Adrian C Traeger, Rachelle Buchbinder, Adam G Elshaug, Peter R Croft, and Chris G Mahera
Institute for Musculoskeletal Health,
University of Sydney,
PO Box M179, Missenden Road,
Camperdown NSW 2050, Australia.
Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach.
In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients’ self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain.
We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.
Primary Care Centre Versus Arthritis,
School of Primary, Community and Social Care,
Keele University, Keele, United Kingdom.
Evidence-based medicine helps health care professionals and patients decide best care, drawing on research about effectiveness and safety of interventions. Systematic reviews summarise the evidence; guidelines report consensus between experts (including patients) on interpreting it for everyday practice. Although guideline recommendations are only one component of shared decisions that will vary patient-to-patient, the hoped-for outcome is health benefit for each individual. Guidelines also inform starker decisions by policymakers and health care leaders — for example, when to withdraw approval or funding for a poorly evidenced or harmful intervention. To assess whether all this research-driven activity is useful, 2 questions need answering: how well are guidelines followed in real-life practice and do patients benefit in the long-term?
In a new systematic review, Kamper et al.  tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. (aka “usual medical care”) As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally,  and there is good evidence for what constitutes best first-contact treatment.  The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”).
Valerie F. Williams, MA, MS; Leslie L. Clark, PhD, MS; Mark G. McNellis, PhD
Santa Monica, California,
United States of America.
OBJECTIVES: To estimate the cost-effectiveness to the US Veterans Health Administration (VA) of the use of complementary and integrative health (CIH) approaches by younger Veterans with chronic musculoskeletal disorder (MSD) pain.
PERSPECTIVE: VA healthcare system.
METHODS: We used a propensity score-adjusted hierarchical linear modeling (HLM), and 2010-2013 VA administrative data to estimate differences in VA healthcare costs, pain intensity (0-10 numerical rating scale), and opioid use between CIH users and nonusers. We identified CIH use in Veterans’ medical records through Current Procedural Terminology, VA workload tracking, and provider-type codes.
As part of a comprehensive geriatric assessment program, the RAND Corporation studied a subpopulation of patients who were under chiropractic care compared to those who were not and found that the individuals under continuing chiropractic care were:
Free from the use of a nursing home [95.7% vs 80.8%];
Free from hospitalizations for the past 23 years [73.9% vs 52.4%];
More likely to report a better health status;
More likely to exercise vigorously;
More likely to be mobile in the community [69.6% vs 46.8%].
Recipients of chiropractic care reported better overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and were more active than the nonchiropractic patients.
Although it is impossible to clearly establish causality, it is clear that continuing chiropractic care is among the attributes of the cohort of patients experiencing substantially fewer costly healthcare interventions. 
A second review of a larger cohort of elderly patients across the United States compared direct expenditures [hospital care, physicians’ services, nursing home] between groups of patients who were under maintenance chiropractic care and those who were not.
Nearly a threefold savings of mean annual expenditures was reported as follows:
$ 3,105 : Maintenance care
$10,041 : No maintenance care 
One study involving elderly populations reviewed the consequences of implementing an on-site industrial chiropractic program which included the early detection, treatment, prevention and occupational management of musculoskeletal injuries 2 days per week.
James M. Whedon, DC, MS, Andrew W. J. Toler, MS, Louis A. Kazal, MD, Serena Bezdjian, PhD, Justin M. Goehl, DC, MS et al.
Southern California University of Health Sciences,
OBJECTIVE: Utilization of nonpharmacological pain management may prevent unnecessary use of opioids. Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain.
DESIGN AND SETTING: We employed a retrospective cohort design for analysis of health claims data from three contiguous states for the years 2012-2017.
SUBJECTS: We included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. We identified two cohorts of subjects: Recipients received both primary care and chiropractic care, and nonrecipients received primary care but not chiropractic care.
METHODS: We performed adjusted time-to-event analyses to compare recipients and nonrecipients with regard to the risk of filling an opioid prescription. We stratified the recipient populations as: acute (first chiropractic encounter within 30 days of diagnosis) and nonacute (all other patients).
Michael D. Freeman, A. Katz, Scott L. Rosa, Bryan G. Gatterman, Ellen M. F. Strömmer and Wendy M. Leith
CAPHRI School for Public Health and Primary Care,
Faculty of Health, Medicine, and Life Sciences,
Maastricht University, 6211 LM
Maastricht, The Netherlands.
BACKGROUND: Intervertebral instability is a relatively common finding among patients with chronic neck pain after whiplash trauma. Videofluoroscopy (VF) of the cervical spine is a potentially sensitive diagnostic tool for evaluating instability, as it offers the ability to examine relative intervertebral movement over time, and across the entire continuum of voluntary movement of the patient. At the present time, there are no studies of the diagnostic accuracy of VF for discriminating between injured and uninjured populations.
METHODS: Symptomatic (injured) study subjects were recruited from consecutive patients with chronic (>6 weeks) post-whiplash pain presenting to medical and chiropractic offices equipped with VF facilities. Asymptomatic (uninjured) volunteers were recruited from family and friends of patients. An ethical review and oversight were provided by the Spinal Injury Foundation, Broomfield, CO.