Back pain is a major
health problem in today’s society. It is one of the most
common complaints of individuals, with Canadians
reporting a point prevalence of almost 30% and a
lifetime prevalence of 84%.1 Well over 90% of
individuals experiencing back pain suffer from
uncomplicated mechanical back pain and its course is
generally recurrent or fluctuating in nature.1
Despite numerous studies,
the etiology of back pain continues to be poorly
understood. In addition, some studies have reported
gender differences as predictors of back pain.2 In men,
the onset of chronic back pain is associated with low
self-reported health, greater height, heavy physical
work, stress, and age between 45 to 64 years.
Self-reported restrictions in activity, arthritis,
stress, and history of psychological trauma have been
associated with chronic back pain among women.2
Reducing Pain and Restoring Function
Back pain can be
classified into main and minor etiologies. The main
etiologies include muscular, osseous, disc related, and
neural causes.3 All pain-sensitive tissues in the back
are potential pain generators. These tissues include the
facet joint capsule, the outer annular fibers of the
intervertebral disc, the anterior and posterior
longitudinal ligaments, and the lumbar paraspinal
muscles.4 Chiropractors are well trained to assess,
diagnose, and treat the various causes of back pain, as
well as identifying those with red flags that require
appropriate referral.5
Prior to commencing
treatment, chiropractors conduct a thorough patient
history followed by a relevant physical examination that
typically includes neurological, orthopedic and special
chiropractic tests such as posture analysis, soft tissue
palpation, and motion and static palpation of the spine.
In addition, X-rays or referrals for special imaging are
performed if indicated.
The goal of chiropractic
treatment for back pain patients is to reduce the
duration of the symptomatic period, improve functional
status, and facilitate early return to work and normal
activity.6 Research has demonstrated that chiropractic
therapy is effective for pain reduction, improving
functional status, and return to work.6,7 This overview
focuses primarily on uncomplicated back pain and
disc-related back pain; however, there are several other
causes of back pain which are effectively treated by
chiropractors. These include costovertebral joint pain,
facet irritation, simple muscle strains, and postural
syndromes.5
A
Multimodal Approach
Best evidence supports
the use of a multimodal approach for the management of
back pain. Chiropractors are highly trained to deliver
this approach which includes the following:
Patients presenting with mechanical back
pain typically report specific aggravating and relieving
positions and activities. These patients may also
frequently report referred pain into regions such as the
buttocks, thighs, or shoulder regions.8 The majority of
patients with uncomplicated back pain will be improved
within 4 to 12 weeks. Even so, due to the episodic
nature of back pain it is not uncommon for patients to
experience periods of exacerbations.8,9 Although this
form of back pain may be self-resolving, pain levels,
radiculopathy, and disability often lead to functional
limitations and an altered quality oflife.10
In addition to pain management, chiropractic care of
mechanical back pain focuses on improvement of
functional outcomes, mobility and behavior and return to
work and normal activities as quickly as possible.
Disc
Herniation
The prevalence of
symptomatic disc herniations is uncertain, although it
has been reported that internal disc disruptions may
account for up to 40% of low back pain.11,12 The
clinical presentation of nerve root compression
following disc herniation includes dermatomal
lancinating pain or paresthesia into a lower limb(s)
with or without back pain. The clinical course of
symptomatic lumbar disc herniations is generally quite
varied. However, within the first two months following
therapy such as rest, exercises, bracing, and NSAIDs,
60% of patients report a reduction in back and leg pain.
Still, at six months to one year, between 20% and 30% of
patients continue to suffer from some symptoms.
8,1113,14
The goal of chiropractor
treatment is to reduce the duration of the symptomatic
period while improving function. Chiropractic care for
disc herniation is considered conservative therapy and
practitioners may choose a variety of modalities to
treat this complaint. In addition to spinal
manipulation, chiropractors may utilize mobilizations,
electrotherapy, soft tissue therapy, and exercises as
methods of pain control and functional improvement.15,16
These therapies provide periods of decreased pain,
allowing patients to perform their daily activities. One
study notes that 90% of symptomatic disc patients
improved with a course of chiropractic care, while 75%
of patients demonstrated significant clinical
improvements.15 Co-management of these patients with
pharmaceutical pain agents may also be indicated.8
Chiropractors are trained
to refer to medical doctors when appropriate and in a
timely manner. Referral for further investigation is
indicated if there is a progression in neurological
symptoms, evidence of cauda equina syndrome, or poor
response to conservative care.
Individualized Exercise
Chiropractors receive
training in rehabilitation and exercise prescription in
order to assess and devise appropriate exercise programs
for patients. In relation to back pain, core
stabilization programs are a vital component of back
pain therapy. Irrespective of the presenting complaint,
recent literature has highlighted the effectiveness of
exercise and the need for individualized exercise
therapy for back pain patients.5,17,18,19 New
perspectives in the area of exercise research are
focusing on motor control problems in addition to
strength, endurance, and fitness. Segmental
stabilization training is based on research in the
fields of biomechanics, neurophysiology, and
physiotherapy. Research in this area is now being
applied to back pain patients in order to develop an
individualized approach to neuromuscular
dysfunction.20,21
A recent meta-analysis of
exercise therapy for non-specific low back pain
concludes that exercise therapy confers some clinical
benefit in terms of pain reduction and improved function
for adults with chronic low back pain.17 This benefit is
likely to be enhanced when combined with other
chiropractic therapy such as SMT.22
Efficacy, Safety and Satisfaction
The effects of spinal
manipulative therapy and chiropractic have been
extensively investigated. Numerous systematic reviews
have concluded that for acute and chronic low back pain,
chiropractic care and SMT provide greater benefits than
other forms of conservative therapy.6,22,23 In addition,
spinal manipulation followed by exercise was found to
confer a significant clinical benefit to patients at
both three months and twelve months.22 Patients
typically report clinical improvement in their
uncomplicated and disc-related back pain.7,13
Chiropractic care for
back pain and lumbar disc herniations is a safe and
effective form of therapy. It has been calculated that
less than one in 3.7 million manipulations may result in
a disc herniation or cauda equina syndrome (CES).13
Research in the area of
utilization patterns and cost-effectiveness of
chiropractic care has demonstrated that those patients
with chiropractic insurance coverage have lower total
health care expenditures and lower average back pain
episode-related costs.24 The WSIB of Ontario recently
reported that acute low back pain patients had lower
levels of pain and disability and a faster return to
work when treated by chiropractors.6
In addition to the
physical benefits related to chiropractic care, it is
important to consider patient expectations and
satisfaction with care. Individuals treated by
chiropractors repeatedly report very good to excellent
levels of satisfaction with care and a greater level of
satisfaction of care compared to other health care
providers.25,26
Summary
Among the multitude of
musculoskeletal problems that chiropractors treat, back
pain makes up the largest part. Chiropractors are highly
trained to assess, diagnose and manage back pain using a
rational and evidence-based approach, and when
indicated, to refer to medical doctors in a timely
manner. Chiropractors incorporate effective forms of
therapy such as spinal manipulation, exercise,
electrotherapy and advice to improve patients’ pain and
mobility. Patients with back pain have demonstrated
higher levels of satisfaction and earlier return to work
and activities with chiropractic care compared to other
approaches. Medical doctors can be confident that
chiropractors have the knowledge and skills to
effectively manage the significant problem of back pain
in our society today.
This overview has been
researched and written by The Canadian Memorial
Chiropractic College (2005).
References
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