Research Review By Dr. Jeff Muir©

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Date Posted:

November 2018

Study Title:

Spinal manipulative therapy and other conservative treatments for low back pain: a guideline from the Canadian Chiropractic Guideline Initiative
 
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Authors:

Bussières AE, Stewart G, Al-Zoubi F, Decina P, Descarreaux M, Haskett D, Hincapié C, Pagé I, Passmore S, Srbely J, Stupar M, Weisberg J, Omelas J

Author's Affiliations:

School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Canada; Département Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Canada; Private Practice, Winnipeg, Manitoba, Canada; Department of Clinical Education, Canadian Memorial Chiropractic College, Canada; Département des Sciences de l'Activité Physique, Université du Québec à Trois-Rivières; Department of Human Health and Nutritional Sciences, University of Guelph, Canada; University Health Network, Toronto Western Research Institute, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto; Département d'anatomie, Université du Québec à Trois-Rivières; Faculty of Kinesiology & Recreation Management, University of Manitoba, Canada; Human Health and Nutritional Science, University of Guelph; Downsview Chiropractic, Toronto, Canada; Health Systems Management, Rush University, Chicago, Illinois.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2018; 41: 265-293.

Background Information:

Musculoskeletal (MSK) disorders as a group are now the largest contributor to years lived with disability (YLDs) around the world (representing 18.5% of the total). Of that, low back pain (LBP) remains the leading cause of YLDs, constituting approximately half of the MSK burden (1)! Despite the availability of numerous clinical interventions aimed at improving this condition, there was a nearly 3-fold increase in the prevalence of chronic LBP between 1992 and 2006 (2). With annual direct and indirect expenditures expected to exceed $100 billion per year in the United States (2, 3), the need for effective treatments is evident and important.

Diagnosis of LBP can be difficult, as research indicates that 90% of LBP cases are nonspecific in nature (4), compared with only 5% that present as a specific nerve root distribution from either a compression, prolapsed disc, spinal stenosis or surgical scar (5, 6). As such, clinicians are challenged in correctly diagnosing LBP and are thus at risk of providing inefficient treatment, should they be incorrect in their diagnosis. Adherence to evidence-based clinical practice guidelines can minimize this potential problem; however, despite the numerous guidelines available and the shift towards recommending approaches including spinal manipulative therapy (SMT), there has been slow uptake of practice guidelines by health care providers (7). To address this, these authors, on behalf of the Canadian Chiropractic Guideline Initiative (CCGI), synthesized the best available evidence on the diagnosis and treatment of LBP using SMT alone or in combination with other conservative treatments, in order to provide up-to-date guidelines for clinicians.

Summary:

Initial Assessment and Monitoring: What Can Other Guidelines Tell Us About Best Practice?

The following 10 best practice recommendations issued by prior guidelines were reiterated and supported in this CCGI guideline, including:
  1. Give importance to the patient’s individual context.
  2. Conduct a problem-focused health history and clinical examination at the initial visit to screen for red flags.
  3. Explore the presence of additional MSK complaints and comorbidities.
  4. In the absence of pathology, assess patients for prognostic factors of delayed recovery.
  5. Triage patients with spine pain into 1 of 3 broad categories (specific, nonspecific, and back and leg pain/sciatica).
  6. Consider using the new Global Spine Care Initiative (GSCI) classification of spinal disorders, in which back and neck pain can be classified into 6 classes (classes 0 to V) – outlined below.
  7. Avoid the routine use of diagnostic imaging for people with LBP or back-related leg pain regardless of the duration of symptoms unless there are clinical reasons to suspect serious underlying pathology.
  8. Consult with or refer the patient to an appropriate provider if co-management is indicated.
  9. Perform periodic clinical re-evaluations and monitor progression of the patient's self-management strategies.
  10. Consider implementing quality measures aimed at improving the structure, process, and outcomes of care.
Global Spine Care Initiative (GSCI) Classification of Spinal Disorders:
  • Class 0: No or minimal spine-related symptoms, no interference with function, no neurological deficits, no severe pathology (0a = no evident risk factors; 0b = one or more risk factors)
  • Class I: Mild pain, no or minimal interference with function, no neurological deficits, no severe pathology (Ia = acute or subacute; Ib = chronic or recurrent)
  • Class II: Moderate or severe pain, interference with function or activities of daily living, no neurological deficits, no severe pathology (IIa = moderate acute or subacute pain; IIb = moderate chronic or recurrent pain; IIC = severe acute or subacute pain; IId = severe chronic or recurrent pain)
  • Class III: spine-related symptoms with neurological symptoms or deficit, interference with function or activities of daily living, focal pathology compromising neural structures (IIIa = minor or non-progressive; IIIb = acute, major and progressive; IIIC = chronic and stable)
  • Class IV: Spine-related symptoms with stable, severe deformity, with or without interference with function or activities of daily living, with or without neurological deficits (IVa = stable spine pathology, no correlation with symptoms; IVb = symptoms related to pathology (ex. acute, fracture; chronic, scoliosis or instability)
  • Class V: serious spine-related symptoms with severe or systemic pathology, interference with function or activities of daily living, with or without neurological deficits (Va = severe, acute spinal pathology, requires immediate intervention [emergency]; Vb = severe, slowly progressive spinal pathology [non-emergency]; Vc = spine symptoms originating from non-spine pathology [emergency])
Recommendations on the Conservative Treatment of LBP

Five recommendations were presented within 3 focus areas: acute (0-3 months); chronic (> 3 months) and radicular leg pain:

Acute (0-3 months):

Clinical Question: Should Spinal Manipulation Versus Another Treatment Be Used for Acute or Subacute (0-3 months) LBP?
These guidelines recommend SMT, alone or in combination with other commonly used treatments, to decrease pain and disability in the short term, based on patient preference and practitioner experience (based on low quality of evidence; conditional recommendation).

Chronic (> 3 months):

Clinical Question: Should Spinal Manipulation Versus Inactive Treatment Be Used For Chronic (> 3 months) LBP?
These guidelines recommend SMT over minimal intervention to decrease pain and disability in the short term (based on very low quality evidence; conditional recommendation).

Clinical Question: Should Spinal Manipulation Versus Another Treatment Be Used for Chronic (> 3 months) LBP?
These guidelines recommend SMT and other treatments for short-term reduction in pain and disability (based on high quality of evidence; conditional recommendation)

Clinical Question: Should Spinal Manipulation Plus Other Treatments Versus Other Treatments Alone Be Used for Chronic (> 3 months) LBP?
These guidelines recommend multimodal therapy with or without SMT to decrease pain and disability (based on moderate quality of evidence; conditional recommendation)

Radicular Leg Pain

Clinical Question: Should Spinal Manipulation Plus Other Treatments Versus Another Treatment Alone Be Used for Back-Related Leg Pain (Sciatica or Radicular LBP)?
These guidelines recommend for patients with chronic (> 3 months) back-related leg pain, SMT plus home exercise and advice to reduce back pain and disability (based on low quality of evidence; conditional recommendation)

Clinical Application & Conclusions:

These new CCGI guidelines establish best practices for the use of SMT in the management of LBP in acute (0-3 months), chronic (> 3 months) and radicular presentations. The current evidence pertaining to effectiveness, lower risk of adverse events and equivalent costs suggest SMT and other conservative, non-pharmacological treatment interventions should be first line therapies for both acute and chronic LBP. From the conclusion: “Based on patient preference and resources available, a mixed multimodal approach including manual therapy, advice on self-management, and exercise (supervised/unsupervised or at home) may be an effective treatment strategy for acute and chronic LBP and back and leg pain. Progress, particularly with respect to pain alleviation and reduction of disability, should be regularly monitored for evidence of benefit.”

We should keep in mind that the overall quality of evidence we have, based on the GRADE evaluation, is weak. As such, the authors recommend that clinicians devote more time to shared decision-making with the patient, to ensure that informed choices reflect patient values and preferences. As more and higher quality evidence is gathered, these guidelines will be updated.

Study Methods:

The framework and methodology used for this study are consistent with the previous guidelines from the Canadian Chiropractic Guideline Initiative (CCGI).

Selection of Panelists:
One author (AB) was the project lead who appointed two co-chairs (JO, GS), who recruited a diverse panel of specialists including clinical researchers, methodologists, a professional leader/decision-maker and a patient advocate. Meetings were held in February 2017 in Toronto.

Prior Guidelines:
The project lead and co-chairs retrieved best practice recommendations on the initial assessment and monitoring of people with LBP issued in prior guidelines, quality standards and pertinent literature published in the last decade.

Search Strategy:
Systematic methods were used to search for systematic reviews and randomized, controlled trials. Studies were critically appraised using the AMSTAR tool and the Cochrane Back Review Group criteria, respectively. Medline and Cochrane Database of Systematic Reviews from April 27, 2015 to February 5, 2017 were also searched.

Quality of Evidence Assessment:
Quality of evidence of eligible studies was established using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodological approach.

Recommendations:
Recommendations were based on the realization of a minimum clinically important difference (MCID). The panel determined the following clinically relevant changes: a 10-point improvement on a 0-100 VAS pain scale; a 1-point improvement on a 0-10 point numeric rating scale (NRS); a 2-point improvement on a 0-24 point Roland Morris Disability Questionnaire and 10 points on a 0-100 Oswestry Disability Index. For any outcome, a standardized mean difference of 0.2 to 0.5 was established.

Study Strengths / Weaknesses:

Strengths:
  • The CCGI, as always, maintained a rigorous adherence to current scientific standards.
  • Guidelines were peer-reviewed by international experts.
Weaknesses:
  • Most guidelines to date are based overall on low to moderate quality evidence.
  • Eligible studies were limited to those published in English.
  • Descriptions of SMT interventions were generally poor throughout the literature (this has been a problem for years!).
  • The panel included only one non-chiropractic clinician (a physiotherapist) – something future guidelines could aim to improve upon.

Additional References:

  1. Vos T, Allen C, Arora M, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388 (10053): 1545-1602.
  2. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med 2009; 169(3): 251-258.
  3. Katz J. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg (Am) 2006; 88(suppl 2): 21-24.
  4. van Tulder M, Koes B, Bombardier C. Low back pain. Best Pract Res Clin Rheumatol 2002; 16(5): 761-775.
  5. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988; 318(5): 291-300.
  6. Waddell G. The Back Pain Revolution. 2nd ed. Edinburgh, UK: Churchill Livingstone; 2004.
  7. Amorin-Woods LG, Beck RW, Parkin-Smith GF, Lougheed J, Bremner AP. Adherence to clinical practice guidelines among three primary contact professions: a best evidence synthesis of the literature for the management of acute and subacute low back pain. J Can Chiropr Assoc 2014; 58(3): 220-237.