Back Pain Guidelines: The Press Conference

WASHINGTON, D.C. -- On Thursday Dec. 8, the Agency for Health Care Policy and Research (AHCPR) held a press conference to announce the release of its clinical guidelines on acute low back problems in adults.

Dr. Phillip Lee from Health and Human Services, and Clifton Gaus of the AHCPR presented the guidelines. The chairman of the guidelines, Stanley Bigos, MD, professor of orthopedic surgery and environmental health at the University of Washington School of Medicine, and panel member Jeffrey Susman, MD, of the University of Nebraska, also spoke. Dr. Susman presented the majority of the details of the panel's recommendations.

The recommendations of the 23-member interdisciplinary panel came as a surprise to many outside of chiropractic circles: spinal manipulation was identified as the only recommended intervention whose benefits included symptom relief and functional improvement. The chiropractic and osteopathic professions were the only groups associated with the findings on spinal manipulation.

The 160-page Clinical Guidelines had become the focus of many delays and challenges, leaving the release of the document in limbo until late in the day on Dec. 7, 1994. The last such challenge was a request to issue an injunction to block the document's release. That request was denied. A reliable source said the injunction was sought by a surgical device manufacturing company.

The panel included two representatives of the chiropractic profession: Scott Haldeman, DC, MD, PhD, associate clinical professor of neurology at the Univ. of Calif., Irvine, and John Triano, MA, DC, staff chiropractic physician and clinical research scientist at the Texas Back Institute, Plano, Texas.

Following the official statements from the dept. of Health and Human Services, the AHCPR, and the panel leadership, a wide range of professions offered statements of support, including: chiropractic, osteopathy, occupational and environmental medicine, neurosurgery, and orthopedic surgery. The comments were universally supportive of the process of clinical guidelines development, but each group offered their variation of concerns with some aspects of the guidelines.

Presenting statements for the chiropractic profession at the press conference were ACA Chairman of the Board Lowry Morton, DC, and ICA board member and Life Chiropractic College-West President Gerard Clum, DC. The ICA and ACA had additional staff at the news conference to field questions from reporters: from the ACA were Louis Sportelli, DC, and Jerome McAndrews, DC; Dana Rose, DC, and Mr. Ron Hendrickson were there for the ICA.

Representatives of the ACA and ICA both admitted that their members would take exception with some of the recommendations offered in the guidelines. Dr. Clum said that the issue of plain film radiography would be a significant concern to many DCs. "Even those that don't practice techniques with heavy reliance on x-ray will find the suggestion that in many cases of low back pain x-ray is unwarranted to be rather an unsettling perspective."

The guidelines were "endorsed in principle" by the ICA, withholding final judgment until a comprehensive review is made. The ACA applauded the AHCPR. The American Academy of Pain Medicine offered its official endorsement with certain qualifications; the American Assn. of Neurological Surgeons announced its support.

Surgeons were critical of the lack of support the guidelines gave there interventions: Edward Handly Jr., MD (American Academy of Orthopedic Surgeons), referred to the guidelines as a "basis (for care), not an absolute formula." He added: "When something has not been proven efficacious, it does not mean it is not effective or appropriate." (That sounds familiar!)

Edward Seljestos, MD, (American Assn. of Neurological Surgeons) said the panel "overstepped (its bounds) regarding surgical treatment."

Noticeably absent from the parties commenting on the guidelines were the physical therapists. Under the rubric, "physical agents," a host of interventions (acupuncture, biofeedback, diathermy, heat, ice, TENS, traction, and ultrasound) were "not recommended" because of lack of scientific data to support their use. Ice and heat were suggested to be helpful on a home care basis.

Questions from the press included suggesting x-ray, CT, and MRI use was minimized by the guidelines to eliminate provider financial incentives to seek such tests. It was also postulated that the guidelines sought to promote greater cooperation between MDs and DCs. One reporter suggested that the recommendation for manipulation had not been forceful enough, as the absence of manipulation in low back problems allowed for the greater likelihood of abnormal collagen formation and therefore greater restrictions over time.

The panel data is organized into three booklets: a full report, a quick reference guide for providers, and a patient brochure. The patient brochure is also available in Spanish. The information in these reports are in the public domain, and can be reprinted, copied, or quoted without permission or cost. The information is available in print format, on disc, or on CD-ROM. Each publication is available at no cost by dialing 1-800-358-9295, or writing AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.