Back Pain Guide

“Back pain” affects over 80% of people at least once in their lifetime. As a chiropractor, I work a lot with clients suffering from back aches and soreness. In this guide, I hope to share my experiences with you so you can find your own freedom from pain. I will cover:

• What is the most common cause of lower back pain?
• Should I have a MRI?
• When should I go to the orthopaedic surgeon?
• Is chiropractic better than physiotherapy?
• Can exercises help me avoid surgery?
• Can back pain be serious?
• What can I do to relieve my lower back pain?
• What should I do if my low back hurts?

Chiropractic Treatment for Back Pain in Singapore

Everybody wants to know what is the fastest way to recover from back pain. What works and what doesn’t work.

However, when presented with research evidence and clinical guidelines, most people actually opt for treatments that are not grounded on hard science.

Research has been very consistent in recommending exercise PLUS education as firstline treatment for back pain. Yes, you heard that right.

A lot of people think big pharma are pushing for drugs and surgeries. While this may appear to be the case for certain conditions, it’s definitely not what we are seeing when it comes to low back issues.

In fact, despite the abundance of research supporting exercise as the best intervention, most people still opt for poorer quality options such as chiropractic adjustments.

What is the best doctor to see for back pain?

You should always opt to see an evidence-based doctor. An evidence-based doctor or chiropractor will go through your medical history and perform a physical examination before recommending the best next steps.

As a chiropractor that focuses on long-term solutions, we work with clients with chronic pain and help them develop self-management strategies. This effective treatment designed to relieve back pain is a hybrid exercise, education, and lifestyle change programme.

Instead of asking you to come back multiple times a week until you feel better, we use a test-retest process to find out what’s going on. This allows us to develop a truly personalised solutions for you.

Based on how you respond to various exercises and advice, we are able to predict how your unique symptoms behave, and subsequently design a recovery programme that works just for you.

For those of you who are tempted to consider orthopaedic surgery as an ultimate solution, you may be disappointed to learn that surgeries don’t always outperform placebo.

How do I know if my lower back pain is serious?

Your back pain is serious when you start to develop red flags. Red flags refer to symptoms such as fever, unexplained weight loss, loss of control of your bowel and bladder.

You should also pay extra attention if you have a history of trauma, cancer, or have been on  long-term steroid use.

You should go to the A&E if you are experiencing pain that you have never experienced before with red flags.

How do you tell if lower back pain is muscle or disc?

There are some symptoms that are more associated with muscle injury while others that are more associated with disc injury. However, it’s impossible to know without a professional diagnosis.

If you are getting neurological lower limb symptoms, there is a high chance that your disc is involved. Some of you may experience numbness and tingling or a shooting sensation down your leg. These are possible indicators of a slipped disc.

How should I sleep with lower back pain?

The best way to sleep is the way that you are most comfortable with. Some of you may be worried that sleeping in the “wrong’ position will make your spine condition worse. However, this is impossible! Your body is way stronger than that.

It’s true that sleeping in certain positions may aggravate your pain experience. In that sense, it makes you feel worse. It’s hard to imagine this but feeling more pain doesn’t mean your conditioning is worsening!

If you have a papercut and you put your finger under running water, it will hurt more. Despite the increase in pain, your condition isn’t worsening! In fact, washing your wound will do you good!

A good night rest can do wonders for your recovery. Remember, your body is strong and resilient. The best position to sleep is the position that you are most comfortable in.

What causes lower back pain?

What causes lower back pain is one of the most poorly answered question.

Before we can understand what causes lower back pain, we must:

Understand that pain and damage are not one and the same

That is to say you can have:

• Pain without damage e.g. knocking your elbow hard against the wall
• Damage without pain e.g. bruises that you cannot account for

If you think that experiencing lower back pain equals there is something wrong with your back, you’re in for a rude surprise.

The Biomedical Approach

Most people think of pain as injury. It assumes all diseases to be the direct result of “something wrong”. In this approach, getting rid of “something wrong” will bring you back to good health.

In some cases, it makes sense. For example, with an infection you can get rid of it with antibiotics.

Yet at the same time, the biomedical approach cannot explain why two people with the same disease can feel remarkably different. For example, two people with a fever at exactly 41 degrees can have a completely different symptom experience.

This is the difference between disease and illness.

Disease refers to the underlying “something wrong” while illness refers to what you feel (i.e., your symptoms). The biomedical approach can show us what is “wrong” with you (i.e., disc herniation) but cannot explain why people with identical disease can have different illness experience (i.e., some have pain, some don’t have pain).

When it comes to chronic pain, the biomedical approach almost never applies.

Biopsychosocial Approach to Health Care

The biopsychosocial model was offered as an alternative to the biomedical model in the 1970s by New York psychiatrist George Engel. His model includes three components:

• Bio: refers to the biological tissues such as your muscles, joints, ligaments, or nerve roots.
• Psycho: refers to you as person, it includes your thoughts, emotions, attitudes, and beliefs
• Social: refers to the greater community – your friends, family, work, culture

While the biopsychosocial model is not new and likely familiar to most of us, we still tend to process our pain in the biomedical model (i.e. X is broken or Y is damaged).

Having said that, your back pain is unlikely to hurt because you sprain it 10 years ago.

The injury then would have healed by now.

Thinking your back hurts from an old injury is the biomedical way of thinking of your pain. Bad posture, slipped disc and spinal degeneration (i.e., wear and tear) all poorly correlate with pain. They do not explain why you are currently experiencing your pain symptoms.

Remember, pain doesn’t fit into the biomedical framework.

Over 90% of lower back pain presents WITHOUT an identifiable cause!

Research has shown that over 90% of lower back pain presents WITHOUT an identifiable pathology. Infection, rheumatoid arthritis, cancer are examples of specific pathophysiological mechanisms of lower back pain and they account for less than 10% of back pain.

As such, the preferred diagnostic term for lower back pain is: non-specific low back pain (NSLBP). Nope, I am not joking.

While chiropractors (or even physiotherapists) like to attribute your pain to misaligned spinal segments and physiotherapists to tight muscles, bad posture or the likes – they are all NOT validated by current research.

This is also why traditional chiropractic or physiotherapy, including manual therapy or physical therapy such as soft tissue or trigger point massage, stretching, yield very, very poor results. They are addressing the “root cause” that aren’t actually true root causes.

Can MRI show back pain?

Maybe you think an x-ray and MRI will show what is causing your low back pain. You can’t be more wrong. MRI and x-ray are almost useless for back pain.

Clinical guidelines have recommended AGAINST imaging for lower back pain for the longest period of time Unfortunately, chiropractors and orthopaedic specialists still refer back pain patients for unnecessary imaging.

The American Chiropractic Association published their formal recommendation stating:

“In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain.”

MRI could actually make your back pain worse!

MRI leads you to spending more money, making you feel worse, and miss more days at work. It’s lose-lose-lose.

The latest research showed MRI (magnetic resonance imaging) increases your health care spending, absent days from work, and reduces your sense of well-being.

This should come as no surprise given the biopsychosocial aspect of pain. Don’t forget, over 90% of lower back pain patients DO NOT present with an identifiable pain mechanism.

The American College of Physicians Best Practice Advice recommends:

• Immediate imaging only in patients with major risk factors for cancer, tumours in the spinal column, compression fractures, spinal cord infection, cauda equina syndrome, or with severe or progress neurological deficit
• Imaging AFTER a trial of therapy for patients with low risk factors for cancer, inflammatory disease, fracture, radiculopathy (leg pain from spinal nerve compression), stenosis (narrowing of the spinal canal)

These recommendations are also congruent with American Pain Society’s recommendation.

What kind of doctor do I see for back pain?

In Singapore, you have multiple options:

• Medical doctors such as your neighbourhood GP
• Medical specialists such as orthopaedic doctors, neurologist, spinal surgeons
• Chiropractors, osteopaths, or physiotherapist
• TCM sinseh (sometimes sold as “chinese chiropractor)

But, should I see a chiropractor for low back pain?

The most positive research on chiropractic therapy has focused on spinal manipulation for low back pain. As one of the alternatives to pain-relieving drugs, the American College of Physicians low back pain guideline recommends spinal manipulation along with heat, massage and acupuncture.

According to Harvard Medical School, yes.

Furthermore more, the Journal of American Medical Assocation published a study of 750 people with back pain. Half were treated with medications, self-care, physiotherapy while the other half received an additional 12 chiropractic treatments.

After six weeks, those who received chiropractic care experienced:

• Less pain
• Less disability
• Improvement in function
• Higher satisfaction with their treatment
• Reduced need for pain medication

What is the difference between a chiropractor and a physiotherapist?

In private practice, not very much. However, when it comes to management of back pain, there is some research to suggest chiropractic to be better than physiotherapist.

Study 1: Adherence to clinical practice guidelines among three primary contact professions

73% of chiropractors are adherent to best clinical practices, compared to physiotherapists at 62%, and finally medical doctors at only 52%.

It’s common to hear medical doctors and physiotherapists dismissing chiropractors as quacks or that chiropractic care is pseudoscience. They are both unfair statements and we have research data to support this.

Study 2: Low back pain-related beliefs and likely practice behaviours among final-year cross-discipline health students

This study looked at 602 final year students between chiropractors, physiotherapists. medical doctors, pharmacists, and occupational therapists. We are going to focus on the data published for chiropractors and physiotherapists:

When it comes to physical activity recommendations. 76.1% of chiropractors are guideline compliant compared to only 62% for physiotherapists.

When it comes to work recommendations, both professions did well 78.5% for chiropractic vs. 75.3% for physiotherapy.

As for rest advice, 84.8% of chiropractic students were guideline compliant compared to 74.5% for physiotherapy students.

Again, chiropractors do better at lower back pain management across all measured metrics.

We didn’t discuss medical doctor scores because they didn’t do too well. Which is okay because they have more important issues to deal with. Chiropractors and physiotherapists are the musculoskeletal health experts – that is we deal with that muscle and joint parts of the body.

Do you know chiropractors spent 310 hours dedicated to studying the management of spinal conditions while physiotherapy students only spend 112.5 hours? That’s less than half of what we do. It should come as no surprise.

Lastly, this was a study by Western Australia Health Department – not from an affiliated chiropractic institution or organisation.

Study 3: Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain

The study looked at 5511 participants who received worker’s compensation.

This is going to surprise you but patients who saw a chiropractor experienced the shortest duration of compensation while patients who opted to see a physiotherapist experienced the longest.

Back Pain in Singapore

We used the term “evidence base” a lot in our content. In fact, most chiropractors, physiotherapists, orthopaedic surgeons, and sports doctor do use it a lot as well. But what does evidence based practice actually mean?

Evidence based practice is an approach to making health care decisions based on the latest scientific studies, clinical expertise, as well as a patient’s values.

This means evidence based practice is NOT just about the latest research. It also takes into consideration what the clinician is capable of delivering and also your values as a patient.

For example, some Jehovah Witnesses are against receiving blood transfusion due to their religious beliefs. In this case, the evidence based approach will include taking that into consideration when formulating a treatment plan. This gives them the best possible clinical outcome.

Why?

1. Your values as a person is respected. This means you would get to preserve your free will. You also will not have to undergo the emotional and psychological trauma of receiving a medical intervention you do not want.
2. The evidence based framework means researchers and clinicians work together to develop a solution for you. There are substantial papers on the management of Jehovah Witnesses in cases such as the above. This means you get the best possible care without having your freedom of choice taken away from you.

Unfortunately in Singapore, true evidence based practice is rare.

• We have blogged about how an orthopaedic surgeon claimed to be evidence based and objective even though his recommendations were not. He also didn’t provide in-text references for his readers to fact check his claims.
• A sports doctor reached out to us to consider his recommendations in the management of Kingsley Tay’s Achilles tendinitis. He was also unable to provide references to support his recommendations.
• We have also called out a few physiotherapy clinics who were promoting sports massage and stretching as intervention to manage or prevent sports injuries. Again, this is not supported by any research.
• There are chiropractors who claim to be able to realign the spine or cure diseases such as cancer, infertility. These claims are definitely not supported by ANY research. We have blogged about the limitations of a chiropractic adjustment as well.
• The sound you get from a spinal manipulation is due to the gapping of the facet joints in the spine. No different from when you crack your knuckles. If a little ‘pop’ to your back can align your lumbar spine, people who crack their knuckles every few hours should have deformed fingers! (They don’t.)

To quote Max Zuman (1934-2013):

“If the physiotherapy profession wishes to remain a respected provider in the musculoskeletal pain area then it has no choice but to drop the «lip-service» and actually undertake serious philosophical change. To properly secure the clinical freedom and range of benefits the profession has/is seeking in many countries today it needs to abandon its arcane, outmoded empirically-based reasoning and influences”

We cannot agreement more. Of course this applies to not just physiotherapists but ALL health care providers in Singapore.

Don’t forget, the evidence based framework involves you as a patient.

In order for you to achieve truly superior treatment outcomes, you have to play your part in doing your due diligence. That is to consider the person whom you are seeking treatment from.

Is he or she evidence based? Does he or she know how to appraise scientific studies and apply them to clinical practice?

Understanding your low back pain

#1 Pain is 100% an output of the brain 

Do you know your pain experience comes 100% from your brain? Doesn’t matter if it’s dull, sharp, stabbing, or a sore lower back – it all comes from your brain. That is not to say your pain is not real or that your pain is all in the head.

As you live your daily life, millions of information is process by your brain. Based on those information, your brain may decide you are in a threatening or potentially threatening situation. When this occurs, you experience pain.

In cases of acute injury (e.g. accidentally cutting your finger with a knife), you DO experience pain as a result of the tissue. The experience of pain, however, is produced by your brain as a response to the nociception (threat stimulus) from the tissue damage. The pain is not from the finger.

So while your pain is real and not imaginary, it is 100% an output from the brain. It is important that you understand this.

#2 In chronic pain patients, damage is not the reason for your pain

If you have pain for more than three months, it is considered chronic pain. In cases of chronic pain, tissue damage is NOT the main contributor to your pain experience. Most of us with pain will fall into this category.

Your pain is more likely a result of an over sensitive nervous system than a biological defect.

#3 Your pain experience can be altered

Do you know if we apply a cold stimulus to your hand but told you that the stimulus is hot, you experience more pain?

If we were touch you with a red and blue stick of same temperature at the same time, you’d feel more pain with the red visual cue. Fascinating huh?

What about low back pain? A study that compared two types of education strategies on 121 chronic lower back pain patients found that participants in the group focused on understanding pain responded better.

One treatment was based on pain science and how pain works (think biopsychosocial) and the second on ergonomics, anatomy, and physiology (think biomedical). The pain science (biopsychosocial) group experienced an IMMEDIATE increase in pain-free straight leg raise while no change was observed in the second group.

My point is: We can re-train your brain. But not everything works the same.

#4 We cannot tell you the cause of your pain

This is when you might feel the disappointment. The truth is we cannot tell you with absolute certainty the cause of your pain.

The good news here – which is what we want you to really focus on – is that you can change your pain experience without having to identify what caused it in the first place. It’s important you understand this.

#5 There are factors that might increase your susceptibility to lower back pain

We can tell you what are the risk factors that contribute to your pain. They are:

• Being a woman
• Having more abdominal fat
• Smoking
• Strenuous physical work
• Nicotine dependence
• Alcohol abuse
• Depressive disorders

Walking or cycling to work reduces your risk of lower back pain!

References:

• Shiri R et al. Risk Factors for Low Back Pain: A Population-Based Longitudinal Study. Arthritis Care Res (Hoboken). 2019 Feb;71(2):290-299.
• Shemory ST, Pfefferle KJ, Gradisar IM. Modifiable Risk Factors in Patients With Low Back Pain. Orthopedics. 2016 May 1;39(3):e413-6.
• Parreira P et al. Risk factors for low back pain and sciatica. Spine. 2018 Sep;18(9):1715-1721.
• Suri P et al. Modifiable Risk Factors for Chronic Back Pain: Insights Using the Co-Twin Control Design. Spine. 2017 Jan; 17(1): 4–14.

#6 Your pain is phenomenological

Phenomenological is a big word and, until today, I still cannot pronounce it.

Phenomenology refers to the study of consciousness as it is experienced by the person. In the context of pain and stiffness, that means that your pain is unique to you as you live it. No one can know your pain experience. By extension, no one can tell you what your pain is and what it isn’t.

No one can tell you that your pain is not real.

Your pain experience is a lot more complicated than that. An experience requires a meaning in order to be an experience. Being in pain is always unpleasant and, therefore, indicates a negative meaning.

Your pain experience is in part the meaning you ascribed to it. The process of giving meaning to an experience is, needless to say, complex. These meanings are formed during early childhood – from your parents, the people around you, and culture that you are a part of.

Reference:

• Broom B. Meaning-full disease. How personal experience and meanings cause
  and maintain physical illness. Printed in Great Britain: Karnac Books Ltd.
  2007
• Ojala T. The essence of the experience of chronic pain: a phenomenological study. Studies in sport, physical education and health. 2015.

Research has also shown that it is possible to change the meaning you associate with your pain experience. By doing so, it is possible to live in pain without the negative meaning.

A possible way to look at it is to think the soreness you feel after going to the gym or a workout. Perhaps you are not a fan of it. Some people, however, love the muscle ache experience.

Why are we telling you this?

As per in study #3, not all information are created equal. When it comes to low back ache, having a good understanding of your pain yield SUPERIOR results to ergonomics, correct poor posture, and the likes.

Again, an evidence based approach yield superior results compared to the more common, anecdotal “it worked for my other patients so it will work for you” approach.

Lower Back Pain Clinical Guidelines

So that’s us done with our pain content.

Now we want to focus on lower back pain treatments in Singapore. Patients often want to know what are the treatments that will work the best for them. Clinical guidelines are the best place to start.

Clinical guidelines are written by major healthcare organisations or research institutions to provide some framework for healthcare providers to make clinical decisions. In essence, they provide recommendations on what to do and what not to do based on the latest research.

For example, it’s common to hear people say that heavy lifting is bad for your spine. Research does not support this! It’s also common to hear people advising their friends with back muscle spasm to rest more. Guess what? Research recommend AGAINST bed rest!

If you want to separate facts from fiction, this is the best place to start.

Guideline #1: The Lancet Lower Back Pain Series (2018)

There are four parts to The Lancet series but we are only going to discuss the prevention and treatment edition.

• Low back pain: a major global challenge
• What low back pain is and why we need to pay attention
• Prevention and treatment of low back pain: evidence, challenges, and promising directions
• Low back pain: a call for action

Annoying enough, all four articles are behind paywalls. If you would like to have a look at them, do contact us. We will try to arrange something for you. We are going to focus on the prevention and treatment edition of the series.

Exercise plus education is the best treatment for you.

When it comes to prevention of lower back pain, only two strategies were found to be effective: exercise + education and exercise alone. Needless to say, given the complexity of pain, exercise and education is better supported by evidence than exercise on its own.

Back belt (think those wearable contraceptions), shoe insoles, and – surprise, surprise – workplace ergonomic interventions are ineffective strategies.

Which medicine is best for back pain?

Acute pain refers to pain that is less than 12 weeks in duration. Most people think acute pain refers to a type of pain (i.e. sharp pain) or the intensity, this is not the case. Common lower back pain causes for acute pain include lower back strain.

Acute low back pain treatment OPTIONS

FIRST LINE recommendations: advice to remain active and education.

Second line treatments: heat therapy, spinal manipulation, massage, acupuncture, NSAIDs

Paracetamol is NOT recommended.

Chronic lower back pain treatment

This is the one most of us are probably concerned with. Back pain that lasts for more than 12 weeks are considered chronic.

First line treatment: 

• Advice to remain active
• Education
• Exercise
• Cognitive behavioral therapy

Second line treatment: 

• Spinal manipulation
• Massage
• Acupuncture
• Yoga
• Mindfulness
• Interdisciplinary Rehabilitation
• Non-steroidal anti-inflammatory drugs NSAIDs
• Discectomy (for patients with herniated disc + leg pain or nerve pain)
• Laminectomy (for patients with stenosis)

Chiropractic adjustments and other “hands on” treatments do not work.

So if you are wondering why we decided to move from chiropractic adjustments, IASTM, dry needling to become a predominantly exercise + education chiropractic clinic, this is why.

The evidence clearly delineates what is the best treatment option for you.

If we are talking about avoiding drugs and surgery because they are not good for you, we should – by extension – also avoid passive treatments/manual therapy. The evidence supporting their effectiveness is poor.

More recommendations from the Lancet guidelines:

• Lower back pain should be managed in a primary care setting – this means GP, chiropractors, physiotherapists or physical therapist.
• Provide education and evidence-based advice
• Remain active and STAY AT WORK
• X-rays or MRIs should only be ordered if it will change the treatment plan – i.e. if a chiropractor is going to offer chiropractic adjustments regardless of the x-ray findings, there’s no need for x-rays
• First choice of treatment should be non-pharmacological – avoid pain killers if possible!
• “Interventional procedures and surgery have a very limited role, if any, in the management of low back pain” (I am quoting this word for word so I don’t get into trouble with orthopaedic surgeons)
• Exercise IS recommended for chronic lower back pain
• A biopsychosocial framework should guide the pain management (this is why we spent so much time at the beginning explaining what is the biopsychosocial approach)

Gudeline #2: The American College of Physicians & American Academy of Family Physicians – Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain (2017)

This is probably a more straightforward guideline in the sense they condensed their recommendations down to three points:

1. For acute or subacute lower back pain, select non-pharmacologic treatment options first. Among non-pharmacologic treatments, superficial heat is best supported by evidence. There is low quality evidence supporting: massage, acupuncture or spinal manipulation.For medication, NSAIDs and muscle relaxants are preferred.
2. As for chronic lower back pain, it is also recommended that you start first with non-pharmacologic treatments:
   • Moderate quality: exercise, multidisciplinary rehabilitation, acupuncture, mindfulness
   • Low quality evidence for: tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation
3. If chronic lower back pain patients respond poorly to non-pharmacologic treatment, NSAIDs is the first line of treatment. Tramadol and duloxetine are second-line options. Opioids should only be considered if the treatments before failed and if the benefits out weigh the risk.

That’s it! Super clean, super straightforward recommendations. You can see plenty of overlap and the biggest difference is perhaps education was never mentioned in the 2017 guidelines by American College of Physicians but heavily emphasised in the Lancet series.

Interestingly enough, the acupuncture studies cited in this guideline compared acupuncture to sham as well as acupuncture to no acupuncture. All the studies cited reported improvement immediate after the treatment.

There doesn’t seem to be any reported long-term follow up/improvement. I am not sure what is their criteria for classifying acupuncture to be as effective as exercise, which does have an effect on the longer term.

Guideline #3: Evidence-informed primary care management of low back pain (2017)

The Canadian guideline advocates for:

• Patient education on how to prevent back pain and care for the low back with emphasis on patient responsibility and
  workplace ergonomics
• Exercise for Prevention of Recurrence

They recommend against shoe insoles/orthoses as well as lumbar support.

They make no recommendations against spinal manipulation, spinal mobilisation, as well as chair/address options.

I don’t really want to go into details of the other recommendations because they pretty much repeat the first two guidelines.

What is interesting is that the Canadian guideline recommend education on workplace ergonomics even though earlier studies have shown it to be inferior to pain science education. Guidelines published only a year after (The Lancet 2018) found workplace ergonomics to be ineffective.

Clinical Guidelines Summary

We only discussed three clinical guidelines because most of the rest are fairly outdated. Given how much research has been published in the last three years, we don’t think guidelines before 2017 will have much value today.

The Lancet series is the latest addition low back pain guideline. It is also the most comprehensive guideline and, arguably, the most authoritative to date.

Regardless of the differences between each guidelines , the general themes remain:

1. To relieve pain, choose non-pharmacologic treatments first
2. Exercise, stay active (i.e. no bed rest)
3. Use manual therapy as an adjunct therapy (e.g. totally optional, use with exercise).

Lower Back Pain Scientific Studies or Randomised Controlled Trials

Most people think randomised controlled trials are the crème de la crème of health care research. This is not true. Systematic reviews of randomised controlled trials is the top of the top as far as hierarchy of evidence goes.

We want to discuss mainly studies published within the last year or so because the clinical guidelines would have taken into consideration studies published earlier than that. Looking at this studies will give us an idea of what is happening in the low back pain world.

Study #1: Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work (2019)

We have posted this on our social media a couple of times and have also mentioned it in a couple of blog posts. It’s so important that we think it gets a double mention for this post.

Imaging (x-rays, MRIs) is associated with higher medical expenditure, more health care utilisation, and also more days of absence from work.

The clinical indications for x-ray or MRI are:

• Unexplained fever, chills, night sweats
• Sudden weight gain or weight loss
• Progressively worsening neurological symptoms

Again, over 90% of low back pain has no specific pathophysiology. If your chiropractor, medical doctor, or osteopaedic surgeon refer you for an x-ray or MRI, you should 100% question their clinical decision.

What are they suspecting or trying to find? Will it change your management plan?

Just in case, as logical as it may seem, is NOT an acceptable clinical rationale.

Study 2: Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain (2019)

An orthopaedic surgeon has blogged about how you shouldn’t see a chiropractor. Ex-Health Minister Khaw Boon Wan said chiropractors are not regulated because they are alternative health care providers.

My question is: Are chiropractors alternative health care providers because they don’t work or because they don’t cause harm? Think about it.

If you are thinking chiropractors provide worse care than physiotherapists, go check out our blog post where I discussed and referenced that chiropractors are – in fact – better trained and deliver better results than physiotherapists.

So either way, this systematic review of randomised controlled trials (i.e. crème de la crème) looked at a total of 9211 participants. They found that spinal adjustments were just as beneficial as other recommended therapies.

There was one serious event that is possibly associated to a spinal manipulation. That serious adverse event occurred after an osteopathic manipulation by an osteopath.

It is common for articles on social media to blame chiropractors for the adverse events associated with chiropractic adjustments or spinal manipulation. However, studies that looked at chiropractic manipulation or spinal adjustments often include treatments performed by other health care professional including osteopaths, physiotherapists, and medical doctors!

So I guess, back to the question, why are chiropractors considered alternative health care providers in Singapore? First, previous research says chiropractors deliver better results than physiotherapists when it comes to low back pain. Second, latest research on spinal manipulation says they work just as well as other recommended treatments.

Study 3: Expenditures and Health Care Utilization Among Adults With Newly Diagnosed Low Back and Lower Extremity Pain (2019)

This is a cohort study. It comes under randomised controlled trials in the hierarchy of evidence.

Why am I sharing this? Because it looked at almost 2.5 million US patients diagnosed with lower back pain. That’s a massive study!

Their findings were that few patients with lower back pain end up going for surgery. This is congruent with clinical guidelines so it’s a good thing.

They also found that surgery is the main driver of health care costs. I.e. surgeries and the associated-treatment after the surgeries are expensive. Also fair point.

Lastly, which is my favourite point, overimaging of low back or lower extremity pain (i.e. going for unnecessary x-rays or MRI) is associated with a significantly higher health care cost. They study also said this increase in cost is also avoidable.

So, again, if some one sends you for a x-ray or MRI, ask why. Why? Because you are the one footing the bills and you are the one losing out.

Study 4: Muscle Activity During Aquatic and Land Exercises in People With and Without Low Back Pain (2019)

Really, really small study. The study looked at 20 people with chronic low back pain and 20 people without pain. They performed 15 exercises in water vs. 15 exercises on land.

They found heart rate was always higher on land, exertion was higher in water for three exercises and higher on land for six exercises, muscle activation was higher on land.

Pain was reported twice as often on land than in water.

The idea is that water exercises could be as good as land exercises when it comes to management of lower back pain. They truth is that cannot be determined because the study was investigating muscle activity, heart rate, exertion. They study didn’t look at pain score BEFORE and AFTER – that is the only way to determine if pain has indeed improved.

It is common for personal trainers, fitness instructors, or even chiropractors and physiotherapists to misquote studies like this as supporting water exercises for lower back pain. It doesn’t.

Only a long term study that compares them would be able to tell.

Interesting study though.

Study 5: Comparative effectiveness of exercise interventions for low back pain (2018)

This is the paper I really, really struggle with because it published stretching works for lower back pain. I think stretching on its own doesn’t work. I’ve blogged about it at stretching vs. strength training.

This is why evidence based clinicians are better. We follow research, we appraise papers, and we challenge our attitudes and beliefs when we have to. Meaning, I don’t just leave this paper out because I don’t believe in stretching. I am going to look into the studies that support stretching and decide if I need to change my treatment approach to low back pain.

The study looked at 41 randomised controlled trials with a total of 3050 participants. comparable 22 different types of exercises.

From their research, stabilisation plus strengthening exercises (done together) were best for lower back pain. Followed by spinal flexion (bending forwards), spinal extension (bending backwards), and aqua aerobic exercises.

Yes, stretching didn’t make the top four but the study did find stretching on its own to be significant better than standard usual exercises. I really need to look into this!

Study 6: Manipulation and mobilization for treating chronic low back pain: (2018)

The study look at 1176 participants and compared spinal manipulation vs. spinal mobilisation. The results? Both are likely to reduce pain and improve function for chronic low back pain patients. Spinal manipulation produced a greater effect than mobilisation.

Also, both treatments were reported to be safe.

Overview of lower back pain research

Surprisingly, no surgical studies came up in my research. I am sure there are if I looked specifically for them.

You can see that there is a strong interest when it comes to exercise as treatment for lower back pain. When it comes to manual therapy, chiropractic manipulation is still fairly frequently discussed. Again, research shows that they do work comparable to other recommended treatments.

Seek chiropractic first

Now that we know that research says, who is the best person to see for evidence based care?

Believe or not, it is a chiropractor.

What is a chiropractor? A musculoskeletal health care expert trained to diagnose, treat, and manage muscle and joints disorders. Also known as doctor of chiropractic.

What can chiropractors do? Chiropractors are trained to deliver treatments to help with pain relief without pain killers. Chiropractic adjustments, joint mobilisation, soft tissue therapy, IASTM, dry needling are common treatments offered by chiropractors.

At Square One Active Recovery, we take an evidence-based exercise + education/coaching approach to managing lower back pain. With our methodology, our clients achieve their recovery goals within four to seven visits.

What do chiropractors treat? Disorders of the musculoskeletal system and, in particular, spinal conditions. We work with back pain and text neck or neck pain, as well as shoulder pain, knee pain, Achilles tendinopathy and other sport injuries.

Studies have shown that chiropractors are EXCELLENT, more excellent than physiotherapists and medical doctors in fact, when it comes to treatment of lower back pain. Not only are chiropractors more clinical guidelines compliant, we also deliver quicker results. Here is what the research says:

12 takeaway lessons for chronic lower back pain patients

So this conclude our very long entry on low back pain. We didn’t touch much on pain killers and surgeries because they are both last resort options. We don’t think you should be considering them. Here are the takeaway lessons:

#1 DO NOT go for a x-ray or MRI unless there is sufficient clinical justification (“just in case” is not good enough)

#2 Choose lower back pain treatment exercises over passive modalities such as chiropractic adjustments, IASTM, or dry needling

#3 While stretching exercises may work, strength and stability is the best

#4 If you need short-term backache relief, heat (not ice) is the cheapest, most evidence-based option

#5 Passive treatments work but only as adjunct

#6 When it comes to passive treatments, spinal manipulation works better than mobilisation

#7 Chiropractic adjustments are safe

#8 When it comes to medication, NSAIDs is your best bet

#9 Paracetamol doesn’t work, muscle relaxants might work but to a limited extend

#10 Among all the health care providers, chiropractors are the experts when it comes to back pain

#11 Medical doctors are the fared the poorest when delivering guideline-adherent advice (because they have a lot more medical conditions to deal with)

#12 Orthopaedic surgeons can help if you have disc herniation PLUS leg pain or spinal stenosis, and only if conservative care failed

I believe this to be the first low back pain article of its kind by a Singapore health care provider. We believe in creating high value, research-congruent content because you deserve it. If you have any feedback or would like us to make any correction, please do reach out to us via our contact page.

If you are have been living with chronic back pain and it’s simply not going away, book in for an appointment with us to discover the difference the right care can make.

See you soon!