Low Back Pain Clinical Practice Guidelines:

The Dangers with Non-Concordant Recommendations

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

Clinical practice guidelines define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients.

Clinical practice guideline recommendations are based on evidence from rigorous systematic reviews and synthesis of the published medical literature.

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Clinical Practice Guidelines are designed to ensure that patients receive the best of care. Ideally such care would improve recovery rates, reduce harm, and minimize future complications including disability. Cost optimization is also present. Controlling costs benefits everyone, including the patient, the insurance premiums and payments, the government, and all of society.

As noble as the intent of clinical practice guidelines is, there are problems (1):

“The volume of guidelines is overwhelming, growing in size, numbers and recommendations.”

“The average family physician would need 18 hours/day to follow the volume of recommendations for chronic disease and preventive care.”

Primary care physicians are the usual first entry provider for patients into our healthcare system. The range of healthcare conditions and their associated clinical practice guidelines is overwhelming. It is impossible for the primary care physician to be knowledgeable on all clinical practice guidelines.

Also, as a rule, primary care physicians are poorly trained in musculoskeletal healthcare, as exemplified in these statements (2, 3, 4):

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“79% of the participants [medical doctors] failed the basic musculoskeletal cognitive examination.”

“This suggests that training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” (2)

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“These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field.” (3)

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“Both orthopaedic surgeons’ and family physicians’ knowledge of treating LBP is deficient.”

“Orthopedic surgeons are less aware of current treatment than family practitioners.” (4)

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One recent health care policy publication notes (25):

“Medical educators have recognized for years that training in musculoskeletal medicine is suboptimal for medical students, residents, and general practitioners.”

As a consequence of these obstacles, recent publications have called for the establishment of a primary spine care practitioner, and have suggested that the provider should be a chiropractor (5, 25).

Pain is a huge problem in America. The most common location for chronic pain is the low back, accounting for nearly one third of all reported regions (6). Chronic low back pain contributes the most to long-term disability, morbidity, health care, and societal costs (7, 8). In the United States, treatment for low back pain and related spine disorders are the most expensive medical problem, with most costs accrued in ambulatory care settings, including primary care (9, 10).

What Do the Low Back Pain Guidelines Recommend?

A central theme in the evolution of Low Back Pain Clinical Practice Guidelines is a trend away from pharmacology and an emphasis on non-drug approaches.  

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 The October 2007 issue of the journal Annals of Internal Medicine published the comprehensive and authoritative (11, 12):

Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain

An extensive panel of qualified experts constructed these clinical practice guidelines. These experts performed a review of the literature on the topic and then graded the validity of each study. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. The results of their efforts are summarized in two separate articles. The first article is (11):

Diagnosis and Treatment of Low Back Pain:
A Joint Clinical Practice Guideline from the
American College of Physicians and the American Pain Society

This study recommends that for patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits—for acute low back pain, such as spinal manipulation.

For chronic or subacute low back pain, recommendations include intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

These Guidelines note that acceptable non-pharmacologic options for acute, subacute, and chronic low back pain includes spinal manipulation. In this document, spinal manipulation is the only non-drug treatment recommendation for acute low back pain. This article states:

For acute low back pain (duration 4 weeks), spinal manipulation administered by providers with appropriate training is recommended.

“For chronic low back pain, moderately effective non-pharmacologic therapies include acupuncture, exercise therapy, massage therapy, yoga, cognitive-behavioral therapy or progressive relaxation, spinal manipulation, and intensive interdisciplinary rehabilitation.”

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The second article was also in the October 2007 issue of the journal Annals of Internal Medicine and was titled (12):

Non-pharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for the American Pain Society and the
American College of Physicians Clinical Practice Guideline

This article defines spinal manipulation as:

“Manual therapy in which loads are applied to the spine using short- or long-lever methods. High-velocity thrusts are applied to a spinal joint beyond its restricted range of movement.”

These authors note:

There is “good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (4 weeks’ duration) low back pain.”

“For acute low back pain (4 weeks’ duration), the only non-pharmacologic therapies with evidence of efficacy are superficial heat and spinal manipulation.”

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The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) have been in continuous development since 1995. A recent update appeared in the Journal of Manipulative and Physiological Therapeutics in 2006, and is titled (13):

Clinical Practice Guideline:
Chiropractic Care for Low Back Pain

These Guidelines conclude:

“The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain disorders.”

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In 2017 the European Journal of Pain published a study titled (14):

Clinical Practice Guidelines for the
Noninvasive Management of Low Back Pain:
A Systematic Review by the Ontario Protocol for
Traffic Injury Management (OPTIMa) Collaboration

These authors conclude:

“Most high-quality guidelines target the noninvasive management of nonspecific low back pain and recommend education, staying active/exercise, manual therapy, and paracetamol [acetaminophen] or NSAIDs as first-line treatments.”

It is noteworthy that these Guidelines advocate manual therapy for low back pain. They define manual therapy as the application of either manipulation or mobilization, stating:

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Also published in 2017 is an article in the journal Annals of Internal Medicine, titled (15):

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline from the American College of Physicians

The authors note that the target patient population for these Guidelines includes adults with acute, subacute, or chronic low back pain. These authors note:

“…clinicians and patients should select from superficial heat, massage, acupuncture, or spinal manipulation…”

“For patients with chronic low back pain, clinicians and patients should initially select non-pharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.”

These Guidelines for Low Back Pain clearly emphasized “non-pharmacologic treatment” which included spinal manipulation.

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In 2018, an updated version of clinical practice guidelines for the management of non-specific low back pain in primary care was published in the European Spine Journal (16). These Guidelines note that nonpharmacologic interventions, such as heat, massage, acupuncture, or spinal manipulation, are recommended as first-line treatment options, while initial use of diagnostic imaging, specialty consultation, and prescription of opioid medications are not recommended.

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It is no longer controversial to understand that chiropractic and spinal manipulation are safe and effective treatments for back pain (17, 18, 19, 20, 21, 22, 23). It is clear that practice guidelines for the management of all phases (acute, subacute and chronic) of low back pain advocate spinal manipulation while discouraging drug therapies, especially narcotics (including opiates/opioids).

What Are the Consequences of Not Following
Low Back Pain Practice Guidelines
(Non-Concordant Care)

In 2010, a study published in the Journal of the American Medical Association indicated that 2% to 48% (median, 26%) of patients with acute LBP in primary care settings transition to chronic low back pain (24). This stunning statistic has an explanation which was published in 2021 in the Journal of the American Medical Association Network Open, in an article titled (25):

Risk Factors Associated with Transition
from Acute to Chronic Low Back Pain
in US Patients Seeking Primary Care

The author affiliations for this work include the University of Pittsburgh School of Medicine, Johns Hopkins University School of Medicine, University of Florida College of Public Health, Duke University, and Boston Medical Center.

These authors present the results of a large prospective, multicenter study conducted to determine the proportion of patients who transitioned from acute to chronic low back pain in primary care settings across four geographically dispersed health systems. The cohort used 5,233 patients with acute low back pain from 77 primary care practices.

Patient eligibility for this study was being at least 18 years of age with acute, bothersome, axial low back pain or low back pain associated with leg pain. Chronic low back pain was defined as the presence of pain for more than three months and having pain at least half the days in the previous six months.

Participant subject’s low back pain was quantified using the Oswestry Disability Index on a 0 to 100-point scale, as follows:

• Minimal Disability 0-20
• Moderate Disability 21-40
• Severe Disability  41-60
• Very severe Disability ≥61

The authors note:

“Low back pain (LBP) is the leading cause of disability in the United States, annually accounting for 4.3 million years lived with disability, nearly twice the burden of any other health condition.”

“In the United States, treatment for LBP and related spine disorders now represents the most expensive medical problem, with most costs accrued in ambulatory care settings, including primary care.”

“Chronic LBP contributes most to long-term disability, morbidity, health care, and societal costs, while acute LBP is given less attention because patients are generally considered to have a favorable prognosis.”

The authors note that acute low back pain is highly prevalent within the society. Yet, claiming that the natural history of acute low back pain is resolution of symptoms in 1-3 months is false. This presumed favorable prognosis for acute low back pain is misplaced. A medium of 26% of those with acute low back pain progress to chronic low back pain, and in some studies the incidence is as high as 48% (essentially half) (24). Once low back pain becomes chronic, it is a disabling and expensive condition.

Non-concordant recommendations are those that go against guideline recommendations. Non-concordant recommendations include these three processes:

Opioid use [First Process]

“Any prescriptions that included opioids were considered non-concordant.”

“Prescriptions that included benzodiazepines and/or systemic corticosteroids alone without the presence of nonsteroidal anti-inflammatory drugs or short-term skeletal muscle relaxants wereconsidered non-concordant.”

Referral for diagnostic imaging [Second Process]

“Non-concordant diagnostic imaging consisted of an order for lumbar radiograph or computed tomography/magnetic resonance imaging (CT/MRI) scan.”

Referral to a specialists [Third Process] 

“Non-concordant medical subspecialty referral included referrals to nonsurgical or surgical specialties (e.g., physiatrists, orthopedists, neurologists, neurosurgeons, or pain specialists).”

After controlling for all other variables, patients exposed to non-concordant processes of care within the first 21 days had these increased risks of developing chronic low back pain as compared to those with no exposure:

• 1 non-concordant processes 39% increased risk
• 2 non-concordant processes 88% increased risk
• 3 non-concordant processes 116% increased risk

In this cohort study involving more than 5,000 subjects, the transition rate from acute low back pain to chronic low back pain was substantial. The increased transition rate corresponded with early exposure to guideline non-concordant care. The authors noted:

“Exposure to non-concordant care was associated with increased odds of developing chronic low back pain.”

“Non-concordant care can lead to direct and indirect harm, given that it has been linked with medicalization and unnecessary health care utilization.” 

“These results indicate that the transition from acute to chronic low back pain is much greater than historically appreciated.”

“Early exposure to guideline non-concordant care was significantly and independently associated with the transition to chronic low back pain after accounting for patient demographic and clinical characteristics, such as obesity, smoking, baseline disability, and psychological comorbidities.”

“Our findings demonstrate that independent of these factors, exposure to non-concordant processes of care during the early phase of treatment was associated with developing chronic low back pain.”

Distressingly, 48% of these patients received at least one non-concordant care process within three weeks of their initial low back pain visit.

An interesting and important associated finding from this cohort study was that practice guidelines erroneously believe that acute low back pain has a favorable prognosis. The transition from acute to chronic low back pain for the entire group, including for those who were not given non-concordant care, was an astonishing 32% rate at 6 months. Stated differently, a third of 5,233 acute low back pain subjects went on to developed chronic low back pain at six months.

The authors ascribe this high transition to chronic low back pain on the dogmatic allopathic management approach of uniformly applying a minimalist approach (e.g., advice, reassurance, pharmacology, etc.) to all patients with acute low back pain. They state that such a minimalist approach “is unwarranted and may lead to suboptimal care.”

The authors acknowledge that the “successful management of low back pain is a vexing problem.” “Once chronic, low back pain is particularly problematic to manage; thus, preventing the transition from acute to chronic low back pain is important.” The most important goal in the management of acute low back pain is to prevent it from becoming chronic.

Yet, they also acknowledge that “medical educators have recognized for years that training in musculoskeletal medicine is suboptimal for medical students, residents, and general practitioners.” They criticize medical establishment norm of “high caseloads and the overwhelming volume of guidelines directed at primary care.”

So, what do clinical practice guidelines for low back pain recommend in an effort to improve clinical outcomes and to reduce the rate of transition from acute to chronic low back pain? Essentially it is the interventions that are routine in chiropractic clinical practice:

“Non-pharmacologic interventions, such as heat, massage, acupuncture, or spinal manipulation, are recommended as first-line treatment options, while initial use of diagnostic imaging, specialty consultation, and prescription of opioid medications in the absence of red flags are not recommended.”

As such, the authors advocate the use of a Primary Spine Practitioner “in which chiropractors and physical therapists serve as the initial or early point of contact for patients with low back pain.” 

The conclusion key points from the authors included:

“In this cohort study of 5,233 patients with acute low back pain from 77 primary care practices, nearly half the patients were exposed to at least 1 guideline non-concordant recommendation within the first 21 days after the index visit.”

Patients were significantly more likely to transition to chronic low back pain as they “were exposed to more non-concordant recommendations.”

In this study, the “transition rate to chronic low back pain was substantial and increased correspondingly with risk strata and early exposure to guideline non-concordant care.”

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Low back pain is the leading cause of disability and the most expensive medical problem in the United Sates. Medical students, residents, and general practitioners are poorly trained in the musculoskeletal system, and especially in the management of low back pain.

 Low back pain Practice Guidelines are based upon the best evidence:

• The best evidence discourages the use of narcotics, referral for imaging diagnostics, and referral to medical specialists, specifically physiatrists, orthopedists, neurologists, neurosurgeons, or pain specialists.

• The best evidence advocates as first-line treatment the use of massage, acupuncture, and spinal manipulation.

This study shows 2 problems with the allopathic management of low back pain:

• Providers often refer patients for care that is ill advised (narcotics, imaging, and specialists), all of which promote the patient transition from acute to chromic low back pain.

• Providers rarely refer out for care that is supported by their own Practice Guidelines (massage, acupuncture, chiropractic).

Chiropractors should be the initial contact and providers for patients with low back pain.

REFERENCES

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“Authored by Dan Murphy, D.C.. Published by ChiroTrust^® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”