by Michel Tetrault, D.C.
DYNAMIC CHIROPRACTIC
September 18, 2000

While attending the May 2000 World Health Organization (WHO) Annual Assembly, as the representative for the Chiropractic Diplomatic Corps, I was given a copy of a recent WHO publication titled the Low Back Pain Initiative. (1) This is a multi-site, multi-national, multi-disciplinary research effort that took place from 1993 to 1997 by the 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 the Life University team. The document is available thru the WHO online in it's 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 Lower Back Pain (LBP) falls into one of two main categories:

1. Those with specifically identifiable causes such as protruding disk, spondylolisthesis, infections, fractures, etc.

2. The "Non-specific" LBP category representing the highest percentage of LBP.

 In fact, "non-specific LBP is so common that it has been recognized as epidemic, perhaps even pandemic," (2) according to Professor George Ehrlich. However, it is disappointing to see that the chiropractic subluxation is still not being 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 is 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, well known and respected in the field, stated that "biomechanical factors matter less than workers' perceptions about the nature of their jobs" or "about 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 LBP. 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 LBP. If you have been objectively following the studies on Acute LBP, it has likely become apparent to you that almost anything done, or everything done or nothing done for that matter produces the same results. The greater majority of Acute LBP is self-limiting.

 Perhaps the strongest message that has come out of the Low Back Pain Initiative is the significant difference between acute and chronic LBP management. "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 LBP 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 proclaiming healthcare benefits from the management of their spines and their general health over the past century of service by chiropractors. Although this has nothing to do with acute LBP there are scant studies that are 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 the Low Back Pain Initiative publication: How do we identify THAT percentage of acute LBP cases which become chronic and how to best care for these patients? The role played by chiropractic could and should be the primary and major provider.

 Returning to the study, we find the participants questioning the validity of further investigations into Acute LBP because the majority of socio-economic burdens tend to result from Chronic LBP and not from 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 LBP 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 the neuromusculoskeletal conditions, such as acute LBP 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 and that is where most future research needs to be done. Research will best serve patients when it is designed to better understand and to validate the benefits of identifying and correcting vertebral subluxations. The Life University research team is already reversing the research trends by limiting the spinal adjustments to the upper cervical subluxations during this Low Back Pain Initiative sub-acute study. Finally someone is thinking differently! 

There is clearly the need for two research agendas in chiropractic at this time. The existing efforts that attempt to quantify and improve our effectiveness in specific areas and in comparison with other providers who work in similar areas. Secondly, 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, Province of Ontario, Canada (4). Moreover, the WHO study concludes: "Prevention of chronic back pain should be a major goal." (5) Research studies 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 see the value of integrating chiropractic care into government programs.

In conclusion, it is fair to state that the past 15 years of research has more than adequately addressed the acute lower back issue. The lesson from this WHO publication, the Low Back Pain Initiative, is how future research programs can effectively use and improve on the objective measuring instruments/tests listed earlier. It is not this writer's intention to denigrate what is a significant research effort which included some fine chiropractic researchers in a multi-disciplinary study. The advantage of retrospective analysis is how new and special 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 an equal stakeholder 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. 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!

  (1) Low Back Pain Initiative, by WHO 1999/2000 - index # WHO/NCD/NCM/CRA/99.1

(2) Low Back Pain Initiative, by WHO 1999/2000 - p. 81

(3) A benefit of spinal manipulation as adjunctive therapy for acute low back pain: a stratified control trial.

      - Spine 1987, 12:702-706 by Hadler NM, Curtis P, Gillims DB, Stinnett S.

(4) "Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain," Province of Ontario, Canada, by Pran Manga, Ph.D.

(5) Low Back Pain Initiative, by WHO 1999/2000 - p. 83