with the feet shoulder width apart, look straight ahead to get your balance and then close the eyes and try not to sway counting to 30 by, “…one thousand one, one thousand two, one thousand three, etc.” Repeat this with your feet closer together until they touch each other. You can make this harder by standing on a pillow or cushion — but don’t start that way!
  2. Medium (Level 2): Lunges – from a similar starting position as #1, step forwards with one leg and squat slightly before returning back to the start position. Repeat this 5x with each foot/leg. As you progress, you can take a longer stride and/or squat down further with each repetition. You can even hold onto light dumbbells and/or close your eyes to make it more challenging.
  3. Hard (Level 3): Rocker or wobble board exercises – use a platform that rocks back & forth or, wobbles in multiple directions. Rock back and forth, eyes open and then closed, once you get comfortable on the board. You can rotate your body on the board, standing straight ahead (12 o’clock) followed by 45 degree angles as you work your way around in a circle at 45 degree increments (12, 1:30, 3, 4:30, 6, 7:30, 9, 10:30 and back to noon). Repeat these eyes open and closed. The Wii Balance board is a fun way to exercise – check that out as well.

You can “improvise” and mix up different exercises and create your own routine. Just remember, stay safe, work slowly until you build up your confidence and keep challenging yourself.

Low Back Pain: Where Is My Pain Coming From?

Low back pain can emanate from many anatomical locations (as well as a combination of locations), which always makes it interesting when a patient asks, “…doc, where in my back is my pain coming from?” In context of an office visit, we take an accurate history and perform our physical exam to try to reproduce symptoms to give us clues as to what tissue(s) may be the primary pain generators. In spite of our strong intent to be accurate, did you know, regardless of the doctor type, there is only about a 45% accuracy rate when making a low back pain diagnosis? This is partially because there are many tissues that can be damaged or injured that are innervated by the same nerve fibers and hence, clinically they look very similar to each other. In order to improve this rather sad statistic, in 1995 the Quebec Task Force published research reporting that accuracy could be improved to over 90% if we utilize a classification approach where low back conditions are divided into 1 of 3 broad categories:

  1. Red flags – These include dangerous conditions such as cancer, infection, fracture, cauda equina syndrome (which is a severe neurological condition where bowel and bladder function is impaired). These conditions generally require emergency care due to the life threatening and/or surgical potential.
  2. Mechanical back pain – These diagnoses include facet syndromes, ligament and joint capsule sprains, muscle strains, degenerative joint disease (also called osteoarthritis), and spondylolisthesis.
  3. Nerve Root compression – These conditions include pinching of the nerve roots, most frequently from herniated disks. This category can include spinal stenosis (SS) or, combinations of both, but if severe enough where the spinal cord is compromised (more commonly in the neck), SS might then be placed in the 1st of the 3 categories described above.

The most common category is mechanical back pain of which “facet syndrome” is the most common condition. This is the classic patient who over did it (“The Weekend Warrior”) and can hardly get out of bed the next day. These conditions can include tearing or stretching of the capsule surrounding the facet joint due to performing too many bending, lifting, or twisting related activities. The back pain is usually localized to the area of injury but can radiate down into the buttocks or back of the thigh and can be mild to very severe.

Low Back Pain: Why Is It So Common?

This question has plagued all of us, including researchers for a long time! Could it be because we’re all inherently lazy and don’t exercise enough? Or maybe it’s because we have a job that’s too demanding on our back? To properly address this question, here are some interesting facts:

  1. The prevalence of low back pain (LBP) is common, as 70-85% of ALL PEOPLE have back pain that requires treatment of some sort at some time in life.
  2. On a yearly basis, the annual prevalence of back pain averages 30% and once you have back pain, the likelihood of recurrence is high.
  3. Back pain is the most common cause of activity limitation in people less than 45 years of age.
  4. Back pain is the 2nd most frequent reason for physician visits, the 5th ranking reason for hospital admissions, and is the 3rd most common cause for surgical procedures.
  5. About 2% of the US workforce receives compensation for back injuries annually.
  6. Similar statistics exist for other countries, including the UK and Sweden.

So, what are the common links as to why back pain is so common? One reason has to do with the biomechanics of the biped – that is, the two legged animal. When compared to the 4- legged species, the vertically loaded spine carries more weight in the low back, shows disk and joint deterioration and/or arthritis much sooner, and we overload the back more frequently because, well, we can! We have 2 free arms to lift and carry items that often weigh way too much for our back to be able to safely handle. We also lift and carry using poor technique. Another reason is anatomical as the blood supply to our disks is poor at best, and becomes virtually non-existent after age 30. That makes healing of disk tears or cracks nearly impossible. Risk factors for increased back injury include heavy manual lifting requirements, poor or low control of the work environment, and prior incidence of low back pain.

Other risk factors include psychosocial issues such as fear of injury, beliefs that pain means one should not work, beliefs that treatment or time will not help resolve a back episode, the inability to control the condition, high anxiety and/or depression levels, and more. Because there are so many reasons back problems exist, since the early 1990’s, it has been strongly encouraged that we as health care providers utilize a “biopsychosocial model” of managing those suffering with low back pain, which requires not only treatment but proper patient education putting to rest unnecessary fears about back pain.