Updated clinical practice guideline issued on chiropractic care for low back pain

The Journal of Manipulative and Physiological Therapeutics (JMPT), the official scientific journal of the American Chiropractic Association (ACA), published an update to a previously issued evidence-based clinical practice guideline on chiropractic management of low-back pain (LBP). The update, which revised and combined three previous guidelines, supports that doctors of chiropractic (DCs) are well-suited to diagnose, treat, co-manage and manage the treatment of patients with low-back disorders.

Clinical practice guidelines require regular updating to be considered current. To that end, a formal systematic review of LPB literature was conducted for the current update using the Delphi technique and included 37 panelists, of whom 89 percent had worked in private practice for an average of 27 years. Panelist consensus was reached after one round of revisions; the vast majority of recommendations remained unchanged. The previous Council on Chiropractic Guidelines and Practice Parameters guidelines were developed in 2008 and expanded twice over the intervening years.

The updated guideline provides recommendations throughout the continuum of care from acute to chronic and offers the chiropractic profession an up-to-date evidence—and clinical practice experience-informed resource outlining best practice approaches for the treatment of patients with LBP. Key recommendations are as follows:

• Routine imaging or other diagnostic tests are not recommended for patients with non-specific LBP. Imaging is indicated in the presence of severe and/or progressive neurologic deficits or if the history or physical exam causes suspicion of serious underlying pathology.
• The hierarchy of clinical methods used should generally correspond to the existing level of evidence (i.e., use treatments that are well-supported by evidence first, before moving on to other treatments that are less supported by evidence but that have been shown to be effective through practitioner experience).
• Active care (exercise) clinical strategies can aid in functional recovery from a re-conditioning perspective and also to improve "locus of control" (promoting patient self-reliance) from a psychosocial perspective.
• Informed consent should be obtained from the patient. The diagnosis, exam and any proposed procedures should be explained clearly. Any material risks associated with the proposed treatment should be reviewed (the definition of what is a "material risk" can vary depending on the state), as well as risks associated with other treatment options and the risk of doing nothing.
• Evidence reviewed does not generally support the use of therapeutic modalities (ultrasound, electrical stimulation, etc.) in isolation; however their use as part of a passive to active care multimodal approach to LBP management may be warranted based on clinical judgment and patient preferences.

"The updated LBP guideline continues to vigorously promote the use of published research evidence along with clinical practice experience to establish recommendations on clinical methods designed to improve patient care and outcomes," said ACA President Anthony Hamm, DC, FACO. "It is expected that through constant improvement in clinical methods, chiropractic physicians can elevate the profession and influence greater acceptance of chiropractic in integrated health care delivery systems so that we can better serve the American public."