Evidence-based clinical guidelines submitted to the Australian National Health and Medical Research Council for the management of acute low back pain: A critical review

Chapter 1. Introduction 

Reference is made to “back pain.” The highly nonspecific term back refers to the cervical, thoracic, and lumbar spines. In his chapter 2 (on page 6, under “Definition”/“Low Back Pain”), Bogduk appears to agree, stating that

the International Association for the Study of Pain (IASP)2 provided definitions based on anatomical topography. The taxonomy does not recognise the colloquial term back pain.

However, the author persists in using it frequently in the draft guidelines. Furthermore, he goes on to say that

back pain is but one of the musculoskeletal problems addressed by the Initiative. Others include neck pain [and] thoracic spinal pain.

Clearly, he should not be using the nonspecific term back pain, which includes the entire spine; later, noting his error, he defines lumbar, sacral, and lumbosacral pain. Nonetheless, he frequently uses the colloquial term back pain thereafter.

Under the heading “How,” Bogduk states that “the cardinal exception is that [the draft guidelines] were not prepared by a multidisciplinary panel.” This is a serious shortcoming, reflected not only in the foregoing criticisms regarding definitions but also in subsequent sections of the document.1

The author goes on to say that the draft guidelines “were based on the best available evidence,” but as I shall show, certain important literature references are missing. He also says that “the process of guideline development was novel, but involved multidisciplinary review and consumers.” However, the list of people who participated in the process of review (given on page 6) does not include all professional groups involved as State-registered primary health care practitioners.

Under the heading “Conflict of Interest,” Bogduk writes that

transparently and unashamedly, [the draft guidelines] have been developed with the medical practitioner in mind, particularly primary care practitioners, on the grounds that it is medical practitioners who have a comprehensive responsibility in the management of their patients. It is they who are ultimately responsible for the assessment and investigation of patients, prior to treatment; and it is they, who have the legal privilege and responsibility concerning the use of specific investigations for specific conditions, when the need of these arises.

This raises several questions, including the following:

Bogduk goes on as follows:

With respect to treatment, comparisons between craft groups and different health professions are avoided as far as possible unless these are mentioned in the literature cited and are pertinent to the evaluation of evidence. Instead, treatments are evaluated in a generic sense, without specification of who did, who can, or who should, provide those treatments. It is the efficacy of the treatment, not the effectiveness of a craft group that is emphasised in [the draft guidelines].

What is the definition of a “craft group” with reference to legally registered health practitioners? Is this meant to be derogatory toward State-registered professionals such as chiropractors? If such treatments as spinal manipulative therapy are evaluated in a generic sense without regard to profession, why does the author bother to identify “craft groups”? This would seem to be a basic contradiction in logic.

Under the subheading “Who,” Bogduk states that “instead of by a multidisciplinary panel, [the draft guidelines] were prepared by a single author on behalf of the Faculty of Musculoskeletal Medicine.” This shortcoming is very evident in the draft guidelines, which I consider lacking in scientific rigor, methodology, and impartiality. It is evident from the list of consultants that the exclusion of chiropractors immediately detracts from the document's credibility, inasmuch as chiropractors are the largest group of professionals who treat spinal pain by manipulation.

Under the final subheading, “What,” Bogduk states that the draft guidelines “are based on the proposition that the treatment, investigation, and assessment of acute low back pain is [sic] predicted by an understanding of the nature of back pain.” However, it is well recognized that chiropractors study the spine in much greater detail than any other primary contact group and therefore have a better understanding of the nature of back pain. That is why patients go to chiropractors, even though they know that their treatment, if it is subsidized by Medicare's public funding at all, will be subsidized to a much smaller extent than medical treatment would be.

Chiropractors having been excluded from the preparation of the draft guidelines, the criticisms that follow provide some examples of how the actual information regarding spinal manipulation has suffered as a result.

Chapter 3. Taxonomy 

Bogduk states that “simple investigations are usually noncontributory.” This is true if the practitioner is not properly trained in biomechanical investigations of the spine and pelvis that use erect posture or stress study imaging to look for postural aberrations—eg, leg length inequality with postural scoliosis3, 4, 5 and disk herniations with the lateral bending sign.6

Chapter 4. Diagnosis 

Bogduk claims that “degenerative joint disease [and] osteoarthritis…have been excluded because they are not recognised by the IASP2 as causes of low back pain.” This is misleading; osteoarthritis is a well-known cause of low back pain.7 Furthermore, according to Weishaupt et al,8 in people less than 50 years of age, osteoarthritis is rare and may therefore be predictive of low back pain in symptomatic patients.

Chapter 5. Natural history 

Bogduk states that “a more revealing picture is provided by studies that followed patients for at least 12 months.” There is no reference to the study by Meade et al9, 10 that compared chiropractic and hospital outpatient treatment for managing acute and chronic low back pain of mechanical origin. The conclusion reached by Meade et al9 was that

chiropractic almost certainly confers worthwhile long-term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain.

Meade et al10 found that “at three years, the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day-to-day practice, those treated by chiropractic derived more benefit and long-term satisfaction than those treated by hospitals.”

Under the heading “Implications” Bogduk states that “patients who have not recovered, or are not recovering by this time [2 months], will require more concerted effort in management.” If a patient still has low back pain after 2-4 weeks, a more concerted effort in management is warranted to prevent the chronic stage (13 weeks) being reached; this is supported by Bigos et al.11

Chapter 6. Prognostic factors 

Under the heading “Objectives,” Bogduk states that “few specific treatments for acute back pain have been validated, leaving only nonspecific management.” In my opinion, this is inaccurate. The Meade et al9 study, which looked at acute and chronic low back pain patients, concluded that

chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain. Introducing chiropractic into NHS practice should be considered.

Bogduk goes on to admit that conventional medicine in the treatment of low back pain has failed, noting “the failure of conventional medical management.”

Under the subheading “The Fear-Avoidance Model,” the author states that “beliefs in Musculoskeletal Medicine and Pain Medicine [are] that persisting with movement despite pain facilitates recovery.” This statement is far too general. The degree of pain—minor, severe, or crippling—should be defined if it is to make any sense.

Chapter 7. History 

Bogduk makes the following statement under the heading “Length of Illness”:

Intensive multidisciplinary therapy [the exact meaning of which he does not specify] may be appropriate for subacute or chronic low back pain but has been proven to be inefficient for acute low back pain.12

However, the following should be noted: (a) Meade et al9 advocate chiropractic treatment; (b) the recommendations in number 14 of the Clinical Practice Guidelines published by the US Agency for Health Care Policy and Research, which were primarily based on published scientific literature, found “manipulation to be a recommendable method of symptom control,”11 and (c) a RAND study concluded that “support is consistent for the use of spinal manipulation as a treatment for patients with acute low back pain.”13

Under the subheading “Severity,” Bogduk uses Carlsson,14 Chapman et al,15 and Strong et al16 as references for the visual analog scale. However, for the sake of accuracy, it would be more appropriate for him to at least reference the original source of the visual analog scale—namely, Huskisson.17

Under the heading “Circumstances of Onset,” the author states that “a physician's imagination may be limited to what they have been taught.” This is an important fact, and it applies in particular to spinal pain, an area poorly taught in medical school. He goes on to say that “there is no point subjecting to investigation patients who are destined to recover anyway in a matter of days or weeks.” What is meant by the imprecise time frame a matter of days or weeks? Greater than 13 weeks equates to chronic low back pain and may imply failed treatment. In addition, the statement that patients are “destined to recover anyway in a matter of days or weeks” is refuted by the findings of Deyo,18 who found that recurrences are frequent, affecting 40% to 70% of patients,19 who continue to suffer from chronic events.

Under the heading “Red Flag Conditions,” Bogduk states that “a meticulous history and physical examination can adequately screen [red flag conditions].” In my opinion, this is not so, inasmuch as in the early stages of low back pain due to malignancy, a meticulous history and physical examination might not detect the disease.

Chapter 8. Physical examination 

Under the heading “Inspection,” Bogduk writes as follows:

Identifying major postural deformities such as scoliosis…has no bearing on making a diagnosis of the cause of back pain. There is no direct relationship between major deformity and any known source or cause of lumbar spinal pain.

However, according to the scoliosis specialist James,20 “there are not infrequently small lumbar scolioses to be found of some 5° to 10°: sometimes showing so little curvature [that] it is sometimes discovered when they attend with backache.” Furthermore, according to Kostuik,21 low back pain can occur with scoliosis.

Bogduk goes on to write, “Similarly, identifying pigmentations, dimples, or patches of hair at the base of the spine is of significance for the recognition of congenital defects of the spine and spinal cord, but it has no direct bearing on the diagnosis of back pain.” However, there may be a condition causing pain—eg, neurofibromatosis with associated central cord pain.22

Under the heading “Palpation,” the author writes, “Bone tenderness over the lumbar spinous processes has been held to be an alerting sign of osseous disorders such as infection or neoplasm.” However, no reference is given for this statement, and certainly it is not commonly considered to indicate infection or neoplasm.

Under the heading “Neurological Examination,” Bogduk states that “if disc prolapse causes pain, it is radicular pain, which is felt not in the back but in the lower limb.” However, radicular pain may well not be present with a central disk protrusion that effaces the pain-sensitive anterior dural tube, causing low back pain.23 It is well known that the anterior dural tube is supplied by the sinuvertebral nerve24, 25, 26 and that disk lesions can cause low back pain without leg pain.27, 28 However, radicular pain will occur if the prolapse is a lateral or far lateral prolapse.29

Chapter 9. Imaging 

Bogduk states that “the available evidence-base questions the propriety and utility of this practice [of plain radiographs of the lumbar spine].” A reference is not provided for this statement. However, erect posture radiographs are of value,3 and flexion and extension stress views can indicate instability.30

Under the heading “Lesions Demonstrable,” the author writes of “plain radiographs…abnormal but of no clinical significance…revealing abnormalities not related to pain, such as…transitional vertebrae, spondylolysis and spondylolisthesis.” However, the following must be noted:

Under the subheading “Yield,” Bogduk writes that “the incidence of normal radiographs in patients with acute low back pain ranges from 21% in medical centre settings.”34, 35 However, it is well known that recumbent radiographs are less informative than erect posture radiographs.3, 4, 5 The author goes on to say that “spondylosis, disc degeneration, facet degeneration or osteoarthrosis are not legitimate diagnoses of the cause or source of back pain.” These conditions indicate motion segment degenerative changes that have been associated with low back pain.30

Under the heading “CAT Scans,” Bogduk states that “CAT scans have no place in the investigation of low back pain of unknown or unsuspected origin.” However, a suspicion of central disk bulge or protrusion by an astute clinician does require computed tomography examination.

The author goes on to write the following:

CAT scans may serve to confirm the diagnosis of disc herniation or other causes of radicular pain…Indicated only if the patient's history and clinical features clearly indicate radicular pain and radiculopathy… Back pain alone, or even back pain in association with somatic referred pain is not a sign of disc herniation, and cannot be justified as the basis of ordering a CAT scan.

I reiterate: a central disk protrusion may well be present in the absence of radicular pain and radiculopathy—ie, with low back pain only. This issue causes me to question the author's understanding of centrally located low back pain.

Chapter 10. Psychosocial assessment 

Under the heading “Vocational Issues,” Bogduk writes the following:

The New Zealand Guidelines recommend the administration of their screening questionnaire at 2-4 weeks after onset of pain. There is no evidence that this is the optimal time.

This criticism is unsupported by research, so the author should not be critical, particularly when he goes on to say that “formal exploration of yellow flags should occur no later than 2 months after onset of pain, and possibly by the end of the first month.” Surely the New Zealand Guidelines' suggestion of 2-4 weeks approximates “by the end of the first month.”

Chapter 13. Reassurance and home rehabilitation 

Under the heading “Recommendations,” Bogduk recommends that practitioners explain to patients with low back pain that “the worst thing they [can] do to their backs [is] to be careful.” However, in my opinion, the best advice to a person with acute low back pain is that he or she “be careful” while maintaining activity. It is possible that a medical practitioner or other health care provider would be exposed to an action for negligence and/or malpractice if (1) he or she gave the aforementioned advice from the draft guidelines to someone with an acute disk tear and (2) that person then continued with heavy manual lifting and twisting and suffered a further injury.

Chapter 16. Manual therapy 

The author first states that “manual therapy is perhaps the most contentious and most bitterly contested treatment for low back pain.” What about surgery? He then writes as follows:

Manual therapy is the principal therapeutic tool of several craft-groups. Manipulation is the hallmark of chiropractic therapy.

The word craft is not defined, but it should be eliminated, as it is akin to the word trade. A well-educated chiropractor makes an appropriate diagnosis; then, if it is indicated, he or she might use manipulation or mobilization treatment (in conjunction with, for example, advice on general principles of healthy living—eg, exercising, eating properly, and not smoking).36, 37 Chiropractic guidelines have been developed by Consensus and a critical review of current literature for Australian conditions.

Bogduk goes on to say that “manual therapy may not work as well as it is professed to do.” This statement is not supported in the literature. For example, with respect to acute and chronic nonspecific low back pain:

many therapeutic interventions are available for and used in the treatment of acute and chronic low back pain. We believe that the quality of the design, execution, and reporting of [randomized control trials] should, and indeed can, be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic [low back pain].

Under the subheading “Efficacy,” Bogduk makes the following statements:

1. “The conclusions of pragmatic review are a function of the discipline of the author of the review.” One could say the same about the draft guidelines.

2. “Some reviews elected to cover only selected literature.” Again, it is interesting that the studies by Meade et al9, 10 are not mentioned. Does this represent the author's own selective review of the literature?

3. “The first major systematic review40…concluded that ‘so far the efficacy of manipulation has not been convincingly shown.’”41 Naturally—because the author has cited a paper of questionable validity! Koes et al40 correctly defined manipulation as involving a “high velocity thrust to a joint beyond its restricted range of movement” and mobilization as using “low velocity passive movements within or at the limit of joint range.” They then made an arbitrary decision and stated that “throughout this article we will use [the term] manipulation to cover both manipulation and mobilization”! In response, Meade et al42 wrote the following:

Whether the term manipulation should be used, as Koes and colleagues used it, to cover both manipulation and mobilisation, is at least arguable. Their conclusions about manipulation (thus defined) in back pain seem analogous to generalisations about antibiotics for sore throat.

Therefore, another serious shortcoming of the entire NH&MRC submission is that it gives NO credence to letters by the original author(s).

4. “The review concluded ‘we could not find evidence in favour of manipulation in patients with acute low back pain.’”41 However, what the authors (Koes et al)41 had actually written was this: “We could not find conclusive evidence in favour of manipulation in patients with acute low back pain.” They had also noted that “there certainly are indications that manipulation might be effective in some subgroups of patients with low back pain.” Bogduk also notes that one review43

focused explicitly on the efficacy of chiropractic manipulation for back pain. It found that the literature did not provide convincing evidence for the effectiveness of chiropractic for acute or chronic low back pain.

However, the conclusion of the study by Meade et al9 was as follows:

For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain.

In addition, Assendelft et al44 wrote that “most of the data does indeed indicate a greater effectiveness of chiropractic compared to physiotherapy.”

5. “The authors38 concluded that ‘there is limited evidence that manipulation is more effective than a placebo treatment’ but ‘there is no evidence that manipulation is more effective than (other) physiotherapeutic applications (massage, short-wave diathermy, exercises) or drug therapy (analgesics, [nonsteroidal anti-inflammatory drugs]) for acute low back pain, because of the contradictory results.’” This completely ignores the findings of Meade et al.9, 10

6. “The results of controlled trials and systematic reviews thereof stand in contrast to the recommendation of manipulative therapy by expert panels in the past.”11, 45 Bogduk goes on to state that “these recommendations seem to be based less on an analysis of the literature and more on socially based consensus.” In my opinion, it would appear that the draft guidelines are based less on an analysis of literature and more on the author's opinion.

The preceding critique (and that which follows) of Bogduk's opinions, as they are presented in the NH&MRC draft guidelines, indicates that the author does not appear to have reviewed all the literature available, including letters to editors, which clarify both aspects of the debate. In other words, the analysis of the literature has serious shortcomings; otherwise, this statement could not be reasonably made.

Under the heading “Level II Evidence,” Bogduk writes as follows:

A recent, high quality study,46 not covered by any systematic reviews to date, provides further evidence. The study compared physical therapy, chiropractic manipulation, and the provision of an educational booklet. Outcomes were evaluated in terms of pain scores, disability, days spent in bed, off work, or away from school, and use of health care. Patients were assessed at 4 and 12 weeks after treatment. No significant differences in any outcome variable were detected.

Bogduk uses this particularly poor study to support his hypothesis that spinal manipulation is not effective. The study by Cherkin et al46 has been severely criticized in the literature.*What follows is a brief critique of this paper in which I show its considerable shortcomings; I believe these in fact invalidate the entire study. Moreover, the credibility of the submission to the NH&MRC is called into question when such studies are cited without criticism.

Chapter 28. Algorithm 

Under the heading “Management,” Bogduk refers to “analgesics, injection, [and] manual therapy.” It is interesting that manual therapy is included in this list. However, there seems to be a flaw in the directional flow of the algorithm: exiting the “Management” box, a patient could end up being caught in a circle, unable to exit. Again, this suggests that critical mistakes have been made throughout the draft guidelines.