Differences in the Relationship Between Psychosocial Distress and Self-Reported Disability in Patients with Chronic Low Back Pain in Six Pain Rehabilitation Centers in the Netherlands

Preuper, Henrica Rosalien Schiphorst MD*,†; Boonstra, Anne M. MD, PhD‡; Wever, Daan MD§; Heuts, Peter H.T.G. MD, PhD¶; Dekker, Jos H.M. MD**; Smeets, Rob J.E.M. MD, PhD††; Brouwer, Sandra PhD†,‡‡; Geertzen, Jan H.B. MD, PhD*,†; Reneman, Michiel F. PhD*,†

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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 14, Number 5, 2008, pp. 465-473

Andre Broussard, D.C.

A new study by Wilkey et al., "A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-Back Pain in an NHS Outpatient Clinic: A Preliminary Study," in which chiropractic care for chronic low-back pain(CLBP)significantly outperformed medical pain clinic care in an outpatient setting within the National Health Service (United Kingdom), may provide the basis for a breakthrough in the way large health care systems handle CLBP cases.

It comes at a moment when chiropractors' ability to provide adequate courses of care for CLBP is under fire on several fronts, including managed care and worker's compensation boards in the United States. The core question is whether chiropractic is judged to be effective (and therefore reimbursable) for acute cases only or for chronic cases as well. A corollary issue is whether chiropractic is being required to meet a higher standard of evidence than medical treatments for the same condition. The first wave (1975-2005) of research on chiropractic treatment of low-back pain dealt primarily with acute cases and focused on comparing spinal manipulation to a comparison treatment or placebo. A strong majority of these studies (there are now over 40 randomized controlled trials1of spinal manipulation for low-back pain) found that manual manipulation outperformed competing options; in no study did a comparison treatment or placebo outperform manipulation. Moreover, not a single participant in any of the trials experienced a major negative reaction to chiropractic care. The evidence supporting spinal manipulation for acute low-back pain is broad and deep, leading government consensus panels in the United States, Canada, Great Britain, Sweden, Denmark, Australia, and New Zealand to recommend spinal manipulation in their low-back pain guidelines, as did recent guidelines jointly developed by the American College of Physicians and the American Pain Society.2

Chronic low-back pain has generally been seen as a separate clinical entity, reflecting the very real challenges posed by chronicity across the spectrum of human illness and across the range of treatments delivered by the various professions. In essence, the longer someone has suffered from a problem, the steeper the climb toward recovery. Overall, guidelines and reviews that endorse spinal manipulation for acute low-back pain have been more hesitant in their conclusions about its efficacy for chronic cases. This has also been true of guidelines evaluating other interventions for low-back pain. We are now entering a second wave of low-back research related to chiropractic. Two major questions at the forefront of researchers' attention are:

1. How does chiropractic management of chronic low-back pain fare in comparison to standard medical care?
2. Which patients, or categories of patients, are most likely to respond to particular approaches? In other words, what are the relevant subsets of the "nonspecific low-back pain" category that is the currently accepted diagnostic dumping station for 85%-90% of low-back pain cases?

Wilkey et al. take a significant step toward answering the first question in their excellent paper. Their study features a head-to-head comparison of chiropractic care (pragmatically defined to allow all procedures the participating chiropractors would normally employ) versus medical care in the hospital's pain clinic (defined in similar pragmatic terms).

The chiropractic and pain clinic groups started at base-line with similar levels of pain, although the chiropractic group was on average a decade older than the pain clinic group, and chiropractic subjects had endured their pain for a mean of 3 years longer (7.34 versus 4.04 years) than the pain clinic group did.

Nevertheless, improvement in pain intensity at week 8 was 1.8 points greater (on a 0-10 scale) for the chiropractic group than for the pain clinic group: a dramatic difference. Disability scores (which measure the impact of pain on daily activities) measured with the Roland Morris Disability Questionnaire also demonstrated a far greater benefit from chiropractic care, with a greater than 5-fold difference in the degree of improvement. These data measured effects through the end of the 8-week treatment period.

Prior studies 3-5 have demonstrated long-term sustained improvement in chronic low-back pain but have been criticized on methodologic grounds, for reasons described by Wilkey et al. in their paper. A follow-up to the current study (with a larger cohort and at least 6-month follow-up) could prove of major value not only for chiropractic but for the broader field of chronic pain management.

Chiropractors currently confront an ingrained mindset on the part of many insurers and medical physicians who demand that courses of chiropractic care be limited in duration, recognizing little or no difference between acute and chronic cases. Doctors and insurers who would never consider limiting chronic pain patients to a 6-week course of prescription anti-inflammatory or analgesic medication in many cases do not hesitate to place such limits on chiropractic management of chronic back pain.

Wilkey et al. have made a major contribution to these much-needed discussions. Chronic low-back pain is disabling to many people and extraordinarily expensive to the health care system as a whole, particularly when both direct and indirect costs (such as time lost from work) are considered. It is in the interest of patients, doctors, and insurers that a level playing field be adopted for the evaluation of treatments for this condition. If the data provided by Wilkey et al. can be replicated in a larger study, chiropractic management should move to the fore front of chronic low back pain care.
REFERENCES

1. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136:216-227.

2. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-491.

3. Meade TW, Dyer S, Browne W, et al. Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment [see comments]. BMJ 1990;300:1431-1437.

4. Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: Results from extended follow up [see comments]. BMJ 1995;311:349-351.

5. Kirkaldy-Willis W, Cassidy J. Spinal manipulation in the treatment of low back pain. Can Fam Phys 1985;31:535-540.

Low Back Pain Guidelines Expanded to Include Interventional Procedures

Susan Jeffrey

May 14, 2008 — The American Pain Society (APS) has expanded its evidence-based clinical practice guidelines on the diagnosis and treatment of low back pain to include recommendations on surgery and interventional treatments.

What becomes clear is the lack of hard evidence to support many of these treatments, said Roger Chou, MD, from the Oregon Health and ScienceUniversity, director of the American Pain Society's Clinical Practice Guideline Program.

The recommendations are still in the draft stage and may change before they are finally reviewed by the APS board and published, Dr. Chou told Medscape Neurology & Neurosurgery. "But based on our review, we couldn't find a lot of evidence supporting the use of many of these interventional therapies that are being done at this time," he said, particularly data from randomized trials.

A draft of the expanded guidelines was previewed at the American Pain Society 27th Annual Scientific Meeting, in Tampa, Florida.

Big Issue

The new recommendations, including surgical and interventional procedures for chronic low back pain, expand on management guidelines published in October 2007 for the evaluation and management of low back pain in primary care settings. (Chou R et al. Ann Intern Med 2007;147:478-491). These guidelines, created in collaboration with the American College of Physicians, related more to initial evaluation and management, Dr. Chou said, including the use of imaging and noninvasive interventions such as manipulation and exercise.

"This second piece is really focusing more on people who aren't responding to those kinds of therapies, who have persistent back pain," he said. This group is a "big issue," he noted, "because about 5% of back pain patients account for about 75% of the costs associated with taking care of people with back pain."

To address surgical and interventional therapies, they added several additional experts in these areas to the multidisciplinary panel that had already been formed for the initial guideline and updated their review of the literature to include data generated since the primary care guideline was published last year.

"Really, the number of trials is very limited for almost all of the interventional therapies, with the exception of epidural steroid injection, where there are somewhere around 20 trials," Dr. Chou said. "For everything else, you're looking at 3 to 4 studies, many of them with small sample sizes. The results are generally not enough to make a firm recommendation."

At the meeting, Dr. Chou and panel members Richard Rosenquist, MD, assistant professor of anesthesiology at the University of Iowa, in Iowa City, and John Loeser, MD, professor of neurological surgery at the University of Washington, in Seattle, reviewed the evidence for interventional procedures.

Some of their recommendations include:

• Invasive diagnostics such as provocative diskography, facet joint block, and sacroiliac joint block tests have not been proven to be accurate for diagnosing various spinal conditions, and their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain, the authors note in a press statement from APS.
• Epidural steroid injections are an option for short-term pain relief of persistent radiculopathy, although not for nonspecific low back pain or spinal stenosis, Dr. Chou noted. Other interventional strategies, such as local injections, prolotherapy, botulinum toxin injections, facet joint injection, sacroiliac joint injection, radiofrequency denervation, and intradiskal electrothermal therapy, "are not supported by convincing, consistent evidence of benefit from randomized trials," the statement says.
• Fair evidence supports the use of spinal cord stimulation in failed back surgery syndrome, those with persistent radiculopathy after surgery, Dr. Chou said.
• There is consistent evidence that for patients with a herniated disk, diskectomy is associated with better short-term outcomes than continued conservative management, although outcomes begin to look similar after 3 to 6 months, he noted. "We think that's a decision to be made with the patients, discussing the likelihood that they are going to improve either way but will improve faster with surgery," Dr. Chou said. Similar evidence supports the use of surgery for spinal stenosis, he noted, although the outcomes look better with surgery out to about 2 years.
• The efficacy of surgery for nonspecific back pain is less certain; the data are not as impressive as those supporting radiculopathy or spinal stenosis, Dr. Chou said. Some studies have shown no benefit of surgery compared with intensive interdisciplinary rehabilitation, with a significant proportion of patients experiencing suboptimal outcomes, including persistent pain or functional deficits after surgery.

On the basis of the evidence, he said, they were unable to give strong recommendations, "but we think there may be some patients for whom surgery, fusion specifically, might be helpful, but it's really important for doctors to discuss the fact that surgery doesn't tend to lead to huge improvements on average," he said. "You're talking about a 10- to 20-point improvement in function on a 100-point scale, so that's pretty small, and a significant proportion of patients still need to take pain medication and don't return to full function."

Peer Review

The draft guidelines will be sent out for extensive peer review to about 30 people outside the panel, additional experts in the field who will provide input, on the basis of which changes may be made to the recommendations. These other experts include interventionalists, "who we suspect are not going to be pleased that we couldn't find good evidence for some of the procedures that they commonly do, but we feel it's important to make sure that we have everything right," Dr. Chou said. "If we have interpreted the data incorrectly, or there are other substantive changes that need to be made, we'll make them." Once the guidelines are reviewed and any revisions are made, they will be submitted for publication, he noted.

They have worked hard at getting a consensus, though, he added, "and we've actually done a pretty remarkable job of getting almost unanimous consensus on all of the recommendations." Their work may also provide some direction for future research to support some of these procedures for which the evidence is not now there. "If we can really clearly lay out where the research gaps are, maybe that will affect funding choices in the future, so we do hope that's 1 effect, in addition to helping clinicians and patients make decisions now."

American Pain Society 27th Annual Scientific Meeting: Symposium 312. Presented May 8, 2008.

Related Links

Resource Centers

Advanced Approaches to Chronic Pain Management Resource Center
Spinal Disorders Resource Center

External Links

American Pain Society 27th Annual Scientific Meeting

 http://www.trentonchiropracticandrehab.com/decompression.html

Acupunct Med. 2007 Dec;25(4):130-6.

Acupuncture needling versus lidocaine injection of trigger points in myofascial
pain syndrome in elderly patients--a randomised trial.

Ga H, Choi JH, Park CH, Yoon HJ.

Department of Family Medicine, Inha University College of Medicine, Incheon,
Korea.

AIM: To compare the efficacy of acupuncture needling and 0.5% lidocaine injection
of trigger points in myofascial pain syndrome of elderly patients. METHODS:
Thirty nine participants with myofascial pain syndrome of one or both upper
trapezius muscles were randomised to treatment with either acupuncture needling
(n=18) or 0.5% lidocaine injection (n=21) at all the trigger points on days 0, 7
and 14, in a single-blinded study. Pain scores, range of neck movement, pressure
pain intensity and depression were measured up to four weeks from the first
treatment. RESULTS: Local twitch responses were elicited at least once in 94.9%
of all subjects. Both groups improved, but there was no significant difference in
reduction of pain in the two groups at any time point up to one month. Overall,
the range of cervical movement improved in both groups, apart from extension in
the acupuncture needling group. Changes in depression showed only trends.
CONCLUSION: There was no significant difference between acupuncture needling and
0.5% lidocaine injection of trigger points for treating myofascial pain syndrome
in elderly patients.

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