What is “best care” for low back pain patients based on scientific research?
The pain and disability associated with low back injuries compounds the frustration involved in making treatment decisions. In today’s world we are bombarded with numerous avenues of care ranging from drugs, alternative therapies (acupuncture, massage etc.), manual therapies (chiropractic, physiotherapy), to surgery. It is very difficult to decipher opinions from factual information.
Not only does back pain have a vast impact on individuals but on society as well. Here are a few North American statistics:
1. Accounts for more than $100 billion in annual health costs.
2. The second leading cause of physician visits and second only to child birth for hospitalizations.
3. The most prevalent chronic medical problem and number one cause of long term disability.
4. The second most common cause of restricted activity and use of prescription and non-prescription drugs.
Leaders in orthopedic medicine now acknowledge that traditional medical management of back pain was a “20th century medical disaster” whose “legacy reverberates into the new millennium”.
Traditional medical management is predicated on a biomechanical model which focuses on pain as a reflection of physical injury or disease. It has a specific mechanism, and the main responsibility for recovery is on the health professional who must find the cause of the pain and correct it, typically with the use of drugs and/or surgery. If there was no visible pathology the patient should rest until the problem resolved naturally. Prolonged pain and disability were likely of psychological origin alone. In other words, for example, “if there’s no pathology on an x-ray, there’s nothing significantly wrong. Go home and rest. This biomedical model has been both expensive and ineffective in cases of non-surgical back pain.
With the evidence based research of the 1980s and 1990s clinical guidelines were now based on a biopsychosocial model. Under this model pain is not physical or psychological but has elements of both. The patient and the health professional must both understand this concept, even where there is a clearly demonstrated physical cause of pain. The patient’s perception of pain is influenced by factors such as workplace satisfaction, whether the injury is perceived as an employer’s fault, marital discord, past similar personal or family experiences and general psychological status including anxiety and depression. With this model responsibility is shared by the health professional and the patient. Ideally patients should see themselves engaged in self-management with the practitioner as a resource. The most respected national guidelines, such as those from multi- disciplinary expert panels in the UK and USA supports this biopsychosocial model which calls for spinal manipulation and/or simple medications to help with pain and function, together with patient motivation, education and continuation of activities of daily living for the great majority of patients.
In most countries, organized medicine was reluctant to accept this change which undercut, the role of physicians in a huge area of practice/economic turf (back problems are the second most common reason patients seek professional help). Medicine has accepted some major modifications over the last decade in practice such as the move from rest to early activity, more education and motivation of patients with self care, conservative use of medication and surgery, but typically only the modifications that leave patients under medical care, despite the contrary best practices guidelines.
There is strong evidence that chiropractic management produces superior results in terms of terms of safety, effectiveness, cost effectiveness and patient satisfaction. The government funded Manga Report in Canada reported these results in 1993 and has been strengthened by much research since. Recently, on October 11, 2004 the Archives of Internal Medicine, a respected journal of the American Medical Association published the results of a 4 year comprehensive study of managed care data in California supporting the cost effectiveness of Chiropractic care.
Even more recently, the United Kingdom Back Pain Exercise and Manipulation trial (BEAM) sponsored by the British Medical Research Council (MRC) and just published by the British Medical Journal asked the fundamental question of- What care should family doctors be offering most of their back pain patients? The results of this well designed and large trial concluded convincingly that the best care of most back pain patients in general now requires referral for a skilled assessment of biomechanical function and provision of physical treatments, particularly spinal manipulation.
The results of these and other studies pose a significant challenge to policy makers and the medical profession. Under most health care systems due to government policies there are financial and other barriers to chiropractic care. From the above studies, particularly the BEAM trial the most rational policy direction is to encourage patients to consult chiropractors (who are well trained in diagnosis and spinal manipulation) directly. Compelling logic for this policy is the good evidence that chiropractic management produces superior results in terms of safety, effectiveness, cost effectiveness and patient satisfaction. Another reason for a policy shift is the fact that it would help take the burden off overworked family physicians and would help ease the financial burden of the health care services in Canada. Current research data shows spinal manipulation provides a cost-effective addition to best care guide lines for low back pain patients in general practice.
With spiraling health care costs, and pressures to follow evidence-based guidelines from government and third party payers there will hopefully be more cooperation between medical and chiropractic institutions. As a patient suffering from back pain that is not responding to traditional medical management, perhaps a discussion with your physician about treatment options prior to accepting another prescription of pain killers and muscle relaxants is indicated. Again based on the scientific evidence a biopsychosocial model of care is the best care for most low back pain patients.