While attending the May 2000 World Health Organization (WHO) Annual Assembly, as the representative of the Chiropractic Diplomatic Corps, I was given a copy of a recent WHO publication titled Low Back Pain Initiative.1 This book describes a four-year (1993-97), multi-site, multinational, multidisciplinary research effort by the WHO's Department of Noncommunicable Disease Management.
The book's purpose is to establish outcome assessment criteria in multiple languages, and has identified the validity of four objective assessment tests that can be useful in future research: the Oswestry Disability Index, the Modified Zung Index, the Visual Analogue Scale and the Schober's test. All four were successfully tested for translation and back-translation. A validating aspect of the study is the inclusion of chiropractic as a significant partner and contributor, thanks to a research team from Life University. For those interested, the document is available through the WHO's website in its entirety (http://whqlibdoc.who.int/hq/1999/WHO_NCD_NCM_CRA_99.1.pdf).
The following presentation supports an opposing view of the current direction in chiropractic research and a plea for more patient involvement in the framing of future research efforts. The study determined that low back pain (LBP) falls into one of two main categories:
- Pain occurring from specifically identifiable causes such as protruding disks, spondylolistheses, infections, fractures, etc.
- "Non-specific" LBP, representing the highest percentage of LBP.
According to Professor George Ehrlich,MD, of the University of Pennsylvania, "Non-specific LBP is so common that it has been recognized as epidemic, perhaps even pandemic."
2 However, it is disappointing to see that the chiropractic subluxation is still not recognized as an identifiable physical cause by the medical participants of this study. At least the chapter on chiropractic written by S.E. Williams,DC - which happens to be the first diatribe on chiropractic present in any WHO text - defined the chiropractic profession within the subluxation-based premise.
In general, the conclusions were not too surprising or revealing, but the results are only preliminary, and full results will be coming in a major refereed journal. There are, however, notable results on the psychosocial studies regarding LBP. Dr. N.M. Hadler, a well-known and respected professional in the field, stated that "Biomechanical factors matter less than workers' perceptions about the nature of their jobs" or the "respect workers hold for their work and position in the workplace and workforce."3
In a reported 1991 study of a Boeing factory in North America, dissatisfaction with work was a major predictor of later presentation to the medical services with low back pain. In another study, the likelihood of developing a new episode of back pain was significantly higher in those who were distressed.
A second area of the publication that merits particular consideration addresses the conclusions for the management of acute low back pain. If you have been objectively following the studies on acute low back pain, it has likely become apparent to you that almost anything produces the same results. The greater majority of acute LBP is self-limiting.
Perhaps the strongest message that has come from the Low Back Pain Initiative is the significant difference between acute and chronic low back pain management. One conclusion reached at the conference was that, "By now, it should be obvious that prevention of chronic pain should be the primary goal, although the factors that convert acute to chronic pain remain elusive."5 What remains confusing and perplexing to providers and researchers of all disciplines are the differentiating factors that account for the high percentage of acute low back pain cases that become chronic.
A question to pose here might be: "What can be gained by stipulating that the vertebral subluxation may in fact account for the missing link in this puzzle?" Beyond the scope of the Low Back Pain Initiative studies are the unrecordable healthcare benefits of other illnesses or conditions patients feel have been prevented because of their commitment to use chiropractic as a primary health care service. In North America, there could easily be millions of similar cases of patients proclaiming healthcare benefits from the management of their spines and their general health over the past century through service by chiropractors. Although this has nothing to do with acute low back pain, there are scant studies designed to better understand these patient experiences. How can future research validate these experiences with protocols that can be scientifically supported? Relating this position relative to Low Back Pain Initiative: How do we identify what percentage of acute LBP become chronic, and what is the best care for these patients? The role played by chiropractic could and should be that of a primary and major provider.
Returning to the study, we find the participants questioning the validity of further investigations into acute low back pain because the majority of socioeconomic burdens tend to result from chronic, not acute, LBP. Research can best serve the public by shifting its focus to identifying those factors that will better identify which acute LBP episodes are likely to become chronic.
In acute low back pain management, studies have repeatedly shown that chiropractic is equally effective as conservative medical care. So what? The fallacy of focusing so much research all these years on neuromusculoskeletal conditions such as acute low back pain or headaches has ultimately degraded the true strength and value of the role chiropractic plays in the delivery of healthcare in the world.
The true strength of chiropractic is (and always has been) in the care of chronic vertebral subluxations. That is where most future research needs to be focused. Research will best serve patients when it is designed to better understand and validate the benefits of identifying and correcting vertebral subluxations. Life University's research team has already reverse the research trends by limiting spinal adjustments to the upper cervical subluxations during this Low Back Pain Initiative subacute study. Finally, someone is thinking differently!
There is clearly the need for two research agendas in chiropractic at this time: the existing efforts to quantify and improve our effectiveness in specific areas in comparison with other providers who work in similar areas; and efforts to challenge the research teams to focus more on the overall health benefits and quality of life aspects of chiropractic care, globally and within specific populations.
Today, we have entire societies under national health care regimes, permitting total population studies of a particular society such as the Manga report from Ontario, Canada.4 Moreover, the WHO study also concludes: "Prevention of chronic back pain should be a major goal."5 Research designed to take the Ontario study to the next level should answer many questions, including viable options in prevention of chronic LBP. Based on the outcomes of such total population studies, governments would then see the value of integrating chiropractic care into government programs.
In conclusion, it is fair to state that the past 15 years of research have more than adequately addressed the "acute lower back" issue. The lesson from Low Back Pain Initiative is how future research programs can effectively use and improve on the objective-measuring instruments and tests listed earlier. It is not this writer's intention to denigrate a significant research effort (which included some fine chiropractic researchers) in a multidisciplinary study. The advantage of retrospective analysis is that new and more specific directions can now be taken based on this knowledge.
Lastly, but not of lesser importance, it will be good to see more involvement of patients as equal stakeholders in the structure and design of future research. This can only improve the process and produce results that are valuable to both the patient and the average chiropractor in the field.
It's time to move on. Imagine patients influencing where research can be directed for their best interest instead of just the academic DC or the research institution's best interests. What a concept!
References
- World Health Organization. Low Back Pain Initiative 1999;99.
- World Health Organization. Low Back Pain Initiative 1999;81.
- Hadler NM, Curtis P, Gillims DB, Stinnett S. A benefit of spinal manipulation as adjunctive therapy for acute low back pain: a stratified control trial. Spine 1987;12:702-706.
- Manga P. Study to examine the effectiveness and cost-effectiveness of chiropractic management of low-back pain.
- World Health Organization. Low Back Pain Initiative 1999;83.
Michel Tetrault,DC
Executive Director
Chiropractic Diplomatic Corps
White Rock, British Columbia, Canada
