NATIONAL INSTITUTES OF HEALTH
NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE
Low-Back Pain: Research and Delivery of
Evidence-Based Care
An Interview With Gert Bronfort, D.C., Ph.D.
Gert Bronfort, D.C., Ph.D.
Gert Bronfort, D.C., Ph.D., is vice president of research and director of the musculoskeletal research program at Northwestern Health Sciences University (NWHSU) in Minneapolis. He is also a member of NCCAM's National Advisory Council for Complementary and Alternative Medicine (NACCAM). After receiving his Doctor of Chiropractic degree from Canadian Memorial Chiropractic College, Dr. Bronfort worked in private practice and research consulting in Denmark before moving to the United States in 1988. Also the holder of a Ph.D. in extramural medicine from Vrije University, in Amsterdam, the Netherlands, Dr. Bronfort oversees patient care in the context of "pragmatic clinical trials"—a type of trial designed to test treatments in everyday clinical-practice settings—for low-back, neck, and headache conditions. An associate editor for the Cochrane Back Review Group, Dr. Bronfort also authors systematic reviews and serves on several national practice committees.
Can you provide any recommendations on preventing low-back pain (LBP)?
GB: There is currently insufficient evidence to suggest that LBP can be prevented before the first episode. However, there is good evidence that physical exercise helps prevent and may diminish the impact of recurrence. There is insufficient evidence to recommend for or against a specific type or intensity of exercise.
How does a provider select the most appropriate intervention(s) to recommend when LBP has not responded to self- or mainstream care?
GB: This is where the ability to provide evidence-informed health care is important. First, the provider must do a comprehensive assessment of the patient's profile that takes into account biological, psychological, and social factors. Then, in collaboration with the patient, he or she should take into account patient preferences and previous treatment experiences. The next step is to design a treatment plan by choosing one, or a combination, of the available effective treatment options.
Psychological and social factors are known to be important in patients' experiences in LBP. What are some of these factors that you have frequently seen, and what have you recommended?
GB: Fear and avoidance of movement is a common phenomenon in LBP patients. We routinely recommend that patients become more active. We assure them that in most cases activity and exercise are beneficial, safe components of their management, and inactivity tends to complicate and prolong LBP. Sometimes patients become depressed as a complication of having pain for a long time. We typically recommend that they see a health care provider who can further assess the depression and recommend any treatment if necessary.
The evidence base on the use of nonpharmacologic approaches to treat/manage LBP appears to be growing. How can such therapies be productively integrated with other LBP therapies?
GB: There is evidence to suggest that, in many cases, multidisciplinary management of LBP is more effective than monotherapeutic approaches. Currently, our research center at NWHSU is researching the development and testing of methods to help integrative care teams decide on optimal, effective care plans.
How can conventional and CAM providers work together to provide integrative care for LBP?
GB: They can best work together by adopting quality-assurance technology and evidence-based assessment and treatment guidelines. They should also use health information technology, in the form of electronic health records and outcomes management strategies, which ensures effective communication between providers and optimal evidence-informed care.
What are some innovations in treatment and management "coming down the pike" that you think might make a real difference in LBP, or pain in general?
GB: There is emerging research evidence that chronic back pain can be complicated by the development of abnormal processing in central nervous system pain centers. In effect, they become "hypersensitized." This perpetuates chronicity. It is a phenomenon that has been demonstrated in a number of other chronic-pain conditions. Finding physical and psychological treatments that can specifically target this malfunction may have a big impact.
Selected References
- Bronfort G, Haas M, Evans RL, et al. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. The Spine Journal. 2004;4(3):335–356.
- Bronfort G, Haas M, Evans RL, et al. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. The Spine Journal. 2008;8(1):213–225.
- Bronfort G, Evans RL, Maiers M, et al. Spinal manipulation, epidural injections, and self-care for sciatica: a pilot study for a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics. 2004; 27(8):503–508.
- Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database of Systematic Reviews. 2004;(3):CD001878.
