As the largest existing analysis of scientific literature on low back pain, the 1993 Ontario Ministry of Health commissioned study drew international attention when it recommended the management of low back pain be moved from medical doctors to chiropractic doctors.

Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

The researchers also stated that studies on the prevalence and incidence of low back pain suggest that it is the leading cause of disability and morbidity in middle-aged persons, and is by far the most expensive source of workers' compensation costs North America.

• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by nonchiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;
• In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:
• the effectiveness and cost effectiveness of chiropractic management of low back pain
• the untested, questionable or harmful nature of many current medical therapies
• the economic efficiency of chiropractic care for low back pain compared with medical care
• the safety of chiropractic care
• the higher satisfaction levels expressed by patients of chiropractors.

The following recommendations were also included in the report:

• There should be a shift in policy to encourage and prefer chiropractic services for most patients with low back pain;
• Chiropractic services should be fully insured under the Ontario Health Insurance Plan;
• Chiropractic services should be fully integrated into the health care system;
• Chiropractors should be employed by tertiary hospitals in Ontario;
• Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs;
• Chiropractic should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients;
• Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with low back injuries;
• A very good case can be made for making chiropractors the gatekeepers for management of low back pain in the workers' compensation system in Ontario;
• The government should make the requisite research funds and resources available for further clinical evaluations of chiropractic management of low back pain, and for further socioeconomic and policy research concerning the management of low back pain generally;
• Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public finding;
• Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.

   1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

The Agency of Health Care Policy and Research Study

On December 8, 1994, the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services released Clinical Practice Guidelines for the management of acute low back pain. Their guidelines were developed after extensive study of diagnostic and treatment methods for acute low back pain.

The guidelines were created by the AHCPR panel to provide primary care clinicians with information and recommended strategies for the assessment and treatment of acute low back problems. The AHCPR panel was made up of 23 members consisting of medical doctors, chiropractic doctors, nurses, experts in spinal research, physical therapists, an occupational therapist, a psychologist, and a consumer representative.
The following conclusions were made in this landmark study:

• Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
• Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.
• Other interesting finds included:
• The risk of serious complications from lumbar spinal manipulation is rare;
• There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
• The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.

   1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (1994) - U.S. Department of Health and Human Services.

Chiropractic vs. Hospital Outpatient Management for Low Back Pain Study Abstract

Objective - To compare the effectiveness over three years of chiropractic and hospital outpatient management for low back pain.

Design - Randomised allocation of patients to chiropractic or hospital outpatient management.

Setting - Chiropractic clinics and hospital outpatient departments within reasonable traveling distance of each other in 11 centres.

Subjects - 741 men and women aged 18-64 years with low back pain in whom manipulation was not contraindicated.

Outcome Measures - Change in total Oswestry questionnaire score and in score for pain and patient satisfaction with allocated treatment.

Results - According to total Oswestry scores 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.

Conclusions - At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.

   1. British Medical Journal. August 05, 1995.

90% Receiving Regular Medical Care Still Suffer Low Back Pain 1 Year Later
Study Overview

1. It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month
2. In a large population based study we examined the outcome of episodes of low back pain in general practice with respect to both consultation behaviour and self reported pain and disability
3. While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability
4. Only 25% of the patients who consulted about low back pain had fully recovered 12 months later
5. Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact

Study Abstract

Objectives - To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month.

Design - Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation.

Setting - Two general practices in south Manchester.

Subjects - 490 subjects (203 men, 287 women) aged 18-75 years.

Main Outcome Measures - Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months.

Results - Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 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 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability.

Conclusions - 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.

   1. British Medical Journal. 1998;316:1356-9

Heavy Lifting Dries Out Vertebral Discs

Heavy lifting may trigger a range of physiological changes that can hasten damage to the discs that cushion the bones of the spine, eventually leading to back pain and disability, according to a study presented by California researchers at a meeting in Belgium on Friday. The study findings may lead to better treatments for back pain and new ways to prevent back injuries.

The report helps shed light on the changes that lead to disc degeneration, a condition in which the spongy cushions separating the vertebral bones in the back become dehydrated and damaged. A common condition, disc degeneration can be painful and debilitating.

"The findings should lead to improved treatments for one cause of low back pain, disc degeneration," noted lead author, Dr. Jeffrey Lotz, of the University of California at San Francisco. The findings should also help researchers determine how much weight people can lift safely.

Lotz and colleagues examined the way compression affects the discs in the tails of mice. A mouse's tail is an extension of its spine, and includes discs similar to those in the human back.

The researchers attached a device that exerted varying degrees of pressure on the discs in each mouse's tail. They found that chronic compression triggered an array of changes in both the structure and biological activity of the discs.

Among other things, chronic compression killed cells in the discs. The greater the pressure, the greater the number of cells killed. Widespread cell death eventually limited the surviving cells' ability to maintain and repair the discs, the authors found. Over time, this caused water loss inside the discs, leaving them dehydrated. Once dehydrated, the discs were less able to withstand pressure, and bulged outward.

Dehydration of the discs triggered other changes, including the release of chemicals that appeared to irritate surrounding nerves, the researchers found. The release of these chemicals, and the pressure that bulging discs might exert on nearby nerves, may cause the pain associated with disc degeneration, the researchers report.

In light of these findings, it may be possible to treat degeneration by injecting damaged discs with growth factors that stimulate cell repair, note the researchers, who are now testing this procedure. If the technique is successful, it could be an alternative to back surgery, the current treatment for disc degeneration.

   1. Reuters. June 12, 1998.