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Dynamic Chiropractic – September 9, 2008, Vol. 26, Issue 19

Lower Back Pain as a Public Health Issue

By Paul E. Dougherty, DC, DABCO and Jonathan Todd Egan, DC, MPH, PhD (cand.); guest author for Rand Baird, DC, MPH, FICA, FICC

In a previous article, we discussed that until the chiropractic profession begins to address public health issues, we will not, in our opinion, progress as a profession. Although you might not think chiropractors get together just to talk about public health, in all actuality they do - and they talk about back pain.

According to the most recent survey from the National Board of Chiropractic Examiners, the most common conditions chiropractors treat are back and neck pain. Recent epidemiologic studies report moderate back pain has an annual incidence in the adult population of 10 percent to 15 percent, with 80 percent of adults experiencing back pain at some point in their life. Of those patients who seek care, 70 percent will do so from either a primary care medical physician or a chiropractor, making lower back pain the second most common reason for visiting a physician's office.

Back pain is the single greatest reason for activity limitation in those under age 45. A recent report on the economic impact of back pain reports costs have increased 65 percent in the last 10 years (even after adjusting for inflation). Yet even with this significant increase in spending, the results of treatment for back pain have not improved. Individuals with back pain have health care expenditures about 60 percent larger than individuals who don't suffer from back pain, causing a significant impact on our health care delivery system. This is an important public health issue.

Remember, we believe when a caring professional addresses public health, it increases credibility for them and their profession. How can chiropractors address the public health aspects of back pain? As we discussed in our previous article, public health includes "health promotion and disease prevention." In the area of back pain, chiropractors are very well-suited to address both.

Health Promotion: An Active Lifestyle Is a Healthy Lifestyle

Patients' attitudes, beliefs and passive coping strategies play an important role in back-related disability. There is significant evidence that staying active and continuing or resuming ordinary activities is more effective than rest. There also is evidence to show premature imaging studies (including plain-film radiographs) and referral to a specialist are unwarranted in most cases of uncomplicated low back pain. There also is evidence to show back pain patients involved in leisure activities expend a certain amount of energy have less disability than patients under a provider's care (this includes both medical and chiropractic physicians).

Medical researcher Richard Deyo, MD, suggests that in order to achieve a paradigm shift from the traditional model of management of back pain, it might be that both the public and health care professionals need to be re-educated. If re-education can change attitudes and beliefs and give rise to an alteration in patients' expectations and physicians' behavior, the rising incidence of disability from low back pain might be significantly decreased.

Rachelle Buchbinder, PhD, demonstrated that a population-based strategy providing positive messages about back pain improved population and generalpractitioner beliefs about back pain seemed to influence medicalmanagement and reduced disability and workers' compensation costsrelated to backpain in Australia. Recent data show the benefits of an active lifestyle not only for preventing back pain, but also for preventing and improving disability associated with diabetes mellitus and cardiovascular disease.

Disease Prevention: Education About Risk Factors

Demographic studies show some risk factors for chronic low back pain such as socioeconomic and employment status might not be easily influenced by increased awareness. However, there are some risk factors that do seem to be influenced by increased awareness. These factors include smoking, diet and stress. Although the data on the relationship between smoking and back pain is somewhat controversial, there do seem to be enough public health data on the overall risks associated with smoking. Thus educating patients on quitting is good, at the very least, for preventing lung disease - and may help reduce low back pain. The data on specific dietary recommendations for the prevention of back pain are somewhat controversial. There are data to suggest healthier eating habits might improve overall health and decrease the incidence of obesity - and some feel there might be benefits from an "anti-inflammatory diet." The third area of public education is stress reduction. Some data suggest psychosocial issues, including stress and depression, might play a role in developing chronic back pain. An interdisciplinary and integrative approach might be most useful to address this issue, specifically working on a team with a behavioral health professional. This interdisciplinary approach to treatment improves patient care and leads to an improvement in the cultural authority of the chiropractic profession.

How Do We Do It?

The first area for improving patient care is to improve our own lifestyle. In our community of Rochester, N.Y., a study was performed evaluating primary care physicians' recommendations of exercise for their patients. It turned out physicians who themselves exercised were more likely to prescribe exercise. Although there are data to suggest we should perhaps not be prescribing "specific" exercises in many circumstances, we certainly can encourage and empower patients to maintain an active lifestyle. This active lifestyle includes regular activities they enjoy that require them to expend a certain amount of energy. This is important for the practicing chiropractor as well. With so much stress associated with practice today, we have to find some activity we enjoy to do consistently and regularly. We will then be that much likelier to encourage our patients to engage in activities that promote a healthy lifestyle.

Additionally, chiropractors can approach special interest groups in their communities and offer to provide a public service lecture. Addressing public health issues is not and should not be from a self serving or marketing perspective. If done in a spirit of community service, it might open doors that would previously have been closed.

In conclusion, chiropractors must view back pain as an important public health issue. We have a responsibility to treat back pain effectively and to give back to our communities through education about the prevention of back pain. Chiropractors must get involved in public health issues in order to progress. One of the fastest ways to start is by getting involved in the American Public Health Association (APHA) which has an active Chiropractic Health Care section and many resources for chiropractors. Please consider joining this group of chiropractors who see that, "It is not until chiropractors stop worrying only about chiropractic and start worrying about public health, too, that we will advance as a profession."

To join the APHA, log on to, click "Member Login" and "Join." Remember to select "Chiropractic Health Care" as your "Section/SPIG 1."

Click here for previous articles by Rand Baird, DC, MPH, FICA, FICC.

Dr. Paul Dougherty, primary author for this month's "Chiropractic in the APHA" column, chairs the Chiropractic Health Care section of the APHA. Contributing to this article is Toby King, executive director of the U.S. Bone and Joint Decade.

Dr. Jonathon Egan is a graduate of New York Chiropractic College and current chief of staff of the NYCC Campus Health Center. Formerly a clinician at the VA facility in Rochester, N.Y., he now chairs the Seneca County Board of Health.

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