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Foundation for Chiropractic Progress Supports Findings of JAMA Chronic Low Back Pain Primary Care Study

SAN JOSE, Calif., Feb. 24, 2021 -- The Foundation for Chiropractic Progress (F4CP), a not-for-profit organization educating the public about the benefits of chiropractic care, has issued a public statement in support of the findings of a cohort study published Feb. 16 in the Journal of American Medical Association (JAMA Network Open).

The study, "Risk Factors Associated with Transition from Acute to Chronic Low Back Pain (LBP) in U.S. Patients Seeking Primary Care" concluded that the transition from acute to chronic low back pain (LBP) is much greater than historically appreciated at 32%, and increased correspondingly with early exposure to nonconcordant guidelines. This is an important finding because the prevailing belief in the medical community was that acute LBP resolves within three months on its own and thus received little attention. It turns out that more attention is warranted at the initial acute stage so that LBP does not become chronic, even among low-risk patients. The study's authors point out that accumulating evidence indicates that guideline-concordant care has not been successfully implemented in primary care.

Clinical guidelines consistently recommend reassurance (e.g., most episodes of acute LBP resolve quickly and have a very low likelihood of serious underlying pathology) and advice to maintain activity as tolerated. Recently, nonpharmacologic interventions, such as spinal manipulation (commonly known as a chiropractic adjustment) heat, massage or acupuncture, are recommended as first-line treatment options, while specialty consultation and prescription of opioid medications in the absence of red flags (e.g., fever, fracture, malignant neoplasms) are not recommended.

"These findings suggest that more emphasis should be placed on strategies to successfully implement guideline concordant care in the primary care setting to reduce the development of chronic low back pain," said Sherry McAllister, DC, president, F4CP. "The F4CP is working to raise awareness of the efficacy of spinal manipulation as a recommended first-line treatment option when performed by a doctor of chiropractic versus another healthcare provider. In the U.S., DC programs include rigorous clinical training that focuses on low back pain."

When is low back pain considered chronic?
Patients were considered to have chronic LBP if they 1) reported the presence of pain for more than three months, and 2) experienced pain at least half the days in the six months.

Low back pain is the leading cause of disability in the United States, representing twice the burden of any other health condition. Treatment for LBP and related spine disorders now represents the most expensive medical problem in the U.S., with most costs accrued in ambulatory care settings, including primary care. Chronic LBP contributes most to long-term disability, morbidity, healthcare and societal costs.

The study suggests that one reason for poor implementation may trace back to physicians' musculoskeletal training. Medical educators have recognized for years that training in musculoskeletal medicine is suboptimal for medical students, residents and general practitioners.

Defining nonconcordant care

The cohort study defines nonconcordant care as:

  • Any prescriptions that included opioids
  • Prescriptions that included benzodiazepines and/or systemic corticosteroids alone without the presence of nonsteroidal anti-inflammatory drugs or short-term skeletal muscle relaxants
  • Orders for a lumbar radiograph or computed tomography/magnetic resonance imaging (CT/MRI) scan
  • Referrals to nonsurgical or surgical specialties (e.g., physiatrists, orthopedists, neurologists, neurosurgeons or pain specialists).

Of the 5,233 patients with acute LBP from 77 primary care practices in the study, nearly half received at least one nonconcordant recommendation within the first three weeks of the first visit. The study found that 1,544 patients received prescriptions for non-recommended medications of which 999 received opioids.

Even after controlling for patient characteristics (e.g., obesity) and clinical characteristics (e.g., baseline disability), increasing numbers of nonconcordant management approaches increased the likelihood of having chronic LBP at six months. Nonconcordant care can lead to direct and indirect harm, given that it has been linked with medicalization and unnecessary healthcare utilization.

"Referrals to doctors of chiropractic for low back pain ought to be part of concordant care," Dr. McAllister explained. "Studies show that when patients start with a non-prescriber (provider), the rate of opioid use goes down. While the availability of non-prescriptive treatment is not a silver bullet for the opioid crisis, it's clear it can reduce prescribing while still addressing the pain management needs of patients."

To access additional research in support of chiropractic care and the efficacy of spinal manipulation, visit

About the Foundation for Chiropractic Progress

A not-for-profit organization with nearly 29,000 members, the Foundation for Chiropractic Progress (F4CP) informs and educates the general public about the value of chiropractic care delivered by doctors of chiropractic (DC) and its role in drug-free pain management. Visit; call 866-901-F4CP (3427).

SOURCE Foundation for Chiropractic Progress

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