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Month: April 2018

CF 019: Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

Non-Opioid More Effective While Chiropractic Maintenance May Be The Most Effective

This Chiropractic Forward podcast this week is a bit of a mishmash of a couple studies that will ultimately intertwine into a valid discussion including chiropractic maintenance and a discussion about non-opioid vs. opioids.

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

Before we get started, I want to draw your attention our website at chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

You have moonwalked into episode #19. I hope you have enjoyed the previous episodes. Particularly the last six which were a part of a series all debunking the “Chiropractors Cause Strokes” myth and then another series of podcasts reviewing the lancet articles on low back pain. The Chiropractic profession NEEDS you to share those 6 episodes in particular

Now, since we have covered the impact of the opioid crisis exhaustively, I will cover it only briefly for reference purposes.

  • Low back pain is the single leading cause of disability worldwide.
  • 8 out of every ten people will experience back pain. I will admit that I have never met anyone in 45 years of life on this Earth that fits into the 20% that apparently never suffers from any low back pain.
  • Back pain is the second most common reason for visits to the doctor’s office right behind upper-respiratory infections.
  • With such gains and leaps in the medical industry as far as treatment goes, low back pain is stubbornly on the rise.
  • More than half of Americans who experience low back pain spend the majority of the work day sitting. 54% to be exact. Did you know that an equal number of patients first seek help with a chiropractor as seek help with a medical practitioner for back pain?
  • Back pain in general costs $100 billion dollars every year when you factor in lost wages and productivity, as well as legal and insurance overheads.

Should there be any doubting the necessity of non-pharmacologic treatments for low back pain at this point, then a person is simply beyond help. We can only refer you to a report from the Executive Office of the President of the United States’ report titled “The Underestimated Cost of the Opioid Crisis” put forth by the Council of Economic Advisers in November of 2017[1].

That reminds me, that paper citation as well as any others we talk about here will be in the show notes so always check out www.chiropracticforward.comfor those show notes.

The report paints a fairly complete picture of this national crisis. The medical field helped create the national crisis. Now, will they help put the fire out? It seems the answer to that question is, “Yes!”

Now that the nation and the medical field understand the danger of opioids, we are certainly starting to see an increase in research having to do with opioids. A brand new paper of particular note was published March 6, 2018 in JAMA, performed by Dr. Erin Krebs, MD, et. al. and is titled “Effect of Opioid vs. Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. The SPACE Randomized Clinical Trial [2].”

Why They Did It

How They Did It

  • 240 subjects
  • 12-month trial
  • Randomized with masked outcome assessments
  • Test subjects experienced moderate to severe chronic back, hip, or knee osteoarthritis pain despite analgesic use.
  • Interventions tested were opioids and nonopioids
  • The first step of the opioid group included immediate-release morphine, oxycodone, or hydrocodone/acetaminophen
  • The nonopioid group’s first step was acetaminophen or a nonsteroidal anti-inflammatory drug.
  • Medication was changed and/or adjusted within each group according to patient response.
  • The main outcome assessment used was Brief Pain Inventory (BPI) scale.

What They Found

  • 240 subjects completed the trial
  • There was little difference between the two groups in terms of function over the course of the 12 months of testing.
  • Pain intensity was actually much more improved (statistically significant) in the NONopioid group.
  • Adverse harms (bad side-effects) were significantly greater in the opioid group.

Wrap It Up

Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

Again, I don’t wish to belabor a point we have covered several times but, for the purpose of this discussion, we must mention them. The medical field is stepping up to the challenge slowly but, I would argue significantly. The American College of Physiciansupdated their treatment recommendations for chronic and acute low back pain just last year. In the report[3]they recommended spinal manipulation prior to taking ibuprofen or other over-the-counter NSAIDs for low back pain. One month later, in JAMA (the journal for the American Medical Association) there was a paper demonstrating the effectiveness of spinal manipulative therapy[4]. IN JAMA!! The significance of this cannot be overstated.

Next, let us talk a little bit about chiropractic treatment for low back pain, what it looks like, and whether chiropractic maintenance care really makes any sense. that recommend preventative (AKA Wellness Care) to their patient bases.

Let me start by stating my opinion and the opinion of most evidence-based chiropractors I would assume: active, complaint-focused treatment should have a start and it should have an end. Plain and simple, cut and dry. How does chiropractic maintenance fit in there?

If a patient is coming in for a complaint such as neck pain, the practitioner should decide whether the pain is acute, subacute, or chronic and, based on history and exam findings, be able to give some good, responsible recommendations for the treatment of the complaint. Typically, the acute schedule will be shorter in terms of treatments and time vs. a chronic condition. A chronic condition is more difficult to treat and one would reasonably expect the schedule for a chronic condition to be longer and more intense. The CCGPP guides[5]can be useful for this sort of decision-making.

For example, Medicare has broken down how they value diagnosis codes into groups A-D. In their system, the secondary diagnosis codes can be the difference between seeing a patient only 12 times or as much as 30 visits for a specific complaint. A simple low back pain diagnosis or muscle spasm diagnosis garners 12 visits from Medicare while degeneration of lumbar intervertebral disk or lumbar spinal stenosis will indicate up to 30 visits for treatment.

In the personal injury world, according to the Quebec Taskforce on Whiplash Associated Disorders, if a patient is assessed with a Grade III whiplash, assuming complications, they can be treated up to 76 visits over 56 weeks. That’s a lot of treatment but the length of treatment reflects the severity of injury as a Grade III whiplash is associated with ligament tearing and/or neurological findings.

For more information on general guides for practice protocol, please reference a previous blog of ours on the topic at https://www.amarillochiropractor.com/valuable-reliable-expert-advice-clinical-guides-practice/or listen to our podcast at https://www.chiropracticforward.com. The guides can be found in Episode #5 which can be found at this link: https://www.chiropracticforward.com/2018/01/18/cf-episode-5-valuable-reliable-expert-advice-on-clinical-guides-for-your-practice/

What does all of that have to do with chiropractic maintenance care? The point being made is that there are a lot of different chiropractors. Seventy thousand plus in America alone and, although there are guidelines out there, chiropractors do not typically seem to have a general overall desire to implement them. One chiropractor may tell you that they will need to see a chronic neck pain patient 50 visits a year to clear it up while another may see the same condition for 18-20 visits. This is not only frustrating for chiropractors, it’s highly frustrating for patients as well.

Of course, this is not true but, don’t chiropractors commonly recommend preventative or chiropractic maintenance care that may resemble “rest of your life” care? It’s my opinion that once a complaint resolves, patients should see their chiropractor once a month. Minimally, they should be seen once every two months. That is chiropractic maintenance and that is my opinion. I will find more than a handful of chiropractors that will disagree with me on both ends of the spectrum but the key to the idea is “chiropractic maintenance” care in some sort of ongoing fashion.

There is research for chiropractic maintenance care. Take this paper from 2011 for example. It is by MK Senna, it’s titled “Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?” and was published in the prestigious Spine journal[6]. For the purpose of this study, keep in mind that SMT stands for spinal manipulation therapy. Also of special note is that chiropractors perform over 90% of SMTs in America so I commonly interchange SMT or spinal manipulation therapy with the term “Chiropractic Adjustment.”

Why They Did It

The authors of this paper wanted to check how effective spinal manipulation, also known as chiropractic adjustments, would be for chronic nonspecific low back pain and if chiropractic maintenance adjustments were effective over the long-term in regards to pain levels and disability levels after the initial phase of treatment ended.

How They Did It

  • 60 patients having chronic low back pain of at least six months duration
  • Randomized into three different groups:
  • 12 treatments of fake treatment for one month
  • 12 treatments of chiropractic adjustments for a month only
  • 12 treatments for a month with maintenance adjustments added every 2 weeks for the following 9 months.
  • Outcome assessments measured for pain and disability, generic health status, and back-specific patient satisfaction at the beginning of treatment,

What They Found

  • Patients in groups 2 and 3 had significant reduction in pain and disability scores.
  • ONLY group 3, the group that had chiropractic maintenance adjustments added, had more reduction in pain and disability scores at the ten-month time interval.
  • The groups not having maintenance adjustments, pain and disability scores returned close to the levels experienced prior to treatment.

Wrap It Up

The authors conclusion is quoted as saying, “SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.”

For my own wrap up this week I would say simply this:

  • Low back pain is a significant issue for Americans
  • It is one of the biggest reasons people get hooked on opioids
  • As shown above, opioids are no more effective than non-opioids so why would anyone use them?
  • Chiropractic has been shown superior to nonopioids (specifically Diclofenac[7])
  • The big boys of the medical field (ACP and AMA) and the White House itself are recommending chiropractic for the treatment of low back pain before using even NSAIDs

So, why is this even in the discussion phase rather than the implementation phase? Why are we not inundated with low back pain patients at this very minute?

We have to go back to a different White House report that came out recently discussing the fact on page 57 of the report that although chiropractic has been proven effective, barriers to chiropractic treatment have been put in place by CMS and health insurance providers[8].

The specific wording is as follows: “A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, chiropractic, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies, as well as health insurance providers and other payers, create barriers to the adoption of these strategies.” “The Commission recommends CMS review and modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain.”

It’s all there. It’s simple. All we can do is continue to tell everyone and beg for your help in telling everyone as well.

It is up to us to spread the good news and all it takes is hitting the Share button on social media. Retweet, help get the word out.

I challenge you to tell your people. It’s so easy but it takes a little initiative on your part. You actually have to do something now. Your profession is poised on the edge of stepping into a role it is uniquely able to fulfill and excel in but NOT unless we reach out and take that role and hold onto it.

Our effectiveness is proven. It’s time. Help us help you. I’m not asking for donations. I don’t want your money. I want your influence. So do us a favor if you will and share this information and, if it didn’t get the response you hoped for, share it again. Print out the parts of this article you find particularly effective and send it to medical practices in your area.

Make a difference.

Did you know that research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic? Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “chiropractic maintenance” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health! And patients have the right to the best treatment that does the least harm. THAT’S Chiropractic folks.

Please feel free to send us an email at dr dot williams at chiropracticforward.com and let us know what you think or what suggestions you may have for us for future episodes.

If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website with more content, products, and chances to learn.

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

Source Material

  1. The Council of Economic Advisers, The Underestimated Cost of the Opioid Crisis. 2017: The Executive Office of the President of the United States of America.
  2. Krebs E, Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain – The SPACE Randomized Clinical Trial.JAMA, 2018. 319(9): p. 872-882.
  1. Qaseem A, Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.Ann Intern Med, 2017. 4(166): p. 514-530.
  2. Page N, Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain.Journal of American Medical Association (JAMA), 2107. 317(14): p. 1451-1460.
  3. Baker G, Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain.Topics in Integrative Health Care, 2012. 3(4).
  4. Senna MK, Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?Spine (Phila Pa 1976), 2011. Aug 15; 36(18): p. 1427-37.
  5. Wolfgang J, e.a., Spinal HVLA-Manipulation in Acute Nonspecific LBP: A Double Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo.Spine, 2012. 38(7).
  6. The President’s Commission on Combating Drug Addiction and The Opioid Crisis. 2017.

 

CF 018: Pt. 3 – Review of The Lancet Article: Low back pain a call to action

Review of The Lancet Article: Low back pain a call to action (Part Three)

On the Chiropractic Forward podcast this week, we are going continue a review of a recent paper published on low back pain that we hope will have a powerful impact in the months and years to follow. This week it will be a review of paper #3 from the Lancet series – low back pain a call to action.

Before we get started, I want to draw your attention our website at chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

Welcome to the podcast today, you have strolled right into episode 17. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go. And this week it’s low back pain a call to action.

As I mentioned at the top of the show, this week, I want to continue with the series published in The Lancet on March 21, 2018. For a quick re-cap this week…. The Lancet is one of the oldest and most respected medical journals in the world. It has been around since 1823. In addition to the credibility of the journal, this series of papers dealing with Low Back Pain was compiled and authored by the leading experts on the matter globally. On top of that, the experts were a group of interdisciplinary practitioners which meant they ranged from medical doctors and PhD’s, to physical therapists and chiropractors.

Essentially, EVERYONE had a seat at the table so, it is the general consensus at this point that this series of papers is as current, as credible, and as accurate as can be had at this point in time and in our understanding of Low Back Pain.

The three papers were broken down as follows:

  1. What low back pain is and why we need to pay attention.
  2. Prevention and treatment of low back pain: evidence, challenges, and promising directions.
  3. Low back pain a call to action.

Last week, we reviewed the first of the three papers which was titled, “What low back pain is and why we need to pay attention.” We went through it note by note and section by section trying to strip away the embellishments to simply boil it down to a leisure read and, hopefully, an enjoyable learning process.

We will do the same this week with the third paper of the series titled, “Low back pain a call to action.”

I want to start this week in the same way we started last week: by discussing how the papers were accomplished.

How They Did It

For this paper, again titled “What low back pain is and why we need to pay attention,” the researchers identified scientific studies through searches of databases:

•MEDLINE (PubMed)

•Scopus

•Google Scholar

•African Index Medicus Database

In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

This week, we’re going to review the last of the three papers from a recent series published in The Lancet on March 21, 2018. If you don’t know the impact or why this series is so important, please review the last two episodes of the Chiropractic Forward Podcast at www.chiropracticforward.com or the last two articles of my blog over at amarillochiropractor.com/blog. That will get you up to speed. In short, the series on low back pain was compiled and authored by an international panel of experts on the matter. Essentially, the best of the best.

This last of the three papers is titled “Low Back Pain A Call To Action.”

Summary

We have already covered several times that low back pain is now the leading cause of disability globally and is only growing in significance because the global population is living longer. The issue may be more profound in low to middle-income countries. In addition, most low back pain doesn’t even appear to be directly related to any specific trigger or origin.

In many cases, patients are being restricted from attempting resolution of the back pain via conservative approaches such as self-management support, specialized interventions like spinal manipulations (I added that part) and multidisciplinary rehab.

The panel suggests the following:

  1. Address the political aspect. They recommend calling on the World Health Organization to make low back pain one of its priorities by putting it on the target list in an effort to increase attention and decrease treatment that is not recommended initially. They recommend calling on political, medical, and social leaders to make sure public health initiatives are properly funded and geared toward the prevention of low back pain and treatment.
  2. Public health challenge.
    • Change priorities – Make low back pain a priority. Create and implement ways to prevent it and combine these strategies with other strategies that are chronic and somewhat related. Strategies such as weighing the right amount, being active physically, and maintaining good mental health as well. These tactics treat more than simply low back pain. The panel also recommends strategies that can modify the factors putting the population at risk of developing low back pain.
    • Change systems and change practice – Provide early recommendations for maintaining work load as much as possible and/or return to work as quickly as possible. Attempt to ensure early ID of people that are at risk of developing long-term, chronic disability as a result of low back pain. Address co-morbidities raising a person’s risk of developing low back pain and promote a healthier lifestyle in addition to altering disability benefits and get people back to work as soon as possible. And lastly, address low back pain through multidisciplinary rehabilitation in an effort to return the patient to work quickly.
  3. Healthcare challenge –
  • Change culture – The panel appears to me to be promoting the use of a Public Relations campaign to focus and promote living well with low back pain, self-management, staying healthy, and to change the public perception of low back pain.
  • Change clinician behavior – After developing the best evidence-based systems, there will be a need to get everyone on the same team in regards to the way clinicians refer and treat, the patients, as well as the professional journals.
  • Change systems – There is a need to develop and implement systems allowing a patient to receive the right care at the right time. Clinical pathways will need a re-boot and will need to become consistent across interdisciplinary lines and differing clinical settings.
  • Tackle Vested Interests – The panel discusses the fact that governments and insurance companies need to regulate in a manner consistent with evidence-based treatment for low back pain and eliminate conflicts of interest. Regulation through contracts, and payment schedules for treatments with little to no evidence for effectiveness.

The idea that a healthy weight and regular physical activity will help reduce low back pain must enter the global subconscious through public programs, especially in low to middle-income countries.

An assertion I fully agree with the authors on is that, thus far, healthcare dollars have been wasted on treatments that are ineffective and, many times, downright dangerous. The risk vs. reward ration just doesn’t make sense more times than not currently. No too mention the issue of opioid addiction which we all should know the stats on by now.

Boiling it down, the panel aims to get rid of practices that harm and create waste while, at the same time, opening the door to effective and affordable means of treating low back pain to patients in need. The authors are quoted here as saying,”Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo.”

The authors promote the idea of implementing a positive health concept as the umbrella idea aiming for prevention of long-term disability. This includes alternative to treatments and cures and promotes more meaningful lives. This truly is a low back pain a call to action recommendation.

Another great quote from this third paper is as follows, “Improved training and support of primary care doctors and other professionals engaged in activity and lifestyle facilitation, such as physiotherapists, chiropractors, nurses, and community workers, could minimize the use of unnecessary medical care.”

The panel also calls for an active monitoring system in order to assess and keep an eye on the recommendations implementation as well as the outcomes of the changes.

To read more for yourself, follow this link to the third paper:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

If access is unavailable, just simply register at The Lancet. It is completely free of charge.

If you are research minded, if you are a low back pain patient, or if you are a practitioner regularly coming in contact with low back pain patients, it is my opinion that taking the time to read these three papers yourself is of utmost importance.

Please find the links to the papers in the “References” section and get it done. Together, we can make a big, big difference in the lives of our low back pain patients. Without a doubt.

For this week’s next step, go register with The Lancet and get this paper for free! You just have to register. That’s it.

We hope you enjoyed this week’s paper called “Low back pain a call to action.” We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!

If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website with more content, products, and chances to learn.

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.

 

Other episodes you may enjoy:

CF 003: Great News: Chiropractic Outpaces Muscle Relaxants

CF 008: With Dr. Craig Benton – Brand New Information Based on Results Chiropractic Proven Effective For Low Back Pain

CF 011: With Dr. Tyce Hergert: It’s Here. New Guides For Low Back Pain That Medical Doctors Are Ignoring

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

CF 017: Pt. 2 – Review of The Lancet Article on Treatment of Low Back Pain

 

 

References:

Paper 1 – “What low back pain is and why we need to pay attention: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

Paper 2 “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext

Paper 3 – “Low back pain: a call for action”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

CF 017: Pt. 2 – Review of The Lancet Article on Treatment of Low Back Pain

Review of The Lancet Article: Prevention and treatment of low back pain: evidence, challenges, and promising directions (Part Two)

On the Chiropractic Forward podcast this week, we are going continue a review of a recent paper published on low back pain that we hope will have a powerful impact in the months and years to follow. This week it will be a review of paper #2 from the Lancet series called Prevention and treatment of low back pain: evidence, challenges, and promising directions. 

Before we get started, I want to draw your attention our website at http://www.chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand  new pops up, we’ll be able to tell you about it quickly and easily.

Welcome to the podcast today, you have strolled right into episode 17. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go.

As I mentioned at the top of the show, this week, I want to continue with the series published in The Lancet on March 21, 2018. For a quick re-cap this week…. The Lancet is one of the oldest and most respected medical journals in the world. It has been around since 1823. In addition to the credibility of the journal, this series of papers dealing with Low Back Pain, prevention of low back pain, and treatment of low back pain was compiled and authored by the leading experts on the matter globally. On top of that, the experts were a group of interdisciplinary practitioners which meant they ranged from medical doctors and PhD’s, to physical therapists and chiropractors. 

The three papers were broken down as follows:

  1. What low back pain is and why we need to pay attention.
  2. Prevention and treatment of low back pain: evidence, challenges, and promising directions.
  3. Low back pain: a call for action.

Last week, we reviewed the first of the three papers which was titled, “What low back pain is and why we need to pay attention.” We went through it note by note and section by section trying to strip away the embellishments to simply boil it down to a leisure read and, hopefully, an enjoyable learning process. 

We will do the same this week with the second paper of the series titled, “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”

I want to start this week in the same way we started last week: by discussing how the papers were accomplished. 

How They Did It

For this paper, again titled “Prevention and treatment of low back pain,” the researchers identified scientific studies through searches of databases:

•MEDLINE (PubMed)

•Scopus

•Google Scholar

•African Index Medicus Database

In order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Paper 2 Summary:

Recommendations commonly offered for those with low back pain include:

  • Pharmacologic implementation is not typically a first line choice
  • Education supporting self-management
  • Resumption of regular daily activities
  • Resumption of exercise
  • Psychological programs for those with low back pain that tends to linger
  • Limited or non-use of medication
  • Limited or non-use of imaging
  • Limited or non-use of surgery

The authors state that these recommendations for prevention and treatment of low back pain are derived from high-income countries and that they are concentrated on treatment rather than preventative recommendations. 

The authors state there is an inappropriate high usage of the following treatments for low back pain:

  • Spinal injections
  • Imaging
  • Opioids
  • Surgery
  • Rest

In the rest of the paper, the authors identify some promising directions and solutions for treatment of low back pain including the redesign of clinical pathways, an integrated health partnership, and occupational interventions to get workers back when possible.

Prevention

  • A 2016 systematic review with 30,850 adults showed that there was moderate quality evidence that exercise alone, or in combination with education, is effective for prevention of low back pain. 
  • However, the review was mainly for secondary prevention and the exercise program required an intense schedule of twenty 1-hour supervised sessions.
  • A 2014 systematic review with 2700 children that found moderate quality evidence that education is not effective. They also found that ergonomic furniture was likely no more help in preventing low back pain than regular furniture. 

Treatment

The authors cite three studies. The studies come from Denmark, the UK, and the USA. 

  • All three of the studies (Danish, UK and USA) recommend spinal manipulation as an effective treatment of low back pain. The UK study specifically recommends spinal manipulation in conjunction with an exercise protocol. 
  • As my own side note, in America, chiropractors perform 90% of all spinal manipulations. When we are discussing spinal manipulation and it’s role in treating low back pain, it is important to keep in mind which profession is the one being recommended. Although the authors do not come out and recommend chiropractic specifically, when spinal manipulations are recommended, it is a well-known fact that chiropractors are the doctors that are best-equipped to perform the treatment. 
  • Also in the US guidelines, there is a recommendations for the marked reduction of pharmacologic care. 
  • Some key advice coming from these updated recommendations (besides the use of spinal manipulation) is to assure patients they are not suffering from serious disease, that they will indeed improve in time, that they should continue as much movement and exercise as can be tolerated, they should avoid bed rest, and they should get back to work as soon as possible. 
  • The authors recommend physical treatments. Certainly for chronic low back pain which refers to pain lasting longer than 12 weeks. Physical treatments included exercise programs targeting the patients’ abilities, preferences, etc. 
  • The authors stated that passive therapies such as electric stim, interferential, traction, diathermy, and back supports seem to be ineffective. As a side note, it’s strictly anecdotal but this panel of experts are going to have a hard time convincing me traction, when done correctly, is not effective. I’ve seen patients avoid surgery from traction therapy alone.
  • They say new recommendations encourage doctors consider psychological therapies such as cognitive behavior therapies, progressive relaxation therapy, and mindfulness-based stress reduction alone or in combination with other physical and psychological treatment for chronic low back pain with or without radiculopathy having not responded to other treatments. 
  • If the condition persists and the patient is functionally disabled, the authors then recommend multidisciplinary rehab with supervised exercise, cognitive behavior, and medication. 
  • Of course, routine use of opioids is not advised.
  • Recommend no spinal epidural injections or facet joint injections for low back pain
  • Do recommend epidural injections of local anesthetic & steroid for radicular pain, however, as we have discussed before, epidural steroid injections show short-term effectiveness only if they are effective at all and have no influence at all on long-term disability or future need for surgery. In my own research, epidural steroid injections have shown to increase risk of spinal fracture up to 21% after each subsequent injection. 
  • Surgery – the benefits for spinal fusion when the back pain was thought to be due to degenerated discs were about equal to the results gained with intensive multidisciplinary rehab and only a modest improvement over non-surgical treatment. In addition, surgery has obvious downsides like expense, recovery, medication, and the risk of adverse events. However, surgery may be indicated when the patient is suffering severe or progressive neurological symptoms and surgery may be indicated when patients suffer radicular pain, have failed first line treatment, and the symptoms can be traced to via imaging to a disc or stenosis origin. 
  • Ultimately, the authors say, low back pain patients have a tendency to resolve with out without surgical intervention so waiting and trying to avoid surgery is certainly appropriate. 
  • Research dealing with low back pain in children or in low and middle income countries is limited so a lot is unknown for those categories, however, the two studies that actually have been done in low and middle income countries (Brazil and Philippines) have similar results as those in high income countries. 

The global gap between evidence and practice

This section masterfully demonstrates the difference between evidence-based medicine and what is really happening in the real world.

  • They start by stating that low back pain should be managed by primary care practitioners and then go on to list studies showing how it is being managed, in many cases, by emergency rooms, hospitals, and surgeons. 
  • Their next directive is to provide low back pain patients with education and advice on self management and then show how, in the real world, roughly only 20%-23% of practitioners seem to actually do so. 
  • The next directive is for low back pain patients to stay active and get to work or stay at work if possible. They go on to cite research showing how, in the real world, medical professionals are recommending rest and time off work. In India, for example, 46% of physiotherapists recommended rest to low back pain patients and in Brazil, rheumatologist recommended rest. 
  • The next comparison was for the guideline that imaging should only be ordered if the practitioner suspects a specific cause that would guide treatment and case management differing from normal care recommendations. In the USA, for example, from 2010-2013 the rate of imaging the low back with no red flags stayed consistent at 53.7%.  If we thought that was excessive, the authors go on to cite information from India showing 100% of chronic low back pain patients in an orthopedic clinic underwent imaging for non-specific low back pain. Similar results were found through the other studies cited for low and middle income countries. 
  • The next comparison was for the guideline that the first line treatments should be non-pharmacologic. They found that this guideline is not commonly followed citing research for high income countries demonstrating that 64.5% of low back pain patients in Australia from 2000-2010 were prescribed meds on the first visit and, on a personal note, I had a patient here in the USA just this morning with acute low back pain that was prescribed pain meds on the first day. To be fair, his pain is severe but, they are not following guidelines and the meds have had no impact on his level of pain still he continues to take them as ordered. Medication for no effect essentially. In the lower and middle-income countries, the authors cite research showing that in South Africa, 90% of the low back pain patients going to a primary care physician received medication. 
  • The next guideline was that many times, there was advice to avoid electrical physical modalities such as diathermy, etc. In the high-income setting, Swedish physiotherapists recommend transcutaneous stim for low back pain to the tune of 38%, 75% of American PTs use lumbar traction, and a Spanish National Health Service study suggested 38.6% of physical therapy costs were for treatments known to have no effectiveness.
  • The next guide comparison was that the use of opioids is discouraged. The authors go on to cite prescription rates from 2004-2009 and, to be honest, I think the opioid epidemic has likely caused the numbers cited to actually drop. Although opioid addiction is on the rise, it’s my opinion that it is now at the forefront of the national story. With the sort of attention it has demanded, I cannot imagine the numbers staying the same. That is my opinion, of course. 
  • Next guide was that surgery and interventional treatment should be very limited or possibly eliminated for low back pain. In the real world, this is not occurring. In the USA in 2011, spinal fusion was the reason for the most costs of any surgical procedure in the nation. US Medicare covered 2,023,481 epidural injections (a substantial increase from 2000-2011), 990,449 lumbar or sacral facet injections as well as 406,378 lumbar or sacral facet neurotomy treatments, Medicare funded 252,654 sacroiliac joint injections. Two-thirds of Dutch spinal surgeons perform spinal fusion surgeries. 
  • The next guide comparison was that exercise is now recommended for the treatment of chronic low back pain. A 2009 paper the authors cited showed that 54% of Americans with chronic low back pain were not prescribed any exercise as treatment. 
  • The final guide comparison was done for the recommendation that a biopsychosocial framework guide the management for low back pain patients. In the USA, only 12% of chronic low back pain patients had been treated for their diagnosed depression in the year prior and only 8.4% were recommended cognitive behavioral treatment. 

Promising Directions

Implementation of the best available evidence

The authors state here that some of the biggest issues toward implementation of new low back guidelines may be short consultation times, the practitioners having a decreased amount of knowledge on the guides, fear of being sued if missing serious pathology, and an effort to appease patients’ desires and, in my opinion, be the “good guy” in the patients’ eyes. However, the authors explain that there are some examples of successful implementation and that widespread use may be achieved through dispelling existing established practice patterns, repetition of the guides, and finding out what is the most effective and cost-effective treatments. 

The authors suggest integrated education of health-care professionals surmising that such a thing could not only educate & innovate but also break through professional barriers that exist. Professional barriers such as exist between many in the medical field and the chiropractic field. 

Clinical systems and pathways

The authors say that one solution in the treatment of low back pain could be a radical departure from current procedure and move toward a stratified primary care model known as STarT Back. This model is a two-part model with the first part consisting of a questionnaire to help the practitioner identify the patient’s risk of persistent disabling pain. The second part consists of treatments tailored to the patients level of risk according to the first part questionnaire. 

Another option along these lines would be to redesign the entire case management paths from first contact all the way through to the specialized care practitioner. They argue that a current barrier to doing this is the fact that healthcare reimbursements are currently geared toward quantity rather than quality. Two programs the authors cited for examples of promising pathways are Canada’s Saskatchewan Spine Pathway as well as NHS England’s program. 

Integrate health and occupational interventions

The authors argue in this section that healthcare and occupational health interventions need to be considered simultaneously when it comes to patients with low back pain and work disability issues. Return to work commonly happens before the absence of pain. Even hurting, people can still return to work. The authors tend to have a very strong recommendation on never leaving work or returning as quickly as possible. 

Due to very specific examples, I have admittedly glossed over this section to avoid inaccuracies and unintended generalizations. I highly encourage your reading the paper on your own time for accuracy. 

Public health interventions

In this section, the authors are discussing public relations: how to get the word out. How to change public perception of back pain and the treatment of low back pain. They cite a successful campaign in Australia that used television ads with prominent public figures serving as the spokespeople. They felt it was well-funded and was successful in part due to the proper messaging but also due to laws and public policies that supported the campaign. 

Conclusions

The authors admit that even the solutions put forth in this paper are based on relatively limited evidence. The following are quotes from the conclusion:

  • “Focusing on key principles, such as the need to reduce unnecessary health care for low back pain, support people to be active and stay at work, and reform unhelpful patient clinical pathways and reimbursement models, could guide next steps.”
  • “No single solution will be effective, and a collective, global effort will take time, determination, and organization. Without the collaborative efforts of people with low back pain, policy makers, clinicians, and researchers necessary to develop and implement effective solutions, disability rates, and expenditure for low back pain will continue to rise.”

Key Takeaways:

A paper of this size and of this magnitude, and with the level of education of contributors honestly cannot be done complete justice by a review such as this. I admittedly hit the high spots on the treatment of low back pain. I am more focused in some areas than in others. More specific for some topics and more general in others. That is the nature of a summarization and I hope I am allowed that latitude. 

If you are research minded, if you are a low back pain patient, or if you are a practitioner regularly coming in contact with low back pain patients and interested in treatment of low back pain, it is my opinion that taking the time to read these three papers yourself is of utmost importance. 

Please find the links to the papers in the “References” section and get it done. Together, we can make a big, big difference in the lives of our low back pain patients. Without a doubt. 

For this week’s next step, go register with The Lancet and get this paper for free! You just have to register. That’s it. 

Next week we will review the third and final paper of this three paper series. Next week’s paper is called “Low back pain: a call to action.” It will continue with ideas toward treatment of low back pain. We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!

If you love what you hear, be sure to check out https://www.chiropracticforward.com

As this podcast builds, so will the website with more content, products, and chances to learn.

 

We cannot wait to connect again with you next week. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

 

Here is the link for Part One of The Lancet Review from last week:

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

CF 014: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 2 of 3)

 

 

References:

Paper 1 – “What low back pain is and why we need to pay attention: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

Paper 2 “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext

Paper 3 – “Low back pain: a call for action”: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30488-4/fulltext

CF 016: Review of The Lancet Article on Low Back Pain (Pt. 1)

Low Back Pain: A Major Global Challenge

On the Chiropractic Forward podcast this week, we are going to do a review of The Lancet article on Low Back Pain. It is a recent paper published in march 2018 that we hope will have a powerful impact in the months and years to follow. 

Before we get started with this review of The Lancet article on Low Back Pain, I want to draw your attention our website at https://www.chiropracticforward.com. Just below the area where you can listen to the latest episode, you’ll see an area where you can sign up for our newsletter. I’d like to encourage you to sign up. It’s just an email about once a week to let you know when the episode is updated and what it’s about. Also, if something brand new pops up, we’ll be able to tell you about it quickly and easily.

Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast where we talk about issues related to health, chiropractic, evidence, chiropractic advocacy, and research. Thank you for taking time out of your day I know your time is valuable and I want to fill it with value so here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall. 

You have illegally u-turned into Episode #16 and criminals are welcome so make yourself at home. Again, we are doing a review of The Lancet article on Low Back Pain.

I’ve been battling a head cold and depending on the day, the head cold is winning. I hope you’ll excuse my graveled voice and my nasal presentation. I’ll do my best on this review of The Lancet article on Low Back Pain. 

Those of us that are hungry for new research and the recommendations that arise from the body of literature being constantly created were excited last week about the release of significant reports coming out in a highly respected research journal called The Lancet. 

Founded in 1823, The Lancet is published weekly is is one of the oldest, most respected, and most well-known medical journals in the world so when it was announced a series of papers were to be published in The Lancet having to do with low back pain, as you may imagine, those of us interested in the research world and musculoskeletal complaints were all ears. 

Not only was the article noteworthy due to its being published in The Lancet, but it was also exciting for those of us in the so-called alternative healthcare world because there were several Doctors of Chiropractic sitting on the steering committee for the series of reports. For some reason, chiropractors are still considered by many to be alternative while this group of papers suggest chiropractic may be a lot more than simply “alternative.”

There are a couple of things in my mind that stand out as reasons for such a series of papers. The first being that low back pain has become a major problem globally and show no sign of stopping the growth of it impact. The second reason would be the ineffectiveness of the treatments commonly used or recommended. This includes surgery, epidural steroid injections, and, the most notable of failed treatments, opioids.

The series of Low Back Pain papers were compiled by a team of leading experts on back pain. The team was made up of an international spectrum  of varied backgrounds. They met for a workshop in Buxton, UK, in June, 2016, to start the journey and the process of setting the outline and some sort of structure for each paper. 

It was quite an undertaking from quite the group of experts. This is not a group of papers to be ignored since these authors and researchers are among the best of the best globally. 

The papers were broken down as follows:

      1. What low back pain is and why we need to pay attention.
      2. Prevention and treatment of low back pain: evidence, challenges, and promising directions. 
      3. Low back pain: a call for action

In this article, I will cover the first of the three papers with plans to highlight the next two papers in the coming weeks so be sure to return for those important discussions. 

How They Did It

For this paper, again titled “What low back pain is and why we need to pay attention,” the researchers identified scientific studies through searches of databases:

  • MEDLINE (PubMed)
  • Scopus. 
  • Google Scholar
  • African Index Medicus Database

In this review of The Lancet article on Low Back Pain I think it’s important to re-iterate the authors assertion that, in order to ensure a high-quality standard, systematic reviews were shown preference for inclusion.

Summary of the introduction of the first paper. 

  • Low back pain is now the leading cause of disability worldwide.
  • Only a small percentage have a well-understood, definite cause for their low back pain. Examples of well-known and udnerstood causes are things like a vertebral fracture, malignancy, or infection.
  • Things that seem to raise the risk of having low back pain complaints would be populations that smoke regulary, people that have physically demanding jobs or routine jobs or jobs that keep them mostly sedentary throughout the day and throughout the work week, people with physical and mental issues that add to a low back complaint or contribute to a low back complaint, and overweight/obese people. These populations are all at risk for developing low back pain.
  • 540 million people were affected at any one time globally.
  • A systematic review (3097 participants) found several MRI findings had a reasonably strong association with low back pain, including Modic type 1 change, disc bulge, disc extrusion, and spondylolysis. To further define Modic 1 changes, in regular vertebral endplate bone, the trabeculae shoud be like a type of scaffolding. Within the trabeculae there is red bone marrow producing blood cells. In a Modic type 1, the trabeculae are fractured intermittently and the patterns are more erratic and the marrow is absent. In the marrow’s place now is serum which is the same substance one can find in a blister. 

Symptoms associated with low back pain

Radicular Pain and Radiculopathy

  • Radiculopathy is usually called sciatica and mostly occurs when there is involvement where the nerve root exits the spine.
  • The authors noted that the term sciatica is used inconsistently by doctors and the public in general and should probably be avoided all together. 
  • The diagnosis of radicular pain relies on clinical findings, such as history of dermatomal leg pain, leg pain that is actually worse than the back pain, aggravation of the symptom when bearing down such as in coughing, sneezing, lying on your back and raising heels off of the table or in going from seated to standing, and straight leg raise test. General rule of thumb for an SLR is that pain in the first 30 degrees of leg elevation hints at a disc origin since that is the movement that first starts to tension the nerve at the root.
  • Patients presenting with low back pain in addition to radicular pain or radiculopathy tend to have worse outcomes than those presenting with low back pain alone.

Lumbar Spinal Stenosis

  • I tell my patients that the simplest way to explain stenosis is to say that a hole that nerves run through has become smaller and, as a result, the nerves sometimes have pressure on them that can cause them to be somewhat dysfunctional. 
  • Lumbar spinal stenosis is clinically characterized by pain or discomfort with walking or standing that radiates into one or both legs and can be eased resting and almost always by lumbar flexion (neurogenic claudication). They call this the shopping cart sign. Meaning, if a person gets relief from leaning on a shopping cart, it sure may be stenosis. If it is aggravated by leaning back or by inducing a “swayback” type of movement, that sure may be stenosis. As a sidenote and from my own studies, if lumbar extension (or swayback) does not hurt, but then rotation in either direction at the endpoint of lumbar extenstion actually does increase the pain, then the patient is likely suffering from a lumbar facet complaint. 
  • Lumbar stenosis is commonly caused by narrowing of the spinal canal or intervertebral foramina as a result of a combination of degeneration such as facet osteoarthritis, ligamentum flavum hypertrophy, and bulging discs. Two or three of these factors can combine to reduce the size and space available for the neural structures to pass through. Obviously that can create issues.
  • Experts tend to agree that the diagnosis of stenosis requires both the presence of the symptoms in addition to imaging findings demonstrating stenosis.

Other causes of Low Back Pain

  • Vertebral fracture, inflammatory disorders, malignancy, infections, intra-abdominal causes.
  • The US guideline for imaging advises deferral of imaging pending a trial of therapy when there are weak risk factors for cancer or axial spondyloarthritis. What does that mean exactly? That means a trial of conservative care. The authors will delve further into this in the second paper from the Lancet series but I will butt my head in here with the opinion of the American College of Physicians. Their updated recommendations from February of 2017 reflect that doctors should be recommending Chiropractic, massage, and/or ice for acute low back pain and should recommend Chirorpactic, acupuncture, and/or exercise/rehab for chronic low back pain. These recommendations are to precede taking even ibuprofen. 

Prevalence

  • Approximately 40% of 9-18-year olds in high-income, medium-income, and low-income countries report having had low back pain.
  • Low back pain prevalence increased 54% since 1990.
  • It is the number one cause of disability globally

Work Disability

Social Identity & Inequality

  • MacNeela and colleagues reviewed 38 separate qualitative studies in high-income countries. They showed found common traits, including: worry and fear about the social consequences of chronic low back pain, hopelessness, family strain, social withdrawal, loss of job and lack of money, disappointment with health-care encounters (in particular with general practitioners), coming to terms with the pain, and learning self-management strategies.
  • Froud and colleagues reviewed 42 qualitative studies from high-income countries, and found that many people living with low back pain struggled to meet their social expectations and obligations and that achieving them might then threaten the credibility of their suffering, with disability claims being endangered. Sometimes we have to almost force low back patients back into the workforce and, did you know that studies show in general that the sooner people are returned to work, the better they tend to recover from the low back pain complaint?
  • Schofield and colleagues found that individuals who exit the workforce early as a result of their low back pain have substantially less wealth by age 65 years, even after adjustment for education. This is just an obvious statement. It makes sense that people that quit working earlier than 65 end up making less money by the time they reach 65. You can also throw the expense of dealing with a back pain complaint in on top of the loss of wages. 
  • Globally, low back pain contributes to inequality. At first, when I read this, it struck me as being silly. Everything’s about inequality these days isn’t it? Certainlly in America it seems. But, this is a little different when you read through the explanation. The authors go on to say that in low-income and middle-income countries, poverty and inequality might increase as participation in work is affected. In addition, regulations on how to properly re-introduce a person into the workforce are absent, and workers are likely to be placed right back into the job they were originally injured without proper re-introduction. The authors felt this might place more strain on family and community livelihoods.

Cost of Low Back Pain

  • Costs associated with low back pain are commonly tallied as direct medical costs, meaning the cost of the doctor’s bill. They are also tallied in terms of indirect costs; meaning the cost of being out of work and the loss of productivity at the work place.
  • Most studies underestimate the total costs of low back pain
  • Although we do not think of low back pain in these terms yet, the truth is that low back pain, in terms of a real problem as far at the cost to treat and the overall indirect costs, are right up there with the biggest issues the global pupulation faces. Issues such as cardiovascular disease, cancer, mental health, and autoimmune diseases. That’s huge. 
  • In the USA, 44% of the population used at least one complementary or alternative health-care therapy in 1997; and the most common reason was low back pain. with 70,000 plus chiropractors in the United States, I can tell you with some confidence the profession most associated with alternative treatment for low back pain or spinal pain of any sort is chiropractic care. 
  • The USA has the highest costs, attributable to a more medically intensive approach as well as higher rates of surgery compared with other high-income countries. We see patients every week that have gone through needless surgeries. Surgeries for which there is plenty of high-level research proving its ineffectiveness yet you see the popularity for these surgeries continuing to rise. 

Natural History

  • A systematic review (33 cohorts; 11?166 participants) provides strong evidence that most episodes of low back pain improve substantially within 6 weeks, and by 12 months average pain levels are low. However, two-thirds of patients still report some pain at 3 months and 12 months
  • The best evidence suggests around 33% of people will have a recurrence within 1 year of recovering from a previous episode.

Risk Factors and Triggers for Low Back Pain Episodes

      • A systematic review (5165 participants) found consistent evidence that people who have had previous episodes of low back pain are at increased risk of a new episode. Likewise, people with other chronic conditions, including asthma, headache, and diabetes, are more likely to report low back pain than people in good health
      • a UK cohort study found psychological distress at age 23 years predicted incident low back pain 10 years later. The Canadian National Population Health Survey with 9909 participants found that pain-free individuals with depression were more likely to develop low back pain within 2 years than were people without depression
      • systematic reviews of cohort studies indicate that lifestyle factors such as smoking, obesity, and low levels of physical activity that relate to poorer general health are also associated with occurrence of low back pain episodes. We know that obesity and lack of exercise has become an American trait that needs to be reversed. 
      • A systematic review found the genetic influence on the liability to develop low back pain ranged from 21% to 67%, with the genetic component being higher for more chronic and disabling low back pain than for inconsequential low back pain.Don’t we all have patients that present to us claimng that their bad back just runs in the family? Mom and Grandma had a bad back so that must be why they have a bad back is the common sentiment. It seems there may be a bit of validity there. 
      • An Australian case-crossover study (999 participants) showed that awkward postures, heavy manual tasks, feeling tired, or being distracted during an activity were all associated with increased risk of a new episode of low back pain. Similarly, work exposures of lifting, bending, awkward postures, and tasks considered physically demanding were also associated with an increased risk of developing low back pain in low-income and middle-income countries

Psychological Factors

For this review of The Lancet article on Low Back Pain, the presence of psychological factors in people who present with low back pain is associated with increased risk of developing disability even though the mechanisms are not fully understood

Social and Societal Factors

      • Cross-sectional data from the USA (National Health Interview Survey 2009–10, 5103 people) found that those with persistent low back pain were more likely to have had less than high-school education and had an annual household income of less than US$20,000. 
      • Suggested mechanisms for the effect of low education on back pain include environmental and lifestyle exposures in lower socioeconomic groups, lower health literacy, and health care not being available or adequately targeted to people with low education.
      • To go along with lower wages, the lower socioeconomic groups are commonly in routine and manual occupations and ahve increased physical workloads is associated with disabling low back pain

Conclusion

In this review of The Lancet article on Low Back Pain, the authors concluded, “Low back pain is now the number one cause of disability globally. The burden from low back pain is increasing, particularly in low-income and middle-income countries, which is straining health-care and social systems that are already overburdened. Low back pain is most prevalent and burdensome in working populations, and in older people low back pain is associated with increased activity limitation. Most cases of low back pain are short-lasting and a specific nociceptive source cannot be identified. Recurrences are, however, common and a few people end up with persistent disabling pain affected by a range of biophysical, psychological, and social factors. Costs associated with health care and work disability attributed to low back pain are enormous but vary substantially between countries, and are related to social norms, health-care approaches, and legislation. Although there are several global initiatives to address the global burden of low back pain as a public health problem, there is a need to identify cost-effective and context-specific strategies for managing low back pain to mitigate the consequences of the current and projected future burden.”

Key Takeaway:

Obviously, if you followed us all the way through on this review of The Lancet article on Low Back Pain, low back pain is an issue that must be addressed in a more effective way globally and irregardless of national ranking in terms of the economy. Just because it’s musculoskeletal doesn’t mean it can be ignored and kicked to the curb while the big stuff like heart disease, diabetes, and cancer are treated. The research for the big stuff is adequately funded but, honestly, in general, most general practitioners don’t have the first clue of what to do for low back pain. I personally suggest they turn to their own American College of Physicians for updated recommendations on chronic and acute low back conditions if I were them. 

Authors

Steering Committee

Rachelle Buchbinder – Australia

Jan Hartvigsen – Denmark

Dan Cherkin – United States

Nadine Foster – UK

Chris Maher – Australia

Martin Underwood – UK

Maruits van Tulder – Netherlands

For this week’s Next Steps in this review of The Lancet article on Low Back Pain, be sure to send us an email at dr.williams@chiropracticforward.com and let us know what you thought or contribute to the show for next week. We love hearing from you all. Also, go and follow Jan Hartvigsen https://twitter.com/JanHartvigsen, and Chris Maher https://twitter.com/CGMMaher on Twitter. 

Next week we will review the second paper of this three paper series. Next week’s paper is called “Prevention and treatment of low back pain: evidence, challenges, and promising directions.” We’ll go through it bit by bit and hit the highlights for those of you that aren’t into reading research papers and things of that sort. Don’t miss it!

If you love what you hear, be sure to check out www.chiropracticforward.com. As this podcast builds, so will the website with more content, products, and chances to learn. This review of The Lancet article on Low Back Pain is just an example of what you can look forward to.

We cannot wait to connect again with you next week for review of The Lancet article on Low Back Pain Part Two. From Creek Stone, my office here in Amarillo, TX, home of the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

Be sure to check out part of our Chiropracrtors Cause Strokes Myth. This is a link to Part Two:

CF 014: DEBUNKED: The Odd Myth That Chiropractors Cause Strokes (Part 2 of 3)

References: