Research Review Corner: May 2009

Pain conditions account for the bulk of visits to primary care
providers, and back pain is the most common of these. The frequency of
back pain complaints has spawned a variety of diagnostic tests and
treatment interventions aimed at reducing pain levels,

Background Information:
Pain conditions account for the bulk of visits to primary care providers, and back pain is the most common of these. The frequency of back pain complaints has spawned a variety of diagnostic tests and treatment interventions aimed at reducing pain levels, limiting disability, and reducing recurrence. Sadly, the use of many of these tools is expanding beyond their scientifically validated indications, driven by doctor concern or confusion, patient advocacy, and aggressive media and marketing campaigns for various products and interventions.

The authors state eloquently that: “Innovation has outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments.”

This study discussed the impact of common interventions used in the medical management of chronic back pain. Manual interventions, including manipulation, were not included in this study. However, prudent clinicians should be conversant in the current impact of other common medical decisions relating to imaging, medication, and referral for injections and surgery for back pain complaints.

Pertinent Results:
Imaging for Low Back Pain:

• the use of lumbar MRI increased 307 per cent in a recent 12 year period (American Medicare data)
• surgery rates are highest geographically where imaging rates are highest – patients who receive early imaging (CT/MRI) have higher rates of surgery than those who receive only plain film x-rays, yet the clinical outcomes are no better
• when judged against clinical guidelines (that all recommend against routine use of imaging for LBP), an estimated 33-66 per cent of spinal CT and MRI studies may be inappropriate
• it is well known now that imaging findings correlate poorly with clinical symptoms and also patient outcomes

Opioid Analgesics:

• prescriptions increased 109 per cent between 1997-2004, resulting in a 423 per cent increase in inflation-adjusted expenditures
• by 2002, there were more deaths attributable to opioid medication use than cocaine and heroin combined
• more than half of all opioid prescriptions are for back pain
• Cochrane Collaboration review indicates that there are few high quality trials assessing their efficacy, while potential side effects are well documented (hyperalgesia, hypogonadism etc.)
• the long-term benefit of these medications for back complaints is questionable

Spinal Injections:

• have limited efficacy in general, and do not reduce the incidence of subsequent back surgery (according
• 
  to systematic reviews)
• a recent 7 year interval demonstrated a 271 per cent increase in epidural injections, a 231 per cent increase in facet joint injections, and a 629 per cent increase in associated fees (of note is that the Medicare patient population increased by only 12 per cent in this time)
• for patients with axial back pain without sciatica there is no evidence of any benefit from injections

Spinal Surgery:

• there was a 220 per cent increase in spinal fusion surgery in the US between 1990-2001
• surgery has a well-established role in treating fractures and deformity, but limited evidence for treating degenerative discs with back pain alone (no sciatica)
• from 1995-2000 Medicare data: there was a 40 per cent increase in spine surgery, 70 per cent increase in spinal fusions, and a 100 per cent increase in the use of implants (it is interesting to note that reoperation rates also increased during this time)

Conclusions and Practical Application:
The overall understanding of back pain mechanisms remains rudimentary. The use of imaging, injections, and surgery has increased sharply in the management of common back pain complaints, with little corresponding increase in treatment efficacy and success. Most patients continue to experience some degree of pain and dysfunction. American data from 2005 indicates that back pain patients are reporting more functional, social and work limitations, as well as diminished mental health compared to 1997 data. Overall, the current management of back pain is not highly successful.

Chiropractors and other manual therapists are ideally positioned to play a leading role in a multidisciplinary approach to chronic back pain. We can expertly provide spinal manipulation and adjunctive therapies, exercise and rehabilitation, and appropriate biopsychosocial support – all of which have shown promise in the literature.

This study did not directly address manual medicine interventions for back pain, but did illustrate that common, often more invasive treatments and interventions do not improve outcomes to a degree that justifies their increasing use.

Study Methods:
This study was a qualitative and narrative review of the literature and Medicare data on interventions for back pain. Studies on manual therapy interventions were not included. For more information on the literature pertaining to chiropractic interventions for back pain and other conditions, visit www.researchreviewservice.com .

Dr. Shawn Thistle is the founder and president of Research Review Service Inc., an online, subscription-based service designed to help busy practitioners to integrate current, relevant scientific evidence into  their practice. Shawn graduated from CMCC and holds an Honours Degree in Kinesiology from McMaster University. He also holds a certificate in Contemporary Medical Acupuncture from McMaster University, and is a Certified Active Release Techniques (ART®) Provider.  For more information about the Research Review Service, visit  www.researchreviewservice.com.