Evidence Based Treatment of Low Back Pain

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Let’s talk about some evidence. 

One of the most common things I hear when someone mentions chiropractic is it is some sort of voodoo magic. There is a common misnomer that there is no evidence behind spinal manipulation and there are better treatment options for low back pain. In this post I’ll talk a little about the chiropractic profession and the evidence behind the treatment options for low back pain.

When most people on this planet mention chiropractic, they instantly associate it with spinal manipulation (adjustments, misalignments, moving bones, something was out of place, etc…). It is important to acknowledge that chiropractic is a profession, not a verb. Chiropractic as a profession treats the musculoskeletal and nervous system using a variety of methods such as manual therapy, exercise, and nutrition. Do chiropractors use manipulation? You bet we do. However, manipulation is not a panacea and has its time and place like other modalities. 

Most of the time there is a muscular imbalance or a dysfunctional movement pattern that needs to be addressed as well (cue manual therapy and corrective exercises!). The way manual therapy and corrective exercises work is a topic for an another post. But for the time being, let’s keep it simple and say that manual therapy and corrective exercises strengthen weak muscles and decreases tension in tight muscles. 

There are three categories of low back pain: serious pathology, mechanical spinal problems, and spinal pain with nerve involvement. A serious pathology is something like cancer or fracture which requires a referral. Majority of low back pain cases do not fall into this category, but it is very important to rule out anything in this category first. Benign spinal problems or spinal pain with nerve involvement are what the majority of people with back pain fit into, which can include disc herniations, sciatica, stenosis, scoliosis, and a whole list of other conditions. 

The treatment of mechanical low back pain (benign spinal problems and spinal pain with nerve involvement) varies depending on the practitioner. A few of the most common treatments include: spinal manipulation, manual therapy, corrective exercise, NSAIDs, & ice/heat packs. So what does the evidence say about these treatments for low back pain?

Well, according to guidelines published in JOSPT, spinal manipulation, manual therapy, and corrective exercise were all recommended for acute, subacute, and chronic low back pain. The recommendation for these treatment modalities was based on strong evidence. The American College of Physicians and the American Pain Society also published guidelines that support the use of these treatments when self-care does not improve symptoms. 

The research has also identified two factors that can predict a successful outcome when treated with spinal manipulation. The two factors were duration of symptoms less than 16 days and not having symptoms below the knee. When the two factors were met, the decrease in disability remained significant at the 6-month follow-up. This means that early treatment of low back pain may prevent long term low back pain. If these factors were not met, a longer recovery time may be expected. 

Other common passive therapies such as ice, heat, traction, ultrasound, and interferential were not recommended by the European Guidelines for the treatment of low back pain. The Cochrane Reviews of ultrasound, heat, and ice also reported limited or no evidence for these therapies. Although some will experience short term relief, passive modalities typically do little to prevent the transition from acute to chronic pain and long-term disability. 

The emphasis in the treatment of low back pain is to transition from passive care to active care quickly to prevent the development of chronic pain and long-term disability. The use of spinal manipulation, manual therapy, and corrective exercises aid in reducing low back pain while also preventing long-term disability. The evidence also supports this approach of spinal manipulation, manual therapy, and corrective exercises for the treatment of low back pain.  

It is also important to realize that low back pain is multi-factorial, so some treatments will work for some while not for others. Therefore, it is important to have a thorough history and physical examination to determine the most appropriate course of action for any given low back pain case. 

In conclusion, the evidence supports the use of conservative options such as spinal manipulation, manual therapy, and corrective exercise. A trial of conservative care should be considered before the use of more invasive options like surgery or injections, which may not be appropriate for the initial treatment of mechanical low back pain. Make sure to always consult a doctor to determine the most appropriate course of action for you. 

References:

Chou, Roger. "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 147.7 (2007): 478-91.

Delitto, Anthony. "Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association." Journal of Orthopedic & Sports Physical Therapy. 42.2. (2012).

Liddle, S. "Exercise And Chronic Low Back Pain: What Works?" Pain. 176-90. (2003).