A series of articles published in March 2018 by The Lancet is rocking the low-back pain (LBP) world, generating expert comment noting that the problem of LBP is “a major global challenge” and the world’s leading cause of disability.1,2
Shortly afterward, the ABC news program Good Morning America featured The Lancet articles with the headline “New report warns of widespread ineffectiveness of lower back pain treatment.”3 The GMA segment summarized their findings with a three-step patient strategy:
- First, stay active, keep moving and continue working.
- Second, educate yourself about strategies to manage pain, and understand more about LBP and your body.
- Then if pain persists, use superficial heat, spinal manipulation therapy (SMT), massage and acupuncture. If all else fails, try NSAID medication.
This information presents a tremendous opportunity for evidence-congruent DCs seeking active participation (and referrals) in the health care system.
LBP: Causes and consequences
The number of years people spent disabled with LBP increased nearly 55 percent from 1990 to 2015, according to “What low back pain is and why we need to pay attention,” in which the Lancet Low Back Pain Series Working Group chronicles the impact on society.4
LBP affects 540 million people globally, yet despite numerous studies the condition remains complex, and specific causes of LBP often can’t be identified, so researchers label most cases “nonspecific LBP.” The rare exceptions can urgently require treatment, like “fractures, inflammatory disorders, malignancy, infections, and abdominal causes.” However, a recent study found such diagnoses in less than 1 percent of cases.5
The Lancet researchers examined widely held beliefs regarding disc and facet degeneration and LBP and found them largely wanting. But the role of genetic predisposition, local social beliefs and marketing messaging were supported.
Consequently, up to 99 percent of cases can be considered “nonspecific LBP,” and much of the current care paradigm isn’t helping. Nonetheless, The Lancet notes that while the way biophysical impairments can become disabling LBP isn’t entirely clear, “impairments are demonstrable in people with persistent low back pain.”
This encapsulates some of the disagreements between evidence-based researchers and the opinions of field DCs. A clinician’s goal is helping the LBP patient, whose prior episodes have led to compensations to avoid pain. And as The Lancet researchers observed, it’s common for people with chronic LBP to differ in muscle strength and mass, and have functional deficits compared to those without pain, and “these changes could be more than merely a direct consequence of pain and are only partly affected by psychological factors.”5
In other words, physiological changes may result from pain over time, but aren’t necessarily causing pain. Addressing these factors might provide relief, or pain might just improve with time. A therapy or technique, or some combination, may help in certain cases, but the research is either inconclusive or yet to be conducted.
The Lancet researchers noted how perceptions affect chronic pain, with spinal and supraspinal centers showing varying levels of activation, recruitment or avoidance based on nociceptive drive, context, cognition, and emotion.4 A related study found moderate evidence that chronic LBP patients can have “structural brain differences in specific cortical and subcortical areas, and altered functional connectivity in pain-related areas following painful stimulation.”6
Solution: Less drugs and surgery
In the section of the report focusing on LBP prevention and treatment, the Lancet Low Back Pain Series Working Group explores what works, what doesn’t and what the research is telling us.7 Their overall recommendations include:
- Avoid opioids (low benefit; high risk).
- Less imaging, medication and surgery. If other options fail, the lowest effective dose of NSAIDs, for the minimum time, can be considered after accounting for gastrointestinal, liver, and cardiorenal toxicity risks.
- Primary care LBP management should emphasize self-care, physical and psychological therapies, and complementary medicine such as SMT.
- Self-efficacy and fear link pain to disability, so chronic pain treatment should shift from pain relief to changing beliefs and behaviors.
Various treatment approaches in isolation showed poor to very-poor evidence for prevention. Combination therapies, such as exercise paired with education, fare better. Yet only half of people with chronic LBP are prescribed exercise—and fewer are compliant.
LBP is complicated by disability economics for patients and profitability for providers. The neglected role of biopsychosocial (BPS) factors is apparent in the gap between evidence-driven research and what clinicians actually do. Imaging, opioids, spinal injections, and surgery are overused despite research and guideline recommendations.
This evidence-versus-practice gap is widespread across countries and cultures. Low-income and middle- income countries experiencing rapid industrial growth show the greatest increase in LBP disability, likely due to reduced physical activity, increased obesity and lack of affordable care.
In high-income areas, The Lancet researchers find that disabling LBP is partly iatrogenic, and overused care can do more harm than good (at least for society and the patient, if not the provider). When the perception of back pain changes from being a fairly benign part of daily life to being a problem requiring medical attention, you see increased use of potentially unsafe treatments like opioids.7
It is stubbornly difficult to shift practitioner behaviors from customary practices, despite the prevalent evidence that:
- For lumbar spinal stenosis, some types of surgery result in good outcomes. But these patients “tend to improve with or without surgery and, therefore, non-surgical management is an appropriate option for patients who wish to defer or avoid surgery.”7
- Early surgery for a herniated disc is associated with faster relief of radiculopathy than with initial conservative treatment with the option of delayed surgery. After a year, however, the benefits diminish.
For non-radicular LBP with disc degeneration, intensive multidisciplinary rehabilitation gives similar results to expensive spinal fusion surgery, with less risk and cost.
The Lancet recommendations:
- Spinal decompression surgery can be considered for radicular pain if non-surgical treatments are unsuccessful, and herniated discs or spinal stenosis symptoms correlate with clinical and imaging findings.
- Avoid spinal epidural or facet joint injections for low back, but for severe radicular pain consider epidural local anesthetic and steroid injections.
Low-back pain treatment: The chiropractic opportunity
The concept of “positive health” is The Lancet group’s strategic global recommendation to prevent LBP disability. They challenge health care providers to deemphasize the current fragmented, biomedical care model and promote a cultural change in LBP interventions by addressing misconceptions among health professionals, patients, the media, and the general public.
The Lancet’s call to action presents an extraordinary opportunity for the chiropractic profession to step up, especially in light of the American College of Physicians 2017 guidelines in advising SMT and motor control exercise over surgery and pharmaceuticals.8 They identify the greatest potential to advance LBP care as “aligning practice with the evidence, reducing the focus on spinal abnormalities, and ensuring promotion of activity and function.”
DCs often say health (and disease) is about the body and mind, with each affecting the other. The Lancet’s series of articles likewise emphasizes evidence for a behavioral BPS approach to reduce disabling LBP with a positive health approach.
The Lancet recommends SMT for LBP. To actively participate with other health care professionals, DCs should support the concept of public health, and be evidence congruent.
Evidence-based doesn’t mean evidence-limited. DCs should provide credible advice for people to understand and avoid pathologizing their pain, and to stay active and remain working when possible. For unresponsive cases or those requiring specific medical care, DCs should refer out appropriately.
The chiropractic opportunity is to parlay evidence for treating LBP with spinal manipulation and exercise into positioning DCs as primary-care gatekeepers for spinal pain.9 Building relationships with MDs, NPs and other LBP providers is already building many practices—an encouraging trend.
People are increasingly opting for a natural path over expensive and risky drugs or surgery, providing opportunities to earn their trust. In the longer term, as chiropractic’s traditional strength of treating LBP systematically shows better results, DCs should see increased respect from patients and referrals from other providers.
Steven Weiniger, DC, is the author of Stand Taller—Live Longer: An Anti-Aging Strategy. He also created the PostureZone assessment app, the Certified Posture Exercise Professional (CPEP) program, and spearheads the PostureMonth.org public health education campaign. He is managing partner of PosturePractice.com and BodyZone.com, and can be reached at 770-922-0700 or DrW@BodyZone.com.
1 Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. The Lancet. https://doi.org/10.1016/S01406736(18)30488-4. Published Mar. 2018. Accessed June 2018.
2 Clark S, Horton R. Low back pain: a major global challenge. The Lancet. https://doi. org/10.1016/S0140-6736(18)30725-6. Published Mar. 2018. Accessed June 2018.
3 Ashton J. “New report warns of widespread ineffectiveness of lower back pain treatments.” Good Morning America. ABC. https:// abcnews.go.com/GMA/Wellness/video/ report-warns-widespread-ineffectiveness-lower-back-pain-treatments-53922320. Published Fri., Mar. 23, 2018. Accessed June 2018.
4 Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. [ITAL]The Lancet.[/ITAL] https://doi.org/10.1016/S0140-6736(18)30480-X. Published Mar. 2018. Accessed June 2018.
5 Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. [ITAL]Arthritis Rheum.[/ITAL] 2009;60(10):3072-80.
6 Roussel NA, Nijs J, Meeus M, et al. Central sensitization and altered central pain processing in chronic low back pain: fact or myth? [ITAL]Clin J Pain.[/ITAL]2013 Jul;29(7):625-38. doi: 10.1097/AJP.0b013e31826f9a71.
7 Prof Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. [ITAL]The Lancet.[/ITAL] https://doi.org/10.1016/S0140-6736(18)30489-6. Published Mar. 2018. Accessed June 2018.
8 Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. [ITAL]Ann Intern Med.[/ITAL] 2017;166:514-530.
9 Konarski-Hart K. “Patients Who Need Treatment Beyond the Spine.” NCMIC. Published April 2017. Accessed June 2018.