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Chronic Low Back Pain: Are You Living With It or Trying to Fix It?
Low back pain is thought to affect around one-third of the UK adult population each year. One in fifteen UK adults consults their GP about back pain annually – about 2.6 million people.
This makes low back pain one of the most common reasons for seeing the doctor. Indeed, it’s fair to say that most people will experience some form of low back pain at some point in their lives.
Given the high prevalence of low back pain and its potential to disrupt quality of life and the ability to live and work normally, one might have thought that treatments would be well advanced and great resources focused on solving the problem.
Yet the truth remains that most people seeking medical care for low back pain will still have the same problem 12 months later.
This suggests that people are simply having to “live with” their back pain and “manage” it rather than being recommended solutions to fix the cause of the pain.
Specialised Manual Therapy has long been an effective treatment for low back pain and here we examine the evidence that demonstrates its efficacy compared with other mainstream medical treatments.
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What causes chronic low back pain?
Low back pain affects the area between the bottom of the rib cage and the buttock creases.
For some people, it lasts for short periods of time, and soon disappears only to return again later. This is a typical cyclical pattern that generally worsens when one gets older.
However, for a proportion of people, the pain persists over a longer period of time without respite. These people seek medical help for their condition, which is generally classed as chronic if it persists for six months or more.
For these people, the track record of treating their pain is relatively poor. Once the pain is present for over a year, few people ever return to normal activities.
It is these individuals that often have to “live with” and “manage” their condition.
The original source of the back pain may be:
– Injury – sprains or strains due to sudden movements or while lifting heavy objects
– A ruptured or herniated disc
– Sciatica
– Spinal stenosis
– Diseases like cancer, arthritis, and fibromyalgia
– Infections of the spine or kidney
A mild injury to the spine is by far the most common cause of low back pain. This normally dissipates after the necessary rest and recuperation.
Whether the pain comes and goes or persists, it points to an underlying health condition that may respond to manual therapy like chiropractic care.
Non-specific low back pain
Persistent or recurrent tension or soreness in the lumbar or lower back region is termed “non-specific” low back pain when no specific cause can be identified.
This is surprisingly common. Put simply, medical professionals don’t know why the pain persists.
It is most often due to structures in the back (joints, discs, and connective tissues) which they are not well-equipped to treat.
The pain may be radicular (resulting from compression of nerves) and may radiate to other areas like the legs.
This problem has become more frequent as people’s lifestyles are defined more by sedentary pursuits, a general lack of movement, poor posture, and poor diets.
Standard treatments for chronic low back pain
While short-lived low back pain is often treated with over-the-counter medications like NSAIDs, prescription painkillers, or injections, the treatment of chronic low back pain is far more challenging.
There is no standardised treatment due to its many possible causes.
The mainstream medical community may recommend continuation of medications and injections (despite poor evidence that they have any long-term benefit) or recommend surgery, which comes with an array of risks and inconveniences.
There is a reluctance in the medical community to embrace the consistently excellent results achieved by manual therapies such as chiropractic care…
Chiropractic care vs. standard hospital care
In 1990, a randomized controlled trial published in the British Medical Journal suggested the great potential of chiropractic care when compared to hospital care.
This study looked at low back pain of mechanical origin in 741 patients aged 18-65 with no contraindications to manipulation and who had not been treated within the past month.
It compared chiropractic treatment (at the discretion of different chiropractors) and hospital outpatient treatment with the following results:
“Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain. A benefit of about 7% points on the Oswestry scale was seen at two years. The benefit of chiropractic treatment became more evident throughout the follow-up period. Secondary outcome measures also showed that chiropractic was more beneficial.”
The conclusion was as follows:
“For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management. The benefit is seen mainly in thosewith chronic or severe pain. Introducing chiropractic into NHS practice should be considered.”
Three years later, a follow-up study was performed on the same patients. The results confirmed the earlier study and showed the following:
“… improvement in all patients at three years was about 29% more in those treated by chiropractors than in those treated by the hospitals. The beneficial effect of chiropractic on pain was particularly clear. Those treated by chiropractors had more further treatments for back pain after the completion of trial treatment. Among both those initially referred from chiropractors and from hospitals more rated chiropractic helpful at three years than hospital management.”
Then, in 2010, a randomized controlled study was performed on the effectiveness of chiropractic-based interventions for 92 patients with acute mechanical low back pain, when compared with family physician-directed care.
Patients were assessed at 8, 16, and 24 weeks after treatment and those receiving chiropractic fared considerably better.
The conclusion was that chiropractic care was “associated with significantly greater improvement in condition-specific functioning”.
In the past 25 years then, chiropractic care has consistently been shown to be more effective than standard medical approaches to low back pain. However, it is still only available through some NHS hospitals, depending on the area of the country you live in.
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Chiropractic care and low back pain: other evidence
A number of other interesting studies on low back pain and chiropractic care are summarised below:
1995: A prospective study in two general practices in Manchester investigated the claim that 90% of episodes of adult low back pain that present to general practice were resolved within one month. It was found that, of 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the three months after the initial consultation. However, of those interviewed at three and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability.
Conclusion:
“The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However, most will still be experiencing low back pain and related disability one year after consultation.”
2004: A randomized, double-blind clinical trial compared the relative efficacy of chiropractic adjustments with muscle relaxants and placebo for subacute low back pain. A total of 192 patients with low back pain of 2-6 weeks’ duration were studied and statistical differences across groups were seen for pain (the chiropractic group improved more than the control group).
Conclusion:
“Chiropractic was more beneficial than placebo in reducing pain.”
2005: A practice-based, nonrandomized, comparative study set out to identify the relative provider costs, clinical outcomes, and patient satisfaction for the treatment of mechanical-origin low back pain (LBP). It considered patients self-referring to 60 doctors of chiropractic and 111 medical doctors in 51 chiropractic and 14 general practice community clinics over a two-year period.
Conclusion:
“Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policymakers in evaluating chiropractic as a treatment option for low back pain.”
2006: A study evaluated the efficacy of chiropractic spinal manipulation, manual flexion/distraction, and hot pack application for the treatment of low back pain from osteoarthritis (OA) compared with moist heat alone. A total of 252 patients were treated, with greater pain reduction and range of motion experienced in the group receiving chiropractic treatment.
Conclusion:
“Chiropractic care combined with heat is more effective than heat alone for treating OA-based lower back pain. Pain reduction occurs more rapidly and to a greater degree, and range of motion increases more rapidly and to a greater degree.”
2007: A Norwegian study reported on and evaluated the results of chiropractic care for 33 patients with low back pain in an orthopedic department. All patients had experienced sudden and painful low back pain caused by lumbar flexion and rotation without axial loading. All but two patients returned to work. The period of sick leave among the patients was reduced by two-thirds compared to that associated with conventional medical treatment.
Conclusion:
“The results support the initiative of the Norwegian government to increase reference to chiropractors in treating patients with neuromusculoskeletal dysfunctions. Based on our experience, we believe that the inclusion of chiropractors within hospital orthopedic departments is feasible and provides a patient care resource that may benefit not only the patients but also the department as a whole.”
2009: A retrospective case series study looked at 100 patients referred for chiropractic care of work-related spinal injuries involving workers’ compensation claims. They were divided into three groups: acute, subacute and chronic injuries. Workers in all categories showed improved post-treatment tolerance for work-related activities and significantly lower post-treatment subjective pain scores.
Conclusion:
“The study identified positive effects of chiropractic management included in integrative care when treating work-related neck or back pain. Improvement in both functional scores and subjective response was noted in all three time-based phases of patient status (acute, subacute, and chronic).”
2014: A prospective cohort study where 148 patients with low back pain and leg pain caused by disc herniation were treated with high-velocity, low-amplitude (HVLA) spinal manipulation. Significant improvement for all outcomes at all time points was reported. At three months, 90.5% of patients were “improved” with 88.0%“improved” at one year. Although acute patients improved faster by three months, 81.8% of chronic patients reported “improvement” with 89.2% “improved” at one year. There were no adverse events reported.
Conclusion:
“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.”
When is the UK going to catch up with the manual therapy?
We have seen that the effectiveness of chiropractic care is well-supported by a strong body of evidence.
Health systems around the world have turned towards manual therapies as treatments for all types of musculoskeletal problems such as low back pain.
For example, it is well-established and respected in Denmark, Finland, Iceland, Norway and Sweden and is viewed as an integral part of the mainstream health care system in these countries.
In Norway, significant government funding is provided for chiropractic services. This is largely due to its cost-effectiveness, its proven success, and the lack of associated adverse side effects.
The UK has plenty of catching up to do in this respect.
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References
National Collaborating Centre for Primary Care (UK). Low Back Pain: Early Management of Persistent Non-specific Low Back Pain [Internet]. London: Royal College of General Practitioners (UK); 2009 May. (NICE Clinical Guidelines, No. 88.) 2, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11709/#
National Collaborating Centre for Primary Care (UK). Low Back Pain: Early Management of Persistent Non-specific Low Back Pain [Internet]. London: Royal College of General Practitioners (UK); 2009 May. (NICE Clinical Guidelines, No. 88.) 2, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11709/
T W Meade et al. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7.
T W Meade et al. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up.BMJ 1995;311:349-351 (5 August).
Peter R Croft et al. Outcome of low back pain in general practice: a prospective study. BMJ 1998;316:1356–9.
Serafin Leemann et al. Outcomes of acute and chronic patients with magnetic resonance imaging–confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulative therapy: a prospective observational cohort study with one-year follow-up. J Manipulative Physiol Ther 2014;xx:1-9.
Paul B. Bishop et al. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal 10 (2010) 1055–1064.
Donald Aspegren et al. Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: a retrospective analysis of 100 cases. J Manipulative Physiol Ther 2009;32:765-771.
Jan Roar Orlin et al. Results of chiropractic treatment of lumbopelvic fixation in 44 patients admitted to an orthopedic department. J Manipulative Physiol Ther 2007;30:135Q139.
Kathleen L. Beyerman et al. Efficacy of treating low back pain and dysfunction secondary to osteoarthritis: chiropractic care compared with moistheat alone. J Manipulative Physiol Ther 2006;29:107Q114.
Mitchell Haas et al. Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain. J Manipulative Physiol Ther 2005;28:555Q563.
Kathryn T. Hoiriis et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther 2004;27:388-98.
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