Why not everyone with low back pain chooses chiropractic care

Dr. Simon Dagenais DC, PhD, MSc

Introduction

It has been estimated that low back pain (LBP) will affect 84% of the general adult population at some point in their life, with 49% reporting some LBP in the previous 6 months, 23% suffering from chronic LBP, and 11% experiencing physical impairment due to LBP.^1,2 Numerous therapies are available for LBP from a variety of clinicians, including primary care providers (PCPs), pain management specialists, spine surgeons, physical therapists, and chiropractors. This vast array of therapies available for LBP was previously compared to a supermarket in which patients can wander down a particular aisle to choose among the many competing products and brands vying for their attention through marketing claims.³

Each clinician likely perceives that the care they offer for LBP is superior to the alternatives, and would like to believe that they hold the solution to the vast public health and economic problem presented by LBP. Chiropractors are probably no different in this regard, believing that nearly everyone with LBP would benefit from receiving spinal manipulation therapy (SMT). However, various surveys suggest that only 5–10% of adults in Canada and the United States visit a chiropractor in any given year.^4–10 The goal of this commentary is to speculate about some of the reasons why not everyone with LBP chooses to seek chiropractic care, which are presented below as factors related to LBP, public perceptions about chiropractic, patient preferences, and the chiropractic profession.

Factors related to low back pain

Not all low back pain is amenable to chiropractic

It is estimated that 80–90% of LBP is of nonspecific or mechanical origin, and therefore cannot be attributed to an identifiable anatomical structure or disease process.¹¹ However, such estimates cannot easily be interpreted as the proportion of LBP that should receive chiropractic care, as some individuals have LBP associated with potentially serious spinal pathology (e.g. cancer, infection, fracture) or substantial neurologic involvement (e.g. progressive motor deficit, incapacitating radiculopathy, central stenosis), while others may have contraindications to SMT.¹² Although the validity of proposed clinical prediction rules for LBP remains unclear, it is highly unlikely that all patients with LBP would in fact benefit from chiropractic care.¹³

Not all low back pain requires health care

Many patients with acute nonspecific LBP experience a marked improvement within a few weeks, making watchful waiting a reasonable initial approach, though of course chronic LBP has a greater probability of recurrence and decreased likelihood of complete resolution.¹⁴ Most episodes of LBP are of relatively mild or moderate severity and do not greatly impair physical function, making it possible for individuals to carry on with their normal activities despite the pain.¹⁵ If watchful waiting proves inadequate to improve symptoms, patients may also choose to manage LBP themselves using heat, ice, over-the-counter analgesics, stretching, exercise, activity modification, or other methods that may not require a health care provider at all, let alone a chiropractor.

Factors related to public perceptions about chiropractic

Negative patient perceptions about chiropractic

Many individuals with LBP have never been to a chiropractor and may not be open to trying it for the first time for a variety of reasons, including negative public perceptions about chiropractic.¹⁶ It may not be possible to clearly identify the origins of this perception, which could be related to negative prior experiences reported by friends, family, or colleagues, dubious advertising claims by chiropactors, or negative reports about chiropractic in the media. Although chiropractors may disagree with those who have negative views about their profession and hope to demonstrate their merits if given the chance, such negative perceptions may prevent that opportunity.

Negative perceptions about chiropractic by physicians and other health care professionals

Another factor that may influence the use of chiropractic for those with LBP is negative perceptions about chiropractic held by physicians, surgeons, and other health care professionals.¹⁷ Older physicians may have been trained in an era where collaboration with chiropractors was considered unethical, while younger ones may be echoing the opinions from senior colleagues during their residency or fellowship training. Other factors may also be involved, including general medical skepticism about the unknown, passive mistrust of non-physician clinicians, enmity toward complementary or alternative medicine, or the belief that chiropractic is not effective. Such perceptions likely dissuade a substantial proportion of those with LBP from seeking chiropractic care or being referred to chiropractors when they first seek care elsewhere.

Fear of potential harms

Many have likely heard about the possibility that chiropractic care may cause serious harms, including vertebral artery dissection (VAD) leading to stroke, paralysis, or death. However, few are likely aware that VAD itself may result in neck pain, prompting individuals to seek care, whether from chiropractors, PCPs, or other providers, after which attempts will be made to link serious harms to a variety of activities involving the cervical spine, including SMT, sports, archery, driving, roller coasters, sex, or sneezing.^18,19 This situation is troubling for all stakeholders, particularly since the extreme rarity of these events makes it very difficult for researchers to study them more closely. Nevertheless, the fear of harms associated with SMT in the cervical spine may deter many individuals from seeking this type of care, even if cervical SMT does not play an important role in chiropractic management of LBP.

Patient preferences

Other therapies may be preferred

Patients have an abundance of options if they choose to seek care for their LBP, and some of the therapies available may be more appealing than others based on awareness, previous experiences, recommendations from friends and family, general preferences about health care, availability, proximity, religious beliefs, or various other reasons. When confronted with numerous therapies with somewhat equivalent effectiveness and safety, patient preference is an important consideration, and may in fact influence the outcomes achieved if beliefs related to expectations are fulfilled.²⁰ In such situations, patients should be encouraged to first seek the type of health care they most prefer.

Financial considerations

Chiropractic continues to be excluded from many public and private health insurance plans, despite a suggestion two decades ago that it could be financially advantageous to payers and society to do so.²¹ The decision to pay for chiropractic out of pocket requires that patients weigh associated costs and benefits against alternative uses for those funds, including other forms of health care or even basic necessities. Concerns related to excessive care, including prolonged treatment plans that continue beyond maximum therapeutic benefit, additional charges for x-rays or other diagnostic tests that may not be medically necessary, or recommendations to purchase nutritional supplements, pillows, or braces sold by some chiropractors, may exacerbate these financial concerns and deter patients from choosing chiropractic care.

Concerns about lack of effectiveness

Chiropractors have seen countless patients walk into their offices grimacing from LBP and leave with a smile shortly after receiving care. However, the assumption that SMT is universally effective for LBP has been challenged by randomized controlled trials, systematic reviews and clinical practice guidelines. Although their findings are generally positive, they suggest that by itself, SMT offers mainly modest, relatively short-term improvements in pain and function that is similar to other approaches such as analgesics and exercise therapy.^22,23 Some patients with LBP may therefore not be interested in chiropractic care because they’ve tried it previously and found it ineffective, or have heard similar experiences from others.

Factors related to chiropractic profession

Ambiguous public identity

Chiropractors can expend considerable energy debating the merits of being evidence-based, primary care spine clinicians vs. remaining true to their historical origins as clinicians who detect and correct spinal subluxations to minimize nerve interference. However, such discussions likely do little to foster public confidence when choosing a clinician for LBP. Focused expertise is likely a desirable trait for a health care profession, being simple to grasp and easy to remember. For example, patients like knowing they can go to the dentist when their tooth hurts, and don’t need dentists to also claim expertise in cardiology, obstetrics, and toxicology – despite possible oral manifestations of many related diseases – to appreciate the benefits of dentistry. Claims by some chiropractors that they can treat virtually any disease remotely associated with the spine likely dilute their perceived expertise in managing LBP. Other clinicians now showing an interest in SMT (e.g. physical therapists, osteopaths) will only intensify the ambiguous public identity of chiropractors as experts in LBP.

Lack of standardization in chiropractic

It is quite difficult for many stakeholders, including patients, chiropractors, other health care providers, third-party payers, and the government to know precisely what will happen when a patient presents to a chiropractor to receive care for LBP. Ideally, any chiropractor would complete a thorough history and physical and neurologic examination to identify serious spinal pathology, substantial neurologic involvement, nonspinal causes, and identify risk factors for chronicity, and offer education, reassurance, instructions on self-care and exercise, and SMT.¹¹ However, reality often clashes with such ideals, and patients may instead be offered “diagnostic” machines with flashing lights and high-pitched sounds indicating “subluxation”, assessment of “nutritional deficiencies” through manual muscle strength testing, x-rays to identify “spinal misalignment”, “detoxifying” foot baths or even, “healing” crystals. Since there is no easy method to predict the type of care that any given chiropractor will deliver for LBP some patients will choose to look elsewhere.

Summary

Some of these reasons described above may not play a role when someone with LBP is trying to choose among the many available therapies, while others that were not mentioned (e.g. lack of awareness, lack of availability) may be the deciding factors. Truth be told, deciphering the reasons why someone does not do something is in many ways more challenging for researchers than explaining why someone with LBP did choose to seek chiropractic care, requiring some degree of speculation. Although data to support some of the proposed reasons are lacking, it should not be necessary to await findings from independently validated, peer-reviewed, large, publicly funded research teams to acknowledge that empty waiting rooms cannot solely be attributed to the general public failing to appreciate what chiropractors have to offer.

At its best, chiropractic consists of quality, affordable, effective, personalized, safe, patient-centered care that is delivered by highly skilled, empathetic, and honorable clinicians who want to help their patients achieve the best health possible. At its worst, chiropractic provides shelter for unscrupulous individuals to offer scientifically dubious services and engage in ethically questionable practices under the guise of providing alternative health care. Should the current utilization of chiropractic somehow be perceived as too low by some chiropractors, which is unclear, any attempt to change this situation will require a long-term, comprehensive and concerted effort involving educational institutions, accrediting agencies, licensing boards, professional associations, researchers, clinicians, continuing education providers, policy makers, third-party payers, government, and patients to promote and reward the former, while identifying and discouraging the latter. Although such efforts may prove difficult for the chiropractic profession to initiate and enforce, they are likely preferable to kneejerk legislative mandates enacted as a consequence of common negative perceptions about chiropractic care for LBP and other conditions.