Chiropractic Excellence: Integrating WHO Guideline on Chronic Low Back Pain in Clinical Practice
In December 2023, the World Health Organisation (WHO) launched its new Guideline for the Non-Surgical Management of Chronic Primary Low Back Pain in Adults in Primary and Community Care Settings, which provides evidence-informed recommendations on non-surgical interventions for chronic primary LBP (CPLBP), to improve CPLBP-related health and wellbeing outcomes. The Guideline Development Group included chiropractors and received evidence commissioned by WHO, from sources including the World Federation of Chiropractic’s Research Committee Chair, Dr Sidney Rubinstein, who led three of the systematic reviews informing the guideline recommendations.
In this article, BCA Board Member, Faye Deane, takes us through the importance of the new WHO Guideline in clinical practice, including the chiropractic involvement in its development.
Musculoskeletal (MSK) Conditions: A Global Public Health Priority
In the UK, low back pain is the leading cause of disability, affecting 17 million people. According to data from Public Health England, it is the largest cause of ill health across all age groups, disproportionately affecting those who are socially and economically disadvantaged.
Comprehensive population health research from the Global Alliance for Musculoskeletal Health indicates a projected global increase in the prevalence, burden, and cost of MSK health impairments, a trend attributed to factors such as population growth, aging, a rising prevalence of non-communicable disease risk factors, and elevated rates of MSK injury and trauma.
Furthermore, direct costs in treating MSK conditions are increasing despite poorer self-reported mental health and functional, workplace and social limitation outcomes (Hoy et al, 2013). A propensity for low value, and often outdated best-practice care in many healthcare systems serves as strong evidence that a systematic approach to both inform and assist practitioners and patient decisions about the best-practice has been warranted for a long time (Briggs et al, 2021).
Professor Richard Brown, BCA Past President and Secretary General of the World Federation of Chiropractic (WFC), joined the BCA as a special guest on Wednesday 17 January during our first webinar of 2024, to explain the importance of the newly launched WHO Guideline in clinical practice. The webinar aimed to share the knowledge and expertise of thought leaders across the healthcare professions, to summarise the key recommendations detailed in the 242-page document and to provide an insight into the role the international chiropractic community played in the development of this Guideline.
Chiropractic Involvement in the Development of the Guideline
Renowned chiropractors from across the globe contributed to the development of the Guideline, sitting in leadership positions on working groups such as External Review and Guideline Development Group. The idea for a Guideline covering low back pain in adults, including older people, was actioned in 2017, following discussions between the WFC and the WHO, involving Professor Richard Brown and others.
Among the five classes of interventions for the management of chronic primary low back pain (CPLBP) in adults considered in the Guideline, conditional recommendations favoured the use of exercise, education and advice, spinal manipulation, needling therapies (including dry needling), cognitive behavioural therapy and the judicious use of non-steroidal anti-inflammatory medicines and topical cayenne pepper.
Interventions which were not recommended in favour of use included a multitude of pharmacological interventions (such as opioids, muscle relaxants, paracetamol and injectable local anaesthetics), traction, transcutaneous electrical stimulation (TENS), lumbar braces, belts and/or supports and therapeutic ultrasound.
Implications for clinical practice
The WFC’s EPIC Principles, which are very much aligned to the BCA’s standards and qualities that we know our members value, are reflected throughout the Guideline. The importance of evidence-informed, person-centred, equitable, non-stigmatising or discriminating care, which is integrated and coordinated in its delivery, is highlighted throughout.
There is a changing landscape in the field of public health with the introduction of health policies prioritising the significant, far-reaching burden of MSK conditions such as CPLBP. During the webinar, Richard spoke about “Monday morning takeaways” in terms of the key points to take from the Guideline. At the BCA, we believe all BCA chiropractors should commit to patient care that is valid, evidence-informed and effective in terms of both patient outcomes and satisfaction. The BCA further commits to this message being shared far and wide within the healthcare community, supported by robust, substantiated, multi-disciplinary research.
WHO Guideline for Non-surgical Management of Chronic Primary Low Back Pain in Adults in Primary and Community Care Setting, 2023. Available at: https://www.who.int/publications/i/item/9789240081789. Last accessed 23 January 2024.
Briggs, A.M., Jordan, J.E., Kopansky-Giles, D., Sharma, S., March, L., Schneider, C.H., Mishrra, S., Young, J.J. and Slater, H., 2021. The need for adaptable global guidance in health systems strengthening for musculoskeletal health: a qualitative study of international key informants. Global health research and policy, 6(1), pp.1-22.
Hoy, D.G., Smith, E., Cross, M., Sanchez-Riera, L., Blyth, F.M., Buchbinder, R., Woolf, A.D., Driscoll, T., Brooks, P. and March, L.M., 2014. Reflecting on the global burden of musculoskeletal conditions: lessons learnt from the global burden of disease 2010 study and the next steps forward. Annals of the rheumatic diseases, pp.annrheumdis-2014.
PHE (2023). Health profile for England, 2021. Available at: https://fingertips.phe.org.uk/static-reports/health-profile-for-england/hpfe_report.html. Last accessed 7 January 2024.
Global Alliance for Musculoskeletal Health (2021). Towards a global strategy to improve musculoskeletal health. Available at URL: https://gmusc.com/wp-content/uploads/2021/07/Final-report-with-metadata.pdf Last accessed 12 January 2024.