T he most recent update to the American College of Physicians Guidelines (ACPG) suggests that a conservative approach to the treatment of low back pain is more beneficial to the patient compared to traditional medical care like drug therapy (Qaseem et al., 2017). Studies suggest that low back pain can improve over time regardless of treatment. Conservative therapies like comprehensive chiropractic care can aid the patient in their recovery with minimal risk and low cost.
In addition, it has been shown that incorporating chiropractic care into standard medical care can improve outcomes in patients with low back pain. Comprehensive chiropractic care addresses musculoskeletal issues to help decrease a patient’s pain and increase their function. The typical treatment will include manual therapy like spinal manipulation and massage, combined with rehabilitative exercise, ice or heat therapy, and other modalities like electric stimulation and cold laser. Treatment varies on a patient-by-patient basis, depending on the diagnosis and other considerations like lifestyle and activities.
What About Traditional Medical Care Options Such As Opioids and Surgery?
Because low back pain symptoms may improve over time regardless of treatment, the ACPG advises avoiding invasive and expensive treatments. For example, they suggest avoiding prescribing narcotics and long-term opioids that could be harmful and instead suggest low-harm and low-cost therapies like massage, heat, exercise, and spinal manipulation. Interventions like spinal manipulation help to restore the normal joint function of the spine, which has been shown to have long term benefits (Haas et al., 2014).
Invasive therapies like surgery or drugs (Webster et al, 2007) could possibly result in adverse effects in patients which can cause problems over time. A study by Keeney et al (2012) suggested that the likelihood of surgery in patients decreased if patients were seen by a chiropractor first versus seeing a surgeon first for their low back pain. This was a cohort study on occupational low back pain where subjects either saw a chiropractor or a surgeon first for their low back pain. It was found that 42.7% of participants who saw a surgeon first for their low back pain ended up having surgery, in comparison to only 1.5% of participants that visited their chiropractor first that underwent surgery.
These findings suggest that undergoing a trial of conservative therapy could provide patients with enough relief that they do not need to participate in a more invasive treatment like surgery. In addition, interventions like spinal manipulation help to restore the normal joint function of the spine, which has been shown to have long term benefit.
Can A Spinal Adjustment Really Help Reduce Pain?
Yes! Spinal manipulation can help reduce patients’ pain (Haas et al., 2014). A systematic review and meta-analysis of 26 randomized clinical trials of spinal manipulation for acute low back pain by Paige et al (2017) suggests that spinal manipulation is associated with some improvement in pain and function and the ACPG suggests spinal manipulation for treatment of all three categories (acute, subacute, and chronic) of low back pain.
In comparison to traditional healthcare, it was found that people had more relief from self-reported pain after manual-thrust manipulation versus those who were treated with medical care (Schneider et al, 2015). Given these findings, suggestions from the ACPG, and the safety of spinal manipulation (Stevenson&Ernst, 2002), spinal manipulation can be a useful tool in helping patients recover from pain.
A Sport and Spine Rehab Case Study
At Sport and Spine, we very frequently see positive results treating musculoskeletal issues using comprehensive chiropractic treatment. An example of a patient that may present into our office and our prescribed treatment plan is detailed below:
- John Doe is a 35-year-old male who works as a software engineer. He presents with low back pain.
- His back pain began one week ago when he was lifting a 45lb box out of the trunk of his car; he felt the pain immediately afterward.
- He describes his pain as a constant dull ache and points to both sides of his low back as areas of pain. He rates the pain to be 6/10 on average but 8/10 with movements like bending and twisting. Sitting for more than 30 minutes becomes uncomfortable and Mr. Doe must walk around to relieve some of the pain.
- Mr. Doe denies pain in his legs. He denies any weakness or clumsiness in his legs. He denies any recent weight loss or night sweats. He has no history of trauma, accidents, or injuries. He denies any history of infection or cancer.
John Doe’s vitals are as follows:
- Height – 5’9”
- Weight – 160lbs
- Left arm blood pressure – 115/80
- BPM: 80
Orthopedic testing revealed the following:
- Range of motion: pain with flexion, left and right rotation
- Sensory dermatomes of the lower extremity revealed equal and normal sensation bilaterally.
- Standard muscle strength tests of the lower extremity were 5/5 without pain except for iliopsoas, which was graded 5/5 with pain localized in the lower back.
- Achilles’ and Patellar tendon reflexes were +2
- Kemp’s: Negative bilaterally
- Slump’s test: Negative bilaterally
- SLR/WLR: Negative bilaterally
- FABER: Negative bilaterally
- SI compression: Negative bilaterally
- Yeoman’s test: Positive bilaterally for localized low back pain
- Valsalva’s test: negative
Hypertonicity and tenderness of bilateral lumbar erector spinae and bilateral quadratus lumborum musculature.
Subjective and objective findings are suggestive of mechanical low back pain, and not suggestive of cancer, infection, or fracture.
Our treatment plan would include:
- Massage therapy to the lumbar erector spinae and quadratus lumborum musculature to help decrease pain and hypertonicity of the muscles
- Spinal manipulation to lumbar spine to decrease pain and increase pain-free ROM
- Rehab exercises, focused on progressive strengthening and stabilization to support his low back
Studies (Paige et al, 2017; Qaseem et al, 2017; Schneider et al, 2015) demonstrate the effectiveness of spinal manipulation for Mr. Doe. He does not have a history of cancer, infection, or trauma. He does not demonstrate any sign of fracture or instability and there are no contraindications to manipulation.
Comprehensive chiropractic care encompasses many conservative treatments which have been shown to address the reduction of pain and increase of function with minimal risk and low cost. A trial of these therapies should be undergone before the patient is a candidate for more invasive or risky treatment like surgery or narcotics.
- Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients with Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study. (2013) Goetz, C.M., Long, C.R., Hondras, M.A., Petri, R., Delgado, R., Lawrence, D.J., Owens, E.F., & Meeker, W.C. Spine: 38(8): 627-634
- Dose-Response and Efficacy of Spinal Manipulation for Care of Chronic Low Back Pain: a Randomized Contolled Trial. (2014). Haas, M., Vavrek, D., Peterson, D., Polissar, N., & Neradilek, M.B. Spine: 14(7): 1106-1116
- Early Predictors of Lumbar Spine Surgery After Occupational Back Injury: Results from a Prospective Study of Workers in Washington State (2013). Kenney, B.J., Fulton-Kehoe, D., Turner, J.A., Wickizer T.M., Chan, K.C., Franklin, G.M. Spine 38(11):953-964
- Association of Spinal Manipulative Therapy with Clinical Benefit and Harm for Acute Low Back Pain: A Systematic Review and Meta-analysis. (2017) Paige, N.M, Isomi, M., Miake-Lye, Marika Suttorp Booth, Beroes, J.M., Aram, S., Mardian, Dougherty, P., Branson, R., Tang, B., Morton, S.C., Shekelle, P.G. JAMA 317(14):1451-1460
- Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute and Subacute Low Back Pain: A Randomized Clinical Trial. (2015) Schneider, M., Haas, M., Glick, R., Stevans, J., Landsittel, D. Spine 40(4):209-217
- Risks Associated with Spinal Manipulation (2002). Stevinson, C., Ernst, E. The American Journal of Medicine 112(7): 566-571
- Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. (2017) Qaseem, A., Wilt, T., McLean, R.M., Forciea, M.A. Clinical Guidelines Committee of the American College of Physicians
- Relationship Between Early Opioid Prescribing for Acute Occupational Low Back Pain and Disability Duration, Medical Costs, Subsequent Surgery, and Late Opioid Use. (2007) Webster, B.S., Verma, S.K., Gratchel, R.J. Spine 32(19): 2127-2132