Clinical practice guidelines for chiropractic management of low back pain

Clinical practice guidelines promote optimal patient care based on research about different treatments, their benefits and potential limitations or side effects. One area of interest for doctors of chiropractic is recommendations for the treatment of low back pain.  

The Journal of Manipulative and Physiological Therapeutics published a paper to update the previously published 2016 best-practice recommendations for chiropractic management of adults with mechanical low back pain (LBP) in the U.S. These best practices have now been updated, providing practitioners with the latest guidance. 

The evidence-based research suggests DCs are well–suited to diagnose, treat, co-manage and manage the treatment of patients with low back pain disorders.  

How the new clinical practice guidelines were developed

When updating the 2016 chiropractic guidelines, a 69-member panel reviewed research published between March 2015 and September 2021. They looked at a variety of recommendations contained within 29 high-quality clinical practice guidelines, systematic reviews and randomized controlled trials. 

Each study was analyzed to determine the best recommendations for easing pain in the lower back. Based on their findings, they came up with 38 updated guidelines to inform practitioners when treating this condition — down from 51 recommendations in 2016. These best practices were published in October 2022, and some were unchanged while others had been modified in some form. 

Updated visit frequencies and durations of care

Best practice advice for treatment frequency and duration has largely been unchanged with the new update. Same as before, it is recommended that individuals with an acute or subacute episode of low back pain engage in two to three treatments per week for two to four weeks, reevaluating at the two– to four–week mark. For ongoing care, one to four visits per month is recommended with reevaluation after six visits. 

The protocol for dealing with exacerbations has also remained the same. In cases of mild exacerbation of low back pain, it is suggested that patients engage in one to six treatments per episode. If the exacerbation is moderate or severe, the protocol for acute and subacute episodes should be followed instead.  

One difference between the 2022 and 2016 guidelines is the new clinical practice guidelines do not provide frequency and duration advice for flare-ups, with past recommendations being one to three visits per week for a total of one to two weeks. They also do not specifically call out recommendations for exacerbations with chronic low back pain, only exacerbations in general. 

New active and passive intervention suggestions

Another difference in the updated clinical practice guidelines is the separation of low back pain management strategies based on whether they are active, passive or a combination of the two. In prior clinical practice guidelines, they were separated based on whether they were procedures, behavior and exercise recommendations or if they involved counseling. 

Active interventions DCs should recommend for patients with low back pain include: 

• Lifestyle advice, such as avoiding being sedentary, weight management and quitting smoking 
• Psychological or mind-body interventions, such as cognitive behavioral therapy (CBT) and reducing stress with mindfulness techniques 
• Movement-based interventions, such as yoga, qigong and exercise 

In addition to spinal manipulation or mobilization, other passive interventions helpful for easing pain in the lower back, according to the updated clinical practice guidelines, include: 

• Acupuncture 
• Low-level laser therapy (LLLT) 
• Massage 
• Transcutaneous electrical nerve stimulation (TENS) 

A multidisciplinary approach including both active and passive interventions may also be recommended. 

Intervention recommendations based on patient risk

The 2022 clinical practice guidelines also make a clear distinction between recommendations based on whether a patient is low- or high-risk. If they are low-risk, fewer interventions are recommended. This might include spinal manipulation, but also education, exercise or home care advice. 

Conversely, high-risk patients benefit from treatments that are more intensive or targeted. This could include engaging in psychological therapy or working with other providers to create a multi-modal treatment plan. 

Above all, patients should be encouraged to take an active role in their own care. Also, DCs should work closely with other healthcare providers to avoid confusing the patient with contradictory treatment recommendations. 

Final thoughts

Research bears out the fact that DCs are well-positioned to provide natural, effective interventions for low back pain. The latest clinical practice guidelines emphasize treating low back pain over the course of several appointments using a combination of active and passive interventions.