Clinical practice guidelines released on December 8, 1994, by the federal Agency for Health Care Policy and Research (AHCPR) criticized some commonly used treatments of acute, low back problems -- including surgery and bed rest -- and recommended "spinal manipulation" as one possible alternative.

Despite initial excitement by the chiropractic community, however, the panel did little to promote chiropractic. The only mention of spinal care in the guidelines overview is the notation: "Spinal manipulation (performed by chiropractors, osteopaths, and other therapists) can be helpful when symptoms begin, but people should be re-evaluated if there is no symptom improvement after four weeks."

In its "Quick Reference Guide for Clinicians," the agency states: "Manipulation, defined as manual loading of the spine using short or long leverage methods, is safe and effective for patients in the first month of acute low back symptoms without radiculopathy. For patients with symptoms lasting longer than 1 month, manipulation is probably safe but its efficacy is unproven. If manipulation has not resulted in symptomatic and functional improvement after 4 weeks, it should be stopped and the patient reevaluated."

In the patient education booklet prepared by the AHCPR to explain the guidelines, the word chiropractic is not mentioned at all. The booklet states that a health care provider may recommend spinal manipulation to be "used alone or along with medicine to help relieve your symptoms."

To explain spinal manipulation to patients, the AHCPR says: "This treatment (using the hands to apply force to the back to 'adjust' the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation. You should go to your health care provider if your symptoms have not responded to spinal manipulation within 4 weeks."

At the top of the AHCPR's list of "proven treatments" is medicine, with over-the-counter drugs being given first preference, and prescription medicine recommended "if your symptoms are severe."

In an ironic turnaround, media coverage of the guidelines put far more positive emphasis on chiropractic than the AHCPR itself, thanks in part to the efforts of chiropractic leaders present during the AHCPR's press conference.

Dr. R. James Gregg, president of the International Chiropractors Association, prepared a written statement for distribution at the press conference which greatly bolstered the chiropractic connection for reporters: "Chiropractic care has for many years been the source of great relief for millions of Americans with this painful condition and we are pleased that the Agency has rated manipulation so highly in its review of care options."

In a separate press release, the ICA noted that although the panel uses the term spinal manipulation, the organization's "preferred terminology" is spinal adjusting.

Also attending the press conference was Dr. Lowry R. Morton, chairman of the board of the American Chiropractic Association, who stated, "This guideline validates what chiropractors have asserted for nearly 100 years and what millions of chiropractic patients already know: Spinal manipulation offers safe and effective relief for low back problems without drugs or surgery."

Picking up on the chiropractic angle, one major newspaper ran the story under the headline: "Exercise, chiropractic treatment endorsed."

The biggest boost to chiropractic may be indirect, however, since the panel criticized many of the commonly used medical approaches such as surgery and medications like oral steroids, colchicine, antidepressants and phenylbutazone.

Philip R. Lee, M.D., assistant secretary for health and director of the Public Health Service, said, "By encouraging people with acute low back problems to resume normal activities, using only those treatments that have been scientifically shown to be effective, these guidelines could save Americans considerable anguish, time and money now spent on unneeded or unproved medical care."

Surgery came under particularly hard fire from the panel, which concluded that only about one in 100 people with acute low back problems can benefit from surgery.

Not surprisingly, the guidelines did not receive an enthusiastic reception from the medical field. Dr. Edward L. Seljeskog, president of the American Association of Neurological Surgeons, said the panel overstepped on its recommendations against surgery.

"They've debunked some of the very marginal" treatments, Seljeskog said, but characterized the recommendation against spinal fusion surgery in the first three months of symptoms as "a little rigid." He added that, "A little wiggle room might be warranted" for most patients.

Dr. Edward N. Hanley Jr. of the American Academy of Orthopaedic Surgeons said it was impossible to judge the quality of the scientific evidence on which the recommendations were based.

Echoing what chiropractors have argued for years, Dr. Hanley claimed, "Just because a particular treatment method for low back pain has not been proven to be efficacious does not necessarily mean it is invalid or harmful."

The guidelines were developed under AHCPR's auspices by a private-sector panel of 23 experts and consumers, and tested in clinics and doctors' offices before their release. Only one doctor of chiropractic, John Triano, D.C., was on the panel.

The rising cost of treating back pain problems was a key incentive in developing the guidelines.

"In 1990 alone, the United States spent more than $20 billion just for the direct medical costs of all low back problems," said Clifton R. Gaus, Sc.D., administrator of AHCPR. "While there are no precise estimates for the cost of treating acute low back problems, a preliminary cost analysis of these guidelines suggests the nation could save as much as a third of the medical expense of treating this condition without any loss of quality of care."

Dr. Gaus said the cost of acute low back problems was only one factor behind the agency's decision to develop practice guidelines. Other, equally important factors included the wide variations in the ways acute low back problems are diagnosed and treated and concern about the quality of care being provided.

The chair of the guidelines panel, Stanley J. Bigos, M.D., professor of orthopedic surgery at the University of Washington School of Medicine in Seattle, said, "One very important goal of these guidelines is to prevent long-term back problems and disability by improving care provided during the acute phase."

Dr. Bigos said that the guidelines do not deal with chronic low back problems, which are the subject of ongoing studies.

The panel found that acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, are effective and safe. The guidelines consider muscle relaxants and opinoid analgesics -- a stronger type of prescription medicine -- to be options for short-term treatment, but they appear to be no more effective that the NSAIDs and appear to cause more side effects.

In addition, the panel said that early use of tests such as x-rays, CT scans, MRI, myelography and bone scans are appropriate only when there are specific clinical findings of a potentially serious underlying condition in the patient's medical history and examination.

The guidelines also emphasize the importance of low-stress exercise such as walking, swimming or biking, for maintaining and even improving the patient's activity tolerance. These types of exercise usually can be started gradually during the first two weeks after symptoms appear. Conditioning exercises for trunk muscles can be started after the first two weeks.

The guideline panel did not find a sound scientific basis for certain treatment methods, including:

*** spinal traction, TENS, and acupuncture;

*** lumbar corsets (except perhaps when used preventively by persons who do frequent lifting on the job); and

*** support belts and back machines.

The panel also did not find evidence of effectiveness to justify potential risks of harmful side effects for:

*** extended bed rest (more than four days) since it can weaken muscles and bones and delay recovery;

*** oral steroid, colchicine, antidepressants and phenylbutazone, whose potential side effects range from gastrointestinal irritation to bone marrow suppression; and

*** therapies involving the injection of local anesthetics, corticosteroids or other substances into the back. The potential harms include rare but serious problems such as nerve damage and hemorrhage.

The guidelines do not recommend other treatments because their insufficiently proven benefits do not justify their costs. These treatments are: heat/diathermy, massage, ultrasound, cutaneous laser treatment and electrical stimulation.

The panel conducted an exhaustive review of over 3,900 studies and held a public meeting in developing the guidelines, which were then reviewed by more than 100 other back care experts and tested in health maintenance organizations, private and group medical practices and occupational medicine clinics.

In addition to chiropractic's sole representative, the panel consisted of experts in orthopedic surgery, family practice, internal medicine, industrial medicine, occupational medicine, neurosurgery, neurology, neuroradiology, rheumatology, osteopathic medicine, orthopedic research, community health nursing, physical therapy and occupational therapy, and a consumer representative with low back problem experience.

AHCPR will disseminate the new guidelines, including consumer versions in English and Spanish, to primary care practitioners, orthopedic surgeons, chiropractors and other back care professionals, managed care organizations and consumers.