What is appropriate care for low back pain?

As a chiropractor, I don’t understand why would academic journals publish articles about appropriate care for back pain only to put it behind a paywall. That doesn’t help many people!

This is why evidence-based practice, while obvious in its advantages, is poorly practised in real world clinical conditions. And you, as a pain sufferer, would have no access to resources that would tell you what are the best clinical practices! This practice does make recovery tricky for the average person.

Ranting aside, the almighty Spine journal just published a new paper on what is appropriate care for low back pain. Because most, if not all of you, would not have access to the original paper, I’ll be sharing the major takeaways here for you.

Why are chiropractors not included in the study?

At a glance, the study seems quite robust and do involve a lot of researchers, including some big names. Admittedly, they would have been more diverse with their team to include chiropractor-researchers. There is no shortage of low back pain researchers with a chiropractic background.

Charlotte Leboeuf-Yde is known for her ridiculously big sample studies (almost 30,000 participants) and eight year study of 9600 twins. Jan Hartvigsen was one of the lead authors for the Lancet low back pain guidelines, which remains the most authoritative guideline published. Just last year, he also stood up against Big Pharma when he walked out of a International Association foHOnesr the Study of Pain (IASP) Task Force.

So, the question remains, why are chiropractors not include in the research team?

Did they deliberately leave us out?

What are the 27 appropriate care clinical indicators?

The paper did make a recommendation on a list of 27 clinical practices. I would not go through them as they are fairly technical and, in my opinion, do not have much value add for the average pain patient. If you would like to know what they are, do reach out to us and we will be able to get that to you.

They did, however, include recommendations on seven key concepts on what should or should not be done when it comes to best clinical practices. In our opinion, this is something you should be looking out for in your search for a chiropractor.

1. Undertake a comprehensive and targeted history to identify (a) serious or specific conditions, (b) factors which may delay recovery.

Because a lot of what is discussed in the paper is already what we do at Square One Active Recovery, we’ll be discussing the recommendations within the context of what we do at our practice. It makes sense. Afterall, we are first and foremost and evidence-based chiropractic clinic.

If you look at our work process, all of our clients would actually have to go through an onboarding request. It’s a three page form that you complete online by yourself. From there, we will have enough information to decide if you are a case we can potentially take on or a case that really should be going to a hospital immediately.

We don’t see the point of getting patients to book in only to tell them that we can’t help them. As much as reasonably possible, we want to be able to do this before the initial consultation. This means you also get to save some money!

Our unique test-retest examination process

One of the things that set us apart from other chiropractic clinic is that we use a test-retest process. A lot of chiropractors and other practitioners would actually run through a series of test during the first session and reach a diagnosis by the end of the session. This is quite a broad stroke approach, and research suggests that orthopaedic testing doesn’t really have very high specificity. Aka, they are not the most reliable.

So, with this in mind, we do more of test-retest approach at our practice. Sure, we do do an assessment during the first consultation. Following which, you’ll bring a set of exercises home to do as well.

We’ll check in on you in seven days to look at your progress.

This test-retest process is unique to you! We look at how your physical body or symptom experience has changed over seven days to make a clinical judgement on what may be going on in your case.

It sounds like a hassle, and it is true that you may not get super clear answers with our approach. However, if you want something more tailored-to-you (rather than a cookie cutter approach), this is how it would look!

2. Provide education and advice.

We are huge on education and advice. I mean, we even have an infographic to show exactly how education and advice (which we call coaching) will help you with long-term results.

You can go for chiropractic adjustments, dry needling, shockwave therapy, whatever it is that you think would work. The problem is that when your pain comes back, you are not going to be able to treat yourself! Sure, you can crack your joints but it’s not exactly like what you’d get from a chiropractor. I am guessing none of you would be sticking needles into yourself or buying a shockwave machine so you can treat yourself at home. Right?

So, we call this dependency care at Square One Active Recovery.

All of these treatments are inferior because it requires you to be dependent on someone. It is disempowering.

So, with that, the firstline treatment (which by the way is consistent across all clinical guidelines) is exercise, education, and advice.

We don’t just tell you what exercises to do so you can help yourself. We also coach you through the recovery process so you can help yourself should your pain ever comes back.

Let’s also be super honest here: Nobody healthy is ever pain-free for life!

3. Partner with patients to co-develop a management and monitor plan for ongoing review of progress.

In the onboarding form that ALL clients must complete before they can make an appointment, there’s a section for you to discuss your goals.

Unlike other chiropractors that tell you exactly what you should “fix”, we ask you what exactly you want out of working with us. Of course we will be able to provide professional advice on what you should be working on but what is most important here is that we work within a client-first approach.

We also don’t do pay-per-session consultation anymore because all of our clients can reach out to us via WhatsApp and we usually reply to them within 24 hours. So, we really do partner you in your journey to freedom from pain.

4. Refer appropriately.

We discussed this earlier in point one. If you are a case that we cannot help with we will actually not take you on as a client.

There are actually prospects who try to wiggle their way around our onboarding but giving us almost zero information about their case. We do not take on such cases.

We take a lot of pride in what we do. And we are also very aware that you are paying us to get results. At the end of the day, if we have no indicator that your case is something can we can help with, we genuinely believe we should not take you on as a client. And, we don’t.

It sounds rude. It sounds abrasive. But at the end of the day, while we are a service business, our job is to help you get results. Not to provide great service and do whatever you want us to do.

And, we are happy to prioritise your recovery over sales.

Not sure how many chiropractic businesses in Singapore can actually say that!

5. Avoid unnecessarily imaging and investigations.

We are not going to discuss this again because we have written about how chiropractic x-rays are a total scam. If you have already gone for one, ask for your radiologist report. Most chiropractic clinics actually withhold that from you and send you their own reports, which usually sound a lot worse than what the radiologist would say.

If you are thinking you need MRI because you have slipped disc or you suspect you have one, you probably want to read this.

6. Avoid inappropriate prescribing of medicines.

We also discuss this before. Muscle relaxants do not work. Paracetamol and NSAIDs could also do more harm than good.

Old news, but make sure you remember it!

7. Do not offer non-evidence-based and low value treatment modalities.

Specifically, they listed acupuncture, manual therapy alone, and epidural injections.

None of this is new news so I’ll not be going into details again.

We have blogged about how chiropractic adjustments is not a long term solution. In fact, they don’t work better than placebo.

Similarly, sports massage is not as useful as you have been led to think.

At this point in time, there’s also no reasonable quality studies to show that acupuncture or dry needling is helpful.

So, these are the seven key takeaways. Let us know if you find them helpful. If you need more information or have questions that are not answered, do drop us an email and we’ll be sure to cover them next time!