Spine J. 2008 (Jan); 8 (1): 1–7 ~ FULL TEXT
Scott Haldeman, DC, MD, PhD, FRCP(C), Simon Dagenais, DC, PhD
Department of Neurology,
University of California,
Irvine, CA, USA.
Patients with chronic low back pain (CLBP) are finding
it increasingly difficult to make sense of the growing list of
treatment approaches promoted as solutions to this widespread
problem. Their confusion is compounded by the financial
and emotional cost of previous failed attempts. This frustration is felt not only by patients, but by all interested stakeholders, including clinicians trying to offer accurate
advice and provide the most effective treatment to their
patients, and third-party payers responsible for providing
access to reasonable and necessary care. All share a common
goal and wish to use limited healthcare resources to support those interventions most likely to result in clinically
meaningful improvements in symptoms and functional capacity. The current approach to the management of CLBP makes this goal virtually unobtainable.
When a new treatment approach is being considered in fields as cardiology, infectious diseases, acute trauma, or neurology, there is a general expectation that adequate research will support its effectiveness, safety, and cost effectiveness
before it is endorsed as a viable treatment option. With CLBP, however, treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence. Treatments that have never been subjected to methodologically sound randomized controlled trials are routinely promoted as cures to unsuspecting patients. Conversely, approaches that have demonstrated only minimal benefit in clinical trials continue to be recommended by proponents who allege that such studies were flawed and do not accurately represent current clinical practice.
Decades spent listening to presentations at scientific
meetings, reading textbooks, discussing the problem with
clinicians and patients, listening to advertisements on the
television or radio, and browsing the internet, could lead
one to conclude that the classical method of making healthcare
decisions based on scientific evidence and expert consensus
appears to have been replaced with a commercial and competitive model akin to shopping at a supermarket. This analogy is reinforced by visiting the commercial displays at spine meetings, where there is intense competition by pharmaceutical companies, surgical instrument makers, and device manufacturers to convince stakeholders of the benefits of their products. Only rarely do such promotional materials accurately present the scientific evidence underpinning a particular approach, and rarer still are discussions of potential harms. Similar concerns about the commercialization of treatments for CLBP have been expressed elsewhere. 
The size of the potential market for CLBP treatments is
extremely large because most of the population can expect
to experience low back pain (LBP of the) at some point in
their life, and many will go on to develop CLBP and require
one or more interventions. A recent study reported that the
point prevalence of LBP in the general adult population is
estimated at 37%, whereas the 1-year prevalence is 76% and the lifetime prevalence is 85%; approximately 20% of sufferers describe their pain as severe or disabling.  A detailed review of the direct and indirect costs of LBP is presented elsewhere in this special focus issue.  Although
most costs associated with LBP are indirect which include disability payments and loss of productivity the money spent on direct medical costs for the treatment of LBP is substantial. As discussed in that review, direct costs of LBP have been estimated at $12.2 to $90.6 billion annually in the US, or $45 to $335 per person each year. This range of estimates is comparable with the annual revenues of large corporations such as Toys ‘‘R’’ Us ($12.2 billion) or Home Depot ($90.8 billion), ranked 202 and 17, respectively, on the 2007 Fortune 500 list. 
The inventory of treatment options
Creating an inventory of the available, advertised, and
commonly used treatment options for CLBP can be a daunting
task, and navigating this selection without an informed
guide is analogous to shopping in a foreign supermarket
without understanding the product labels. Table 1 presents a list of available CLBP treatment options in a manner that one could expect to see if these treatments were being sold
in a supermarket and was developed primarily from the 25
articles presented in this supplement; only a partial list is
presented because of limited shelf space.
In aisle one, there are over 60 pharmaceutical products
that are currently being offered to patients with CLBP. In
aisle two, there are 32 different manual therapies; this is only
a partial list as there are well over 100 named techniques
in chiropractic, physical therapy, osteopathy, and massage
therapy. In aisle three, there are 20 different exercise programs, even after excluding all of the different machines
and products that are widely promoted every night on television.
Aisle four includes 26 different passive physical
modalities; numerous variants exist for each of these approaches. Aisle five is where one may find one of 9 educational and psychological therapies, which is by no means an
exhaustive list. Aisle six has over 20 different injections
therapies, which themselves have numerous subtypes
according to practitioner preference. Aisle seven contains
only a few of the growing list of procedures commonly
included under the umbrella of minimally invasive interventions
widely promoted as alternatives to surgery. Aisle eight lists some of the more traditional and newer surgical approaches. Aisle nine lists only a few of the extensive lifestyle
products sold for CLBP, including braces, beds, chairs, and ergonomic aides. Finally, in aisle ten one can always
find a constantly changing variety of complementary and alternative medical approaches to CLBP, which are used by a large and apparently growing number of patients. 
Patients browsing these aisles who may feel tempted by
more than one product should no longer feel that each is
mutually exclusive. It is now possible to fill an entire shopping cart with treatments that one can try simultaneously or
serially under the guise of ‘‘multidisciplinary care.’’
Conversely, patients who are unwilling (or unable) to purchase
one of the numerous products displayed in aisles one to 10 may indulge in window-shopping. This may take the form of coping and acceptance, activity modification, self education, patient initiated comfort methods passed on from their parents, grandparents, or friends, and what has become known as watchful waiting and reassurance. This group may also simply refrain from making purchases because they have not been sufficiently tempted by available options. If they can only be persuaded to enter the supermarket, they will become recipients of sample medications from their physicians, free spinal examinations from chiropractors, or short massages on vibrating chairs. If
these methods are not sufficient to convert them into shoppers,
this group will nevertheless continue to receive sales
pitches. As the duration or intensity of their symptoms increase, purchases become almost inevitable to cope with
This simplified, partial inventory of treatment options
available to a person with CLBP includes over 200 different
medications, therapies, injections, products, or procedures.
It is a challenge for anyone involved in the management of
CLBP to memorize this list, let alone understand the
relative benefits and harms of each intervention at a level
that is sufficient to provide advice to their patients.
Although true informed consent requires a discussion of
available alternatives, it would be impossibledor at least
unfeasibledfor a clinician to do so fully and accurately
when it comes to CLBP.
The branding of treatments
People who develop CLBP and wish to seek care are first
required to select a health provider from a number of specialists
who claim expertise at treating these symptoms.
Common choices include orthopedic surgeons, chiropractors,
neurosurgeons, physical therapists, rheumatologists,
acupuncturists, neurologists, pain management specialists,
osteopathic physicians, physical medicine and rehabilitation
specialists, internists, and family physicians (Table 2). The education, training, skills, and experience of this diverse
group of clinicians vary considerably when it comes
to CLBP. For example, a physician who trains in general
anesthesia for 5 years before specializing in pain management
will have a substantially different viewpoint than
a rheumatologist who spends the most of their residency
examining patients with inflammatory joint disorders. Similarly,
the training of an orthopedic or neurological surgeon
exposes them to a patient population that is materially different
from that seen by family practitioners and internists
in their training, or by chiropractors who acquired their experience
in student clinics. These distinctions are rarely
known to patients, who simply address each one as ‘‘doctor’’
and reasonably assume that those claiming expertise
in a field and licensed by a regulating body must indeed
possess appropriate qualifications to help them.
The challenge of selecting the correct intervention for
CLBP does not end once the choice of a specific type of
health provider is made, and there is no assurance that different
members of the same profession will offer the samed
or even similardtreatment approaches. There exists a great
deal of variance in expertise and opinion within each health
profession and clinical subspecialty that treats CLBP.
Surgeons may favor one surgical procedure over another
depending on where they were trained, and chiropractors
may pursue radically different techniques depending on
which post graduate courses they have recently attended.
Physicians who prescribe analgesics or other medications
may be influenced by the last lecture they attended, the most
recent journal article they read, or yesterday’s visit from
a pharmaceutical company representative. Interventional
pain specialists may offer different approaches based on
the last course offered by the North American Spine
Society or other groups.
Although it is laudable that continuing medical education
informs clinicians of the most recent innovations with which
to help their patients, rarely do such venues adequately discuss
the deficiencies in the research underpinning the
approach being presented, nor is there a comprehensive
comparison with available options. Instead, vague recommendations
are made, that a treatment should be considered
when othersdwhether conservative for promoters of surgical
techniques or surgical for promoters of nonsurgical
approachesdhave failed to resolve the problem. The fact
that no treatment to date has significantly impacted the burden
of CLBP is driving this demand for new approaches, and
encouraging even the most experienced clinicians to learn
the latest treatment on the market to stay informed.
Branding is particularly important when different
professions have an overlapping inventory of treatments.
For example, practitioners of manual therapy will often
brand their approach by naming their technique with a registered
trademark that cannot be used without certification
or membership. This is analogous to the competition seen
among brands at a supermarket shelf, which has resulted
in rows upon rows of nearly identical products being sold
to consumers at vastly different prices based on the strength
of their marketing and brand recognition. Clinicians who
are not content simply promoting their approach may take
branding one step further by denigrating competing alternatives.
This may occur on an individual level when counseling
their patients, or in more public forums through
publications, scientific, or otherwise. Patients may thus be
told by surgeons that chiropractors are quacks, by interventional
pain specialists that surgeons are attempting to operate
without having located the source of pain, by manual
therapists that physical therapists rely excessively on passive
modalities, or by massage therapists that exercise
may lead to injuries. This competitive atmosphere is detrimental
to patients, not suited to the practice of health care,
and confirms the lack of scientific consensus that is necessary
for an optimal approach to CLBP.
The ideal situation for the management of a condition
such as CLBP would be that all clinicians are knowledgeable
about commonly used therapies and able to counsel
their patients on which treatments may be most appropriate
for their condition. This would lead health providers to refer
patients more frequently to other clinicians who may be
more skilled at providing a particular approach. Under this
scenario, one could reasonably expect that the utilization
and cost of specific therapies would be similar throughout
industrialized nations and in different populations. This is
currently not the case, as reported in the review of economic
burden of LBP studies presented elsewhere in this issue.  Four studies were identified in which the utilization
(ie, market share) of different treatments for LBP was described
in Australia (Table 3), Sweden (Table 4), the United
Kingdom (UK) (Table 5), and the US (Table 6). Although
these studies are not directly comparable as they used different
methodology and studied different populations of patients,
they do provide some insight as to differences in
utilization and costs of specific treatments or health professions
for LBP in developed countries. For example, a study
in the US reported that 65% of patients with LBP sought
care from a family physician , compared with 22% in
Australia.  The utilization of chiropractors also differed
greatly amongst these countries, from 46% in the US  to
19% in Australia.  In Australia, 17% of costs were attributed
to chiropractic , compared with 4.2% in the UK  and 1.7% in Sweden.  The costs attributable to surgery
also varied greatly between countries, from 23% in Sweden  to 13% in the UK.  This difference is perhaps not surprising
given that there is an eightfold difference in the
likelihood of undergoing surgery depending on the specific
region in which one resides in the US. 
The sales pitch
Even in health care, the individual making the sales
pitch for a particular intervention is likely to benefit financially
from a successful sale. Despite their best efforts to remain
neutral when counseling patients, this economic
reality is hard to ignore. In a competitive market, the most
successful salesperson is often the one who truly believes in
the value of the product they are selling. It may therefore be
necessary for clinicians to first convince themselves of the
superiority of their approach to most effectively impart this
message to their patients. In time, clinicians may become
so successful at this process that they are no longer aware
that this subconscious bias may exist.
People with CLBP routinely solicit advice about specific
treatments from health providers. Although evidence-based
medicine (EBM) offers a framework for finding and evaluating
this information, the strict application of EBM methodology
to the evaluation of treatments for CLBP can result
in information that is of little value to clinicians or patients.
Because few interventions for CLBP have been studied
through multiple, methodologically sound randomized controlled
trials, many systematic reviews conclude that there
is insufficient evidence on which to base recommendations.
Patients who are not satisfied with this type of advice will
likely continue their pursuit for information elsewhere until
they find more direct answers. Those searching the internet,
however, are more likely to be directed to a site established
by a commercial sponsor or discussion group promoting
a specific approach than a site offering quality information
from expert clinicians and researchers willing and able to
objectively evaluate multiple interventions.
Evidence-informed management of CLBP
The initial goal of this focus issue was to review the evidence
for just a few of the most common nonsurgical approaches
to CLBP. However, the list continued to grow as
authors suggested new topics and it soon became clear that
a single focus issue could not possibly include information
on every treatment listed in Table 1. As is often the case
with these projects, topics were eventually chosen based
partly on perceived popularity, availability of evidence,
and willingness of invited authors to submit manuscripts.
It should therefore be noted that inclusion in this focus
issue should not be perceived as an endorsement of a particular
intervention, nor should omission lead readers to
conclude that an intervention is marginal.
The format for the articles included in this review was
also the subject of much discussion. Although narrative reviews
are helpful in providing useful recommendations in
the absence of solid evidence, they rarely evaluate evidence
in a transparent manner, and often omit many aspects that
are relevant to those making decisions. And while systematic
reviews are often cited as the gold standard of evidence
in EBM, strict adherence to rigorous methodology often
leaves many questions unanswered. Because the goal of
this focus issue was to provide a useful and quality source
of information to interested stakeholders wishing to compare
available alternatives to treat CLBP, it was important
for articles to follow a similar format that would provide
sufficient information on which to base decision-making.
At minimum, each article should clearly define and
describe a particular intervention, explain the theory or science
behind its mechanism of action, search for and evaluate
evidence regarding efficacy, discuss potential or known
harms, and summarize this evidence for nonexperts.
Authors were encouraged to follow this format closely,
yet given some liberty to provide additional information
where they felt this was most appropriate. The title chosen
to represent this approach was "Evidence-Informed Management
of Chronic Low Back Pain Without Surgery."
We hope information contained in this focus issue will be
a useful companion for reluctant or confused shoppers
who are currently bewildered by the wide array of merchandise
in this vast supermarket.
Pai S, Sundaram LJ.
Low back pain: an economic assessment in the United States.
Orthop Clin North Am 2004;35:1–5.
Schmidt CO, Raspe H, Pfingsten M, et al.
Back pain in the German adult population: prevalence, severity, and
sociodemographic correlates in a multiregional survey.
Dagenais S, Caro J, Haldeman S.
A Systematic Review of Low Back Pain Cost of Illness Studies
in the United States and Internationally
Spine J 2008 (Jan); 8 (1): 8–20
Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC.
Trends in Alternative Medicine Use in the United States, 1990 to 1997:
Results of a Follow-up National Survey
JAMA 1998 (Nov 11); 280 (18): 1569–1575
Long DM, BenDebba M, Torgerson WS, et al.
Persistent back pain and sciatica in the United States: patient characteristics.
J Spinal Disord 1996;9:40–58.
Walker BF, Muller R, Grant WD.
Low back pain in Australian adults: the economic burden.
Asia Pac J Public Health 2003;15:79–87.
Maniadakis N, Gray A.
The economic burden of back pain in the UK.
Hansson EK, Hansson TH.
The costs for persons sick-listed more than one month because of low back or neck problems.
A two-year prospective study of Swedish patients. [see comment].
Eur Spine J 2005;14:337–45.
Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES.
United States’ trends and regional variations in lumbar spine surgery: 1992–2003.