Background: Although many chiropractors will examine and provide passive therapy, including spinal manipulation, to their patients; the evidence supporting that traditional approach is lacking in the literature.
Objective: The purpose of this literature review was to examine the natural history of back pain and the commonly used diagnostic procedures. The literature was also reviewed for evidence of physical modalities and spinal manipulation effectiveness. Evidence-based guidelines were also examined.
Methods: The global research strategy was to perform on-line searches of pertinent databases. The focused strategy was to search allopathic and Complementary Alternative Medical (CAM) databases for the most current literature available, including evidence-based and clinical practice guidelines.
Results: The natural history of acute back pain is 6 weeks. Almost all of the commonly used diagnostic procedures and passive modalities utilized by chiropractors are not supported in the available literature. Spinal manipulation has mild support in the treatment of acute low back pain, only being equal to or slightly superior to a placebo. The manipulable lesion appears to be hypothetical.
Conclusions: The literature supports the following statements: The natural history of acute back pain is 6 weeks. The most commonly used diagnostic tests to determine the anatomical site of acute back pain lack reliability and validity. The common therapeutic interventions used in treating acute back pain, spinal manipulation and passive therapies, are not improving patient outcomes.
Evidence-based literature for the diagnosis and treatment of acute mechanical back pain is voluminous. With a wide variety of treatment approaches, many with little or no evidence-based data to support them, the need for consistent and valid treatment remains. The purpose of this paper was to review the literature focusing on the natural history, validity of diagnostic tests, spinal manipulation, passive modalities, and clinical guidelines for acute mechanical back pain.
Methods and Materials
The global research strategy was to perform on-line searches of pertinent databases. The focused strategy was to search allopathic and Complementary Alternative Medical (CAM) databases for the most current literature available, including evidence-based and clinical practice guidelines.
The majority of the referenced literature came from The National Library of Medicine and its retrieval engine PubMed. Healthstar and Internet Grateful Med were available at this site. The National Guideline Clearing House, The Cochrane Library, and Trip Data Base provided numerous sources of information. The National Center for Complementary and Alternative Medicine provided several databases and referenced materials. All of these databases can be found on-line. Specific sites that produced useful documents were the University of Illinois Library and its Evidence-Based Medicine Service. The British Medical Journal and the Centre for Evidence-Based Physiotherapy were also found to be productive.
The natural history of a disease is generally defined as the expected improvement rate even without therapeutic intervention. Baker (1999) stated, “There is something we can’t ignore. Back pain, like other health problems,has a natural history” (p.1). Henderson, Chapman-Smith, Mior, and Vernon (1994) stated that frequency and duration of treatment and/or care should never extend beyond the natural history (p. 88).
After an extensive review of the available literature, Frymoyer found that the natural history of acute low back pain (i.e., what will happen in patients with the problem if no intervention is undertaken) is such that the symptoms resolve in 6 weeks in 90% of cases (Baker, 1999). Nordin and Campello (1999) indicate that the natural history of non-specific low back pain is known and the prognosis is good. Ninety percent of the patients presenting with acute back pain recover within 6 weeks (p. 78). Guides published in Amsterdam were also in agreement that 6 weeks is the natural history of low back pain. They state that episodes are usually self-limiting and most of the patients (90%) seem to recover from an attack of back pain within 6 weeks regardless of the type of treatment given (Jonsson, 2000). In another study, Coyer found that at the end of 6 weeks only 12% of the manipulated group had signs and symptoms (Fugh-Berman, 1997, p. 53).
The American Academy of Orthopedic Surgeons – North American Spine Society (1996) stated that lower back pain tended to be a self-limiting problem of relatively short duration and the majority of patients could be expected to improve completely or significantly after approximately 4 weeks of treatment (p. 2). The natural history is the same for practitioners of spinal manipulation. Herzog recommends that patient reassessment should occur at 4 weeks and therapy stopped, if functional improvement has not been achieved (2000, p. 209). The U.S. Department of Health and Human Services Agency for Health Care Policy and Research (AHCPR) recommends spinal manipulation should be stopped at 4 weeks, if there is no patient improvement. Once the acute condition has abated, usually within 4 to 6 weeks, as evidenced by a decrease of symptoms; negative physical findings; and fuller range-of-motion, patients can be released from active care (Gatterman, 1990, p. 241).
The Scientific Monograph of the Quebec Task Force on Whiplash Associated Disorders established the natural history of whiplash. The task force concluded, “It is reasonable to estimate a healing period between four and six weeks. Many cases are mild and will heal in a much shorter time” (Cassidy, 1995, p. 22S).
Nachemson (1985) indicates that the natural history of back pain is extremely good. Only 10% suffer, even when disabling, for more than 6 weeks. Almost 60% return to work within 1 week. Nachemson believed it was difficult to establish effectiveness in prospective randomized clinical trials in a disease where the natural history is so good. The Mayo Foundation for Medical Education and Research (1997) developed a medical essay on back care. According to this essay, “Episodes of back pain usually resolve within two weeks. And regardless of the type of treatment, 80% to 90% of back pain resolves within six weeks” (p. 4). An Australian group, the NSW Therapeutics Assessment Group (1998), stated that 90% of patients with acute episodes of back pain recover within 2 weeks (p. 1).
Validity of Diagnostic Evaluations
A variety of diagnostic tools are routinely used to monitor a patient’s natural history to recovery. French, Green, and Forbes (2000) examined the 8 most frequently used spinal diagnostic methods for intraexaminer and interexaminer reliability. These techniques included postural analysis, patient pain description, plain x-ray, leg length discrepancy, motion palpation, static palpation, neurological tests, and orthopedic tests. The study revealed that the measures tested were not reproducible. Individual tests unique to chiropractic medicine have come under scrutiny. Hawk et al. (1999) stated, “Palpation is one of the most common methods for identifying manipulable lesions but has not demonstrated consistently high intra or interexaminer reliability” (p. 382). Even chiropractors trained in the same technique found no common ground as to when and where to provide treatment.
Hestboek and Leboeuf-Yde (2000) found that “The detection of the manipulable lesion in the lumbosacral spine depends on valid and reliable tests. Thus far no manual or visual test has been identified that fulfills minimal criteria of consistent reliability and validity” (p. 258). Based on their project and other authors, they concluded that “procedures found to be useless should then be excluded from our clinical perspective and useful tests, if any, should be promoted at undergraduate and postgraduate levels” (p. 258).
The biomedical approach to back pain has not changed considerably for decades with the most common interventions still being physical therapy, allopathic or surgical techniques. With the advent of evidence-based medicine and clinical practice guidelines, the old-line approach is being challenged. Hansson and Hansson (2000) stated, “Almost none of the commonly occurring and frequently practiced medical interventions for patients, who are sick-listed because of low back pain, had any positive effects on either the recorded health measures or work resumption” (p. 3062). Seferlis, Nemeth, Carlsson, and Gillstrom (1998) concluded that patients with or without sciatica symptoms improved after 1 month, regardless of conservative treatments being utilized. There were no differences at short or long term follow-ups (p. 468). Bogduk (1999b) concluded that the current evidence did not support most of the physical therapy, allopathic or surgical techniques practiced. He fel
t reassurance was most important in acute cases and nothing really was proven effective in chronic low back pain (p. 261).
Under the direction of Dr. Toyoshima, M.D., thedepartment of family medicine at the University of Iowa compared physicians’ approaches to acute back pain.Patient outcomes did not differ when treatments by a chiropractor, orthopedic surgeon, or family practitioner were given. He also concluded that the general practitioner was the most cost-effective method. A Cochrane Library review of the literature determined that there is little information from randomised clinical trialsto support the use of physical therapy modalities (Gross,Aker, Goldsmith, & Peloso, 2000, p. 4).
A similar study by Koes, Assendelft, van der Heijden, Bouter and Knipschild (1991) was performed at the University of Limburg of the Netherlands. Patients were compared at 3, 6 and 12 weeks after receiving a placebo, physical therapy, and manual therapies. A difference in effectiveness between physical therapy and manual therapy was not present; and any subjective improvement by patients appeared to be due to the placebo effect (p. 33). Godfrey, Morgan and Schatzker (1984) did a second study relating to this research. It gave rotational treatment to acute low back pain; controls were provided with minimal massage and low- level electrical muscle stimulation. No statistical significance between the two groups was shown (p. 303). Hansson and Hansson (2000) conducted a prospective 2-year cohort study in six countries confirming that almost none of the commonly used medical interventions had any positive effect on recorded health measures or returning to work status (p. 3062).
A commonly used intervention for back pain is manual therapy in the form of spinal manipulation. Koes, Assendelft, van der Heijden, and Bouter (1996) performed a systemic review of randomised clinical trials and published the following conclusion, “The efficacy of spinal manipulation with acute or chronic low back pain has not been demonstrated with sound randomised controlled trials” (p. 2873). Northwestern College of Chiropractic concluded that no conclusive evidence exists for spinal manipulation, short or long term (Bronfort, 1999, p. 110).
Bennett (1990) found what he called a peculiar feature, “The number of chiropractic treatments (spinal manipulation) bore no clear relationship to the results” (p. 2). According to Gottlieb (1998), researchers from the University of Washington challenged the main reason patients seek chiropractic care, spinal manipulation. This study concluded that spinal manipulation and specialized physical therapy are only slightly better than doing nothing at all (p. 1036). The Institute for Clinical Evaluative Sciences (1995) reported on a vast array of back pain treatments. The institute concluded that manipulation was one of a few procedures with some support in the acute phase, but not after one month or as a prophylactic measure (p.2). The results of a study by Kjellman, Skargren and Oberg (1999) were inconclusive when the efficacy of physical therapy or chiropractic treatment for patients was reviewed and related to outcome improvements in neck pain treatments. The limited number of trials of methodological quality made it difficult to form any conclusions about the benefits of reviewed treatment (p. 151).
Although there are several forms of passive modalities, research focused on the three main forms: ultrasound, massage, and traction. The researched studies did not provide any evidence that these therapies are effective, nor could the studies promote usage of them.
Ultrasound therapy is used frequently by physical therapists and chiropractors. When evaluating its effectiveness, it is lacking therapeutic substance. According to van der Windt et al. (1999) , “As yet there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders” (p. 270).
Another popular passive therapy is massage. Massage is frequently used to relieve the symptoms of back pain. A systematic review of therapeutic massage revealed only a few studies. In addition, the studies were of poor methodological quality. What was evident was a need for more studies of increased quality (Ernst, 1999, p. 68). Ernst suggested massage was no better in results than doing nothing, similar to spinal manipulation. Another Ernst study placed massage below spinal manipulation in effectiveness. A Cochrane database systematic review of the literature stated, “There is insufficient evidence to recommend massage as a stand-alone treatment for nonspecific low back pain”(Furlan, Brosseau, Welch, & Wong, 2000, p. 4).
Another utilized treatment modality has been traction. There are numerous types of traction such as manual, mechanical, and intersegmental. Beurskeus et al. (1997) conducted a randomized controlled trial to determine traction’s benefits. They determined that proponents of this passive modality could not support the treatments’ claim of effectiveness (p. 2761). As with other modalities, the quality of studies concerning traction is also less than desirable. Beurskeus et al., in a randomized controlled trial from the Netherlands, concluded that its study could not support traction’s claim to be a therapeutic procedure (p. 2761).
Guidelines are international in scope, independent in research, and consistent in recommendations. Specific examples from the French legislation, Israeli Low Back Pain Guideline Group, Danish National Board of Health, and the University of Amsterdam have been included in this review. Other guidelines examined were from the AHCPR, the New Zealand Guidelines Group, the Australasian Guidelines, and CAM providers.
The French legislation restricts spinal manipulation to only those qualified to perform it; however, they do not recommend it due to the poor studies showing lack of any proof of efficacy (Vautravers & Isner-Horobeti, 2000, p. 1786). The Israeli Low Back Pain Guideline Group states that a doctor’s main responsibility is to diagnose the 10% of back pain that is not mechanical in origin (Borkan, Reis, Werner, Ribak, & Porath, 1996, p. 224). The Danish National Board of Health, in response to guideline development and systematic reviews, organized a multidisciplinary team of back pain specialists to create their guidelines. Their major conclusion was that providing information was preferable to treatment (Manniche & Bendix, 1998, p. 239). The University of Amsterdam produced guidelines for the Dutch general practitioners that don’t recommend spinal manipulation therapy in the treatment of acute low back pain (Assendelft, & Lankhorst, 1998, p. 686).
The AHCPR (Bigos, 1994) was the first attempt by the United States at clinical practice guidelines for acute low back problems in adults. These consensus opinions were “anchored on published scientific evidence and that such evidence should take priority over panel opinion in making guideline recommendations” (p. 7). A problem for the AHCPR panel was similar to most of the published research on low back pain; few can meet selection criteria for efficacy. This 23-member, multidisciplinary committee reviewed literature after 1984 through the Library of Medicine. Over 10,000 abstracts were reviewed with only 38%, or approximately 4,000 articles, being included. Out of the 4,000 articles, only 360 are listed as references, which once again establishes the poor methodological quality of back pain treatments.
The New Zealand Guidelines Group (1996) published its version of a consensus guideline. Its recommendations were also based on a review of the best available scientific evidence, but included an additional major recognition. The Group’s guideline was “to be used in conjunction with the Guide to Assessing P
sychological Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disability and Work Loss” (p. 1). This is the first in-depth psychological evaluation of back pain and its treatment regimes. New Zealand’s definition of natural history is that most back pain improves in a few days or, at worst, in a few weeks. This guide was consistent with the other published works pertaining to the major components of natural history, x-rays, psychosocial, activity, and commonly used intervention.
The Australasian guidelines published in November 1999 became the first and only guide solely based on evidence-based medicine, not allowing consensus or expert’s opinions (Bogduk, 1999a). Congruent to the previously mentioned guides and peer-reviewed journals, manual therapy is extensively explained. Bogduk describes it as follows, “Manual therapy is perhaps the most contentious and most bitterly contested treatment for low back pain. This arises because manual therapy is the principal therapeutic tool of several craft groups. Each group is therefore sensitive to any suggestion that manual therapy may not work as well as it professed to do” (p. 85).
Due to the poor quality of the reviews, Bogduk (1999a) suggests only blinded studies in the future to improve literature reviews on the subject. He could not recommend chiropractic or manual therapy by concluding, “The results of controlled trials and symptomatic reviews hereto stand in contrast to the recommendation of spinal manipulation by expert panels in the past. These recommendations seem to be based less on analysis of the literature and more on socially based consensus” (p. 86). The Australasian guideline is very comprehensive in scope and consistent in findings when compared to the other international guides. Its literature review source is extensive. One major conflict is the lack of recommendation for spinal manipulation. Abenhaim and Bergeron (1992) reviewed 20 years of randomized controlled trials for spinal manipulation. Twenty-one trials that offered some short-term benefit were reviewed, but confirmation that spinal manipulative therapy was the sole therapeutic agent responsible for subjective improvement in patients could not be given (p. 533).
The evidence-based literature reviewed is consistent and well written, explaining the recommendations for the treatment of acute low back pain by the authors. According to Brown, Brown, Sharma, and Garret (1999), a dominant concern for CAM providers is that evidence- based medicine is based on clinical evidence and not anecdotal story (p. 221). Improving patient outcomes is the definitive goal in guideline implementation. Heffner (1998) stated,
“An evidence-based method increases the likelihood that we will achieve the goals of clinical practice guidelines which are as follows: (1) to promote greater effectiveness and appropriateness of health care, (2) to improve access to quality care, (3) to identify our knowledge gaps to which expert judgments must be applied and therein set research priorities. (p.1765) “
In a study by Smits, Verbeek, van Dijk, Metz and ten Cate (2000), practice guidelines have been shown to improve physician performance. The quality of care improved due to the newly acquired knowledge of doctors. Similarly, compliance with the guidelines improved treatment of low back pain (p. 645). Another study by Frankel, Moffet, Keen, and Jackson (1999) revealed that a structured clinical approach to the treatment of low back pain brought some improvement to clinical outcomes and patient satisfaction improved as well.
CAM providers are not as fully aware of evidence-based medicine as their allopathic counterparts. CAM providers have recognized the following:
“These guidelines are based on the current state of scientific research and formalized consensus efforts not on unsubstantiated clinical or theoretical opinion…It has been shown that the amount of care that a chiropractic physician uses to manage various common conditions varies as much as seven fold, which is the kind of statistic that typically engenders criticism about wasteful practice and overutilization. (Hanson, 1994, pp. 2-3) “
This realization may assist CAM providers in general, and specifically chiropractors, to educate and incorporate clinical practice guidelines. Bigos (1999) stated that on a national basis, effectiveness has shown considerable benefits. Florida, Kentucky, California, Colorado, Montana, Oklahoma, Texas, and Utah require guideline use for the basis of treatment in the worker’s compensation arena (p. 191).
According to Koes, Bouter, and van der Heijden (1995), there are many types of therapeutic modalities for treating acute low back pain and most have not been studied adequately (p. 233). A growing number of physicians are realizing the importance of using the best evidence available in clinical decision-making. They feel it would help form a consensus among doctors and avoid professional biases within specialties. They hope that this is the best way to dissolve differences between allopathic and CAM providers.
A review of current scientific literature suggests that there is a consistent and predictable natural history associated with acute mechanical back pain. Many of the diagnostic tests appear to lack validity and reliability. The ability to detect a manipulable lesion is subjective and hypothetical. Spinal manipulation may offer temporary relief in patients with low back pain, but not greater than the effects of a placebo. Use of passive therapies in the treatment of acute back pain lack support in the literature.
Acute mechanical back pain has been called an epidemic in the United States. The biomedical approach appears to be failing its patients and its practitioners. A review of the literature offers some insight into the future of treating back pain. Anecdotal approaches lacking evidence may no longer receive third party reimbursements. Re-educating providers to the benefits of evidence-based protocols may be required. The natural history is established and should be encouraging to sufferers of back pain. Use of passive therapy is not supported by the literature. A recent study by Hurwitz, Morgenstern, & Harber (2002) states that physical modalities used by chiropractors did not appear to have any benefit over manipulation alone. The implications to providers could be important. The number of patient visits and the services rendered during those visits should be re-evaluated.
The major limitation of this study may be that it lacks some peer-reviewed literature not reported on or discovered during the investigation. Generalizability to other types of back pain is a potential concern. Future investigations of manual therapy could include pediatrics and veterinary practices.
The literature supports the following statements: The natural history of acute back pain is 6 weeks. Any therapeutic intervention must improve upon the natural history. The most commonly used diagnostic tests for acute back pain lack reliability and validity. The common therapeutic interventions used in treating acute back pain, spinal manipulation and passive therapies, are not improving patient outcomes. Evidence-based medicine and clinical practice guidelines are emerging as a solution to practice variations seen by both allopathic and CAM providers. The biomedical approach to treating acute back pain is failing and may become replaced with evidence-based clinical practice guidelines. Continuing double blind randomized clinical trials to solidify the current literature is encouraged.
Systematic reviews and randomized controlled trials are establishing the best evidence available for health care providers, whether medical or holistic. This paradigm shift has furthered the advancement of clinical guidelines and evidence-based medicine. Dr. Phil B. Fontanarosa, senior editor of JAMA, stated, “there is no alternative medicine, there is only scientifically proven evidence-based medicine supported by solid data proving or disproving its effectiveness” (Fontanarosa & Lundberg, 1998, p. 1618).
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Preston H. Long, Ph.D., is a Diplomate with the American Board of Forensic Examiners and acts as their Chief Liaison Officer to the state of Arizona.
Dr. Long is a Certified Disability Examiner with the National Association of Disability Evaluating Professionals.
Dr. Long is on the Editorial Board of the Journal of Quality Health Care. His corporation, Evidence-based Health Services, Inc., provides forensic examinations of documents and individuals for third parties.
He is the author of The Naked Chiropractor Insiders’ Guide to Combating Quackery and Winning the War Against Pain.