When it comes to treating acute and chronic spine pain, the research is on your side.
Everyone knows that
chiropractors treat the health of the spine,
and when it comes to treating both acute and chronic spine pain, chiropractors
are in an excellent position to use a variety of tools to not just ease
patients’ discomfort, but to fix the cause of the problem as well.
Over the
last 20 years, the body of scientific evidence has grown, and it confirms that
chiropractors treat acute and chronic spine-related disorders with great
efficacy. More to the point, it’s safe to say that based on the published
clinical practice guidelines in the medical literature, many of the things you
do in practice every day have strong scientific evidence.
In addition to the
scientific literature, however, evidence-based practice (a combination of
related scientific evidence, clinician experience and patient values) shows
other modalities can also be effective. In fact, absence of evidence is not
lack of evidence of efficacy. If a patient wants electrical stimulation and it
has helped them with acute back pain, that is an evidence-based recommendation
and an intervention that is completely acceptable to alleviate pain because
it’s what the patient values.
Because what most do as
chiropractors is evidence-based, their style of practice is in alignment with
clinical practice guidelines. That being said, there are some chiropractors who
perform interventions that are not necessarily within clinical practice
guidelines because there is not a lot of hard scientific evidence for the
approach. If a modality helps patients and if chiropractors have found it
effective in their practice, then it’s totally appropriate to provide that
intervention.
Guidelines are just
that—guides. They are not prescriptive cookbooks. Clinician experience with
tools that help patients should also be part of that guide.
Acute interventions
The
Annals of Internal Medicine clinical practice guideline for low-back pain recommends
non-pharmacologic interventions.1 Acute spine pain is effectively
treated with manual approaches—spinal manipulation
and soft-tissue techniques. In addition, acupuncture is highly effective,
according to this published guideline. In fact, for all three categories of
back pain—acute, sub-acute, and chronic—only spinal manipulation and
acupuncture were recommended across the board.
When it comes to acute
spine-related pain, it is critical to manage it correctly from the start. Therapies should be based on what
the evidence says works and incorporate your own experience. Managing acute
pain is important so it doesn’t become chronic, and it is critical in the
overall rehabilitative process because pain alters how a person moves and can
create secondary compensations.
With acute pain, the
frequency of care matters, especially in the first few weeks. According to
several studies, for patients treated at a higher frequency in the first few
weeks of acute pain, the faster the reduction in pain and disability.2
Further, when you are making recommendations to patients about treating their
spine-related pain, providing interventions and explanations of those
interventions to prevent secondary recurrence is crucial.
The operative phrase in
creating a treatment plan whereby the patient adheres to the plan is shared
decision-making. Making sure patients play a role in how (and how frequently)
they are treated matters. Strong communication and teaching skills are required
to set the stage for patients to understand the why, the what, the how, and the
frequency of care.
Chronic considerations
When
it comes to chronic spine-related pain, according to the Annals publication, there is an
even larger menu of options. This includes
adjustments and rehabilitative exercise, as well as acupuncture, behavioral-cognitive
therapy, and other psychosocial interventions. There are also psycho-social
techniques that reward good behavior and punish bad behavior, and this can work
in the chiropractor’s tool kit to mitigate chronic spine-related pain.
While
the amount of scientific evidence supporting some of the passive modalities
used in chiropractic offices may be in short supply, if patients want the
service or modality and it provides them with an improved outcome, then why not
provide it for them? The key, however, is to move patients from passive to
active care as quickly as possible.
Think empowerment
when it comes to care delivery, especially with the chronic pain patient.
Empowerment ensures patients have the knowledge,
skills, attitudes, and self-awareness to improve the quality of their lives.
Because chiropractors provide care to people with chronic pain at some point,
it is your responsibility to prepare patients to make informed decisions about
their treatment. Empowering patients to self-manage their chronic pain can lead
to improved patient-centered outcomes.
International
practice guidelines as published in Lancet state spinal manipulation and exercise were the only two
recommendations for both acute and chronic spine pain.3 The bottom
line is that the common denominator for both clinical practice guidelines—the Annals
paper and the Lancet paper—is spinal manipulation. It is critical for
pain management of spine-related disorders.
Supplement options
In additional to spinal manipulation, there are certain
supplements that have
evidenced efficacy as it relates to controlling inflammation, which in turn may
be able to help with spine-related pain.
These include:
- Proteolytic enzymes and protease supplementation
- Omega 3, 6, 9 (must contain GLA to avoid lipid peroxidation)
- Curcumin
- Vitamin D
- Bromelain
- Glucosamine and chondroitin
There are many other
supplements that offer relief of spine- and joint-related pain, and, as stated
above, a chiropractor can incorporate those interventions with evidence-based
therapies as they see fit to alleviate both chronic and acute pain. Use your
own personal experience, in addition to evidence-based guidelines, to determine
the treatments that are right for your patients. And always listen to patients’
past experiences with pain management. What has worked for them in the past is
worth considering incorporating into your treatment plan now.
Jay S. Greenstein, DC, CCSP, CGFI, CKTP, FMS, is the founder and CEO of Sport and Spine Companies in Fairfax, Virginia. He has served as the team chiropractor for several professional sports teams and was awarded as Chiropractor of the Year in 2007 and 2010 for the Maryland Chiropractic Association and Chiropractor of the Year in 2010 for the Virginia Chiropractic Association. He can be contacted through ssrehab.com.
References
1 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. Ann Intern Med. 2017;166:514-530.
2 Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;(9):CD004249.
3 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 March 2018. Accessed June 2018.
