American College of Physicians & American Pain Society Issue "Integrative" Back Pain Guideline: Sportelli, Choate Respond

Summary: The American College of Physicians (ACP) and the American Pain Society (APS) recently issued a comprehensive joint clinical practice guideline for the diagnosis and treatment of low back pain. Published in the October 2, 2007 issue of the Annals of Internal Medicine, the guidelines may be considered "integrative" as they include self-care and "non-pharmacologic" approaches. Chiropractic and integrative care veteran Lou Sportelli, DC, who brought the guidelines to my attention, shares views on the pros and cons of this guideline, as does former NIH NCCAM health services researcher Christine Goertz Choate, DC, PhD.

Lead role in the pain guideline

The October 2, 2007 issue of the Annals of Internal Medicine

"When self-care options do not result in improvement, clinicians should consider adding non-pharmacologic modalities shown to be of benefit. For acute low back pain, the only modality in this category is spinal manipulation. For chronic or subacute low back pain, modalities shown to be of benefit are intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation."

Roger Chou, MD, lead author of the Annals article

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"So, what did you think on reading this?  Is it a positive that the natural therapies are even there? Or do you view it as a step backwards, more of the same, what? Funny that the 'least invasive' is the LAST thing they talk about."

"I view the guideline as a step backwards in the global sense of (not) understanding that the focus should be on the least invasive. The guideline is a step backwards in the lack of recognition that chiropractic care is more than spinal manipulation. Relegating that therapeutic intervention to one issue is reducing the complexity of the care process.  Interventions are complex encounters they involve the human communication, trust, understanding, confidence, belief and culture surrounding the experience. Note that I said 'experience.'

"These studies are funded by groups that are still, intentionally or unintentionally, jaundiced and biased by the medical model. They remain caught up in a reductionist and mechanistic model of care which as we are understanding more with each passing day is less and less the model of tomorrow.  So it is good that an intervention which a decade or more ago was deemed quackery is now included but not good in the lack of understanding of the human health encounter."

The concept has been a grounding influence and a guiding light. It seemed common sense to use the least invasive (fewest adverse effects) therapies first, all else being equal. Growing awareness of the awful and not infrequent killing effects of pharmaceuticals over the past 2 decades reinforced the value of this grandmotherly wisdom.  One might even say that an approach with somewhat less evidence, but with little or no side-effects, might reasonably be considered first as a matter of course, as long as no harm would come from waiting.

Now, in 2007, we are facing growing evidence of the human cost associated with our culture's rapidly escalating use of pain medications - following the pain guidelines of Joint Commission on Health Care Organizations in 2001.  These merging data may in fact dwarf any previous findings on adverse effects.

Lou Sportelli, DC

One might have hoped in this context that we would see a guideline which would affirmatively embrace trying approaches without adverse efforts first. For various reasons reported in the interview with Chou, the therapeutic order appears to have bobbed toward a balance but ultimately failed to right itself. The failure may rest, as Sportelli asserts, in the group remaining firmly ensconced in a reductive view of the healthcare encounter.

Meantime, more practically, as Choate points out, the guideline writers may be doing an injustice to spinal manipulation by lumping it with less researched non-pharmacological approaches. The guideline may need to have more than one recommendation in this category.

• Focused history and physical examination should help categorize patients into 1 of 3 broad groups: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. Evaluation of psychosocial risk factors is essential during history taking because these predict the risk for chronic disabling low back pain (strong recommendation; moderate-quality evidence).

• For patients with nonspecific low back pain, clinicians should not routinely perform imaging studies, including radiographs, CT scans, and MRI, or other diagnostic tests (strong recommendation; moderate-quality evidence).

• Patients with severe or progressive neurologic deficits, or in whom history and physical examination suggest cancer, infection, or other underlying condition as the cause of their low back pain, should undergo imaging studies and other appropriate diagnostic tests (strong recommendation; moderate-quality evidence).

• Patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis should undergo MRI or CT only if positive results would potentially lead to surgery or epidural steroid injection for suspected radiculopathy. In choosing an imaging procedure, MRI is preferred to CT (strong recommendation; moderate-quality evidence).

Chrstine Choate, DC, PhD

• Patient education by clinicians should include provision of evidence-based information on low back pain. Topics that should be covered include expected course and effective self-care options. Clinicians should also counsel their patients to stay physically active (strong recommendation; moderate-quality evidence).

• When pharmacotherapy is considered, drugs of choice should be those with proven benefits, and they should be used together with self-care and back care education. Before starting a patient on pharmacotherapy, clinicians should evaluate pain and functional deficits at baseline. They should also review the risk-benefit ratio of specific medications before prescribing them and should consider the relative lack of long-term efficacy and safety data (strong recommendation; moderate-quality evidence). Acetaminophen or NSAIDs are preferred first-line drugs for most patients.

• When self-care options do not result in improvement, clinicians should consider adding non-pharmacologic modalities shown to be of benefit. For acute low back pain, the only modality in this category is spinal manipulation. For chronic or subacute low back pain, modalities shown to be of benefit are intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation; moderate-quality evidence).