Treatment and Management of Back Pain
A Proposal to the Baskets of Care Steering Committee
Submitted on Behalf of:
Northwestern Health Sciences University and the Minnesota Chiropractic Association
By:
Gert Bronfort, DC, PHD, Vice President of Research,
Northwestern Health Sciences University
Michele Maiers, Associate Dean of Research and Knowledge Transfer,
Northwestern Health Sciences University
January 7, 2009
We propose the Baskets of Care Steering Committee consider back pain as a condition
for which to create a basket of care. Further, from an evidence-based perspective, we also
propose that an integrative team of both allopathic (including MDs, cognitive behavioral
therapists, rehabilitative and exercise specialists) and alternative providers (including
chiropractors, massage therapists, and acupuncturists) collaborate to optimize the
treatment and management of back pain.
Background and Significance
It is well recognized that low back pain (LBP) is one of the most prevalent, costly and
debilitating problems facing the US health-care system.1-4 Approximately 80% of
individuals will experience non-specific LBP in their lifetime5 and 75% will experience
lingering problems one year after onset.6 In the United States, back-related conditions are
the second most common reason for seeking a physician’s care,3the costs attributable to
them are estimated to exceed $100 billion dollars annually.7
A recent article in the St. Paul Pioneer Press (January 3, 2009) underscored this problem
locally. Health Partners has recently instated a new requirement of surgeons to explore
conservative alternatives to back surgery prior to authorizing such costly and, according
to their internal records, often unsuccessful intervention. Additional research8 suggests an
overuse of invasive procedures to treat LBP, and point toward the need for treatment
strategies that emphasize effective conservative therapies.
Treatment and Management
At present, more than 500 randomized controlled trials have been published evaluating
conservative and alternative treatments for LBP. It has become clear that for non-specific
LBP, there appears to be no one treatment that is best for all patients, but instead several
viable treatment options.9-11 Multiple efficacious treatments introduce greater opportunity
for patient choice.
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Conservative, or non-operative management, is the first line of therapy for most LBP
patients.11,12 Traditionally, this has included conventional approaches such as
medications, cognitive behavioral therapy, exercise, and patient education. Importantly,
there has been an increasing body of scientific evidence to support the use of various
alternative or integrative therapies (the most common being chiropractic, massage, and
acupuncture) for the management of LBP, establishing them as equally viable treatment
options.10,13-15 Finally, there is evidence16 suggesting that providing individualized
treatment within multidisciplinary environments result in faster return to work for chronic
LBP patients.
Reference List
1. Skovron ML. Epidemiology of low back pain. Arch Phys Med Rehabil 1992;6:55973.
2. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318:291-300.
3. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain.
Frequency, clinical evaluation, and treatment patterns from a U.S. national survey.
Spine 1995;20:11-9.
4. Waddell G. Keynote address for primary care forum. Low back pain: a twentieth
century health care enigma. Spine 1996;21:2820-5.
5. Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: low back pain
and the health of the public. Annu Rev Public Health 1991;12:141-56.
6. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low
back pain in general practice: a prospective study. BMJ 1998;316:1356-9.
7. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and
consequences. J Bone Joint Surg Am 2006;88 Suppl 2:21-4.
8. Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar
fusion surgery for degenerative conditions. Spine 2005;30:1441-5.
9. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and
mobilization for low back pain and neck pain: a systematic review and best evidence
synthesis. Spine J 2004;4:335-56.
10. van Tulder M, Koes B. Low back pain (chronic). Clin Evid 2006;15:1634-53.
11. Airaksinen O, Hildebrandt J, Mannion AF. European Guidelines for the Management
of Chronic Non-specific Low Back Pain. 2004.
12. Wheeler AH. Diagnosis and management of low back pain and sciatica. Am Fam
Physician 1995;52:1333-41, 1347-8.
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13. Tulder MW, V, Cherkin DC, Berman B, Lao L, Koes BW. Acupuncture for low back
pain. Cochrane Database Syst Rev 2000;CD001351
14. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative
therapy for low back pain. Cochrane Database Syst Rev 2004;CD000447
15. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low back pain. Cochrane
Database Syst Rev 2002;CD001929
16. Haldorsen EM, Grasdal AL, Skouen JS, Risa AE, Kronholm K, Ursin H. Is there a
right treatment for a particular patient group? Comparison of ordinary treatment, light
multidisciplinary treatment, and extensive multidisciplinary treatment for long-term
sick-listed employees with musculoskeletal pain. Pain 2002;95:49-63.
Information about the Authors
Dr. Bronfort has conducted several randomized clinical trials for low back, neck and
headache conditions for which he's received nearly $10 million in federal funding. With
investigators from Hennepin County Medical Center and the University of Minnesota, he
and his team conducted the first randomized clinical trial investigating chiropractic care
for acute neck pain, which was funded by the National Institutes of Health (NIH). They
have also received federal funding from the US Health Resources and Services
Administration (HRSA) to investigate exercise and spinal manipulation for neck and
back pain in elderly and non-elderly populations. Recently, Dr. Bronfort received HRSA
funding for an innovative randomized clinical trial investigating integrative care for low
back, involving health care professionals from several disciplines. In addition, he is the
principal investigator of the first randomized clinical trial to investigate chiropractic care
for chronic back-related leg pain (or sciatica) also funded by HRSA.
In addition to his work at Northwestern, Dr. Bronfort is an Associate Editor for the
Cochrane Back Review Group and is actively involved in several systematic reviews. He
serves as a reviewer for the National Institutes of Health and is a member of the National
Advisory Committee for NCCAM, and was on the Chiropractic Advisory Committee for
the Department of Veteran Affairs. He is also is a reviewer and consultant for the
CCGRP Chiropractic Best Practices Initiative. His research interests include assessing the
clinical and cost-effectiveness of non-surgical treatments for back, neck and headache
conditions, and the identification of biomechanical and patient-oriented measures that
will help identify which treatments are most appropriate for certain patients. Dr. Bronfort
is also dedicated to the application and transfer of research results into clinical practice
through the conduct of systematic reviews and promotion and practice of evidence based
health care and best practices in clinical settings. He is presently the principal investigator
of a Best Practices Pilot Project which aims to bring clinicians, patients and researchers
together to integrate clinical judgment, patient preferences and research evidence in
Northwestern's clinic systems.
Dr. Maiers is the co-principal investigator of the HRSA-funded Integrated Care for Low
Back Pain Study. She is also co-investigator of three additional federally funded
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randomized clinical trials investigating chiropractic and exercise for seniors with low
back and neck pain, and chiropractic for back-related leg pain. Dr. Maiers is also the lead
investigator of the Minnesota College of Acupuncture and Oriental Medicine Data
Collection Project, and co-investigator of several unique qualitative research studies
evaluating patient perceptions and expectations of treatment for back and neck
conditions. As the Associate Dean of Research, she provides leadership and management
for knowledge transfer related activities including design and pursuit of funding for new
programs and projects. She is also a co-investigator and the lead instructor on the CAM
Research Education Partnership Project funded by the National Center of Complementary
and Alternative Medicine.
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