Chiropractic and Low Back Pain: The Research Evidence

By July 2, 2014 Blog, chiropractic No Comments

X-ray for Chiropractic

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Here are just a few of the studies showing chiropractic care being very effective for the treatment of low back pain.

Waagen, GN, et al. (1986) Short term trial of chiropractic adjustments for the relief of chronic low back pain. Manual Medicine, vol. 2, pp63-7.

This 1986 study was the first randomized, controlled trial of manipulation against a placebo sham maneuver. While it was small, with only 19 subjects, it was conclusive. The patients receiving chiropractic adjustments showed a significant improvement in pain relief and objective measures of spinal mobility as compared to the sham group. Thus both subjective and objective measures supported chiropractic treatment. Waagen followed this up in 1991 with a larger study comparing general medical care with sham manipulations and chiropractic care using adjustments. While both the medical and chiropractic groups improved in pain and function as compared to the sham group, only the chiropractic group improved significantly. These results held at 3 and 24 month follow-ups.

Ongley, MJ, et al. (1987) A new approach to the treatment of low back pain. Lancet, Vol. 2, pp 143-6.

This randomized trial was carried out by MDs looking at low back pain treatments. The experimental group received forceful spinal manipulations and injections of a proliferant solution to reduce pain. The control group received “less extensive” manipulation and a local anesthesia injection in place of the proliferant. Subjects were evaluated for effectiveness of the treatment at onset, one, 3 and 6 month intervals using pain and disability scales and objective evaluation of physical signs. The experimental group (manipulation) showed significantly better improvement in all evaluation modes at all three intervals. These MDs concluded manipulation is “a safe and effective treatment”.

Meade, TW, et al (1990) Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. British Medical Journal, Vol. 300, pp 1431-37.

Meade, TW, et al (1995) Randomized comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. British Medical Journal, 311:349.

This was a Medical Research Council study done in England, published in the British Medical Journal, looking at low back pain. It was a large (741 subjects) and meticulous study comparing treatment outcomes at hospital outpatient clinics and chiropractic clinics. In this randomized, controlled format, treatment outcomes were measured by pain and disability questionnaires, straight leg raise and lumbar flexion, and patients were tracked for 2 years.

Meade reported that chiropractic care demonstrated significantly better long-term benefit that started soon after the onset of care. The medical care group showed deterioration after 6 months, even though the medical group had more follow-up visits after that stage. Meade also reported that the greatest benefit in the chiropractic group was with the chronic and severe low back pain patients.

A longer-term follow-up study by Meade in 1995 addressed some minor criticisms and produced the same results and showed longer lasting effects for the chiropractic group. It also noted there was significantly less lost time at work in the chiropractic group.

Manga, P et al (1993) The effectiveness and cost-effectiveness of chiropractic management of low back pain. Pran Magna and Associates. University of Ottawa, Ontario Canada.

Manga, P et al (1998) Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and improving the public’s access to cost-effective health services. University of Ottawa, Ontario, Canada.

This study was commissioned by the Ontario government to look at the effectiveness and cost-effectiveness of therapy provided for low back pain by MDs, chiropractors and physiotherapists. Pran Magna was a health economist at the Univeristy of Ottawa who undertook this review of the research evidence and government health statistics. His summary points are emphatic: As compared to medical and physiotherapy treatment in Ontario, chiropractic care is significantly better in,
1. effectiveness
2. safety
3. cost effectiveness
4. patient satisfaction

He made a strong recommendation for the Ontario government to utilize chiropractors in the treatment of low back pain patients. He estimated the savings of “hundreds of millions” of dollars annually if the treatment of back pain was transferred from MDs to chiropractors.

In 1998, Manga published a second study. In his results he comments that,
1. Musculoskeletal disorders are the greatest cause of pain and disability in Ontario.
2. They are also the second most costly health care problem
3. Doubling the proportion of patients who visit chiropractors from 10% to (only) 20% would save the government $348 million per year in direct costs and $1.85 billion in indirect costs.

(Ironically, after commissioning these studies, six years later, in a budget crisis, the Ontario Government dropped chiropractic care from its public health insurance program (OHIP) using the savings for increased hip and knee surgeries and the construction of more MRI and CT scanners.)

Jarvis, KB and Phillips, RB, et al (1991) Cost per case comparison of back injury of chiropractic versus medical management for conditions with identical diagnosis codes. Journal of Occupational Medicine, 33(8), 847-852.

U Ebrall, PS (1992) Mechanical low back pain: a comparison of medical and chiropractic management within the Victorian welfare scheme. Chiropractic Journal of Australia, 22(2), 47-53.

These are two of many studies undertaken internally by Workers’ Compensation Boards. Jarvis was in the US, Ebrall in Australia.
In Utah, Jarvis reported patients with back injuries took 10x the number of days off work (20.7 vs 2.4) and used 10x the compensation costs ($668 vs $68) when they chose medical care vs chiropractic care.

In Australia Ebrall reported chiropractic claim costs were almost 3/5s lower than medical care costs ($963 per claim vs $2308). Medical patients were also 10x more likely to develop chronic low back pain (11.6% vs 1.9%).

Both of these studies, as well as many other worker’s compensation studies, strongly recommend the utilization of chiropractors in the treatment of low back pain claims.

(In the mid-1990’s the Worker’s Compensation Board in Ontario changed its policy regarding the management of injured workers with low back pain to strongly recommend a course of treatment with a practitioner thoroughly trained in manipulation.)

BEAM Trial: United Kingdom back pain and Manipulation (UK BEAM) randomized trial: cost-effectiveness of physical treatments for back pain in primary care. British Medical Journal Online First, Nov 19, 2004:1-6

This is a large multi-disciplinary trial by the British Medical Research Council looking at the effectiveness of physical treatments for back pain patients. They looked at general medical care, exercise classes, manipulation or a combination of the latter two as the treatments. The trial was a randomized, controlled design looking at 1334 subjects.

The results showed manipulation was a significantly better treatment on all measurement scales than general medical care, through the full year of the trial. Exercise alone significantly improved only function/disability, and only up to the 3 month follow-up. Exercise combined with manipulation showed similar results to manipulation alone.

In a very sophisticated analysis of cost effectiveness the study “shows consistently that both manipulation alone and manipulation followed by exercise provide cost-effective additions to care in general practice.”

Responses by Government Agencies:

Bigos, S, et al (1994) Acute low back problems in adults. Clinical practice guideline No. 14. AHCPR publication No. 95-0642. Rockville, MD. Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services.

Rosen, S, Breen, A, et al (1994) Management guidelines for back pain appendix B in report of a clinical standards advisory group committee on back pain, Her Majesty’s Stationary Office, London.

Manniche, C, et al. (1999) Low back pain: frequency management and prevention from an HDA perspective. Danish Health Technology Assessment. 1(1).

In the 1990s governments in the US, UK and Denmark established multidisciplinary research agencies to develop guidelines for the treatment of back pain. The US and UK led the way in 1994, Denmark followed in 1999. These guidelines consistently recommend manipulation by qualified practitioners as an essential component in treatment strategies for most patients, essentially the chiropractic protocol of care. The traditional medical advice of bed rest and surgery is not generally endorsed before conservative care is first applied. Generally, the regime is similar in each case:

• analgesics or anti-inflammatories only briefly
• advice on staying active, and the earliest possible return to normal activities
• manipulation
• back education classes with exercises
• patient reassurance
• focus on the functional as opposed to structural cause of the pain
• consideration of the biopsychosocial factors associated with the pain

The medical associations have been very slow in adopting these guidelines, especially in the US where the AMA immediately published their own guidelines promoting the traditional protocols of medications and bed rest before a surgical consultation.

The most recent chiropractic self-analysis of scope and effectiveness as found in a massive scientific review:

Bronfort G, Haas M et al. (2010) Effectiveness of Manual Therapies: The UK Evidence Report. Chiropractic and Osteopathy 18:3 (25 Feb 2010). Doi: 10.1186/174601340018-3. Available at www.gcc-uk.org

After an organized challenge to claims made on British chiropractic websites in 2010, a team of the most respected chiropractic researchers were commissioned to conduct a literature review of the effectiveness of chiropractic treatments, essentially outlining the effective scope of practice for chiropractic based on the best available evidence. The researchers looked at randomized, controlled trials and “16 widely accepted evidence-based international clinical guidelines”.

The controversy that precipitated this challenge to the profession were the claims made by more than half the british chiropractic websites that good results could be found in the treatment of colic, eneuresis (bed-wetting), ear infections, ADHD, asthma and other childhood afflictions. Here’s what the researchers found:

Spinal manipulation is effective in adults for:
• acute, subacute and chronic low back pain
• migraine and cervicogenic headache
• cervicogenic dizziness
• acute, subacute and chronic neck pain
• several extremity joint conditions

There is inconclusive but favourable evidence for chiropractic management of other musculoskeletal conditions:
• ankle sprains
• sciatica
• coccydynia
• TMJ disorders
• tension headache
• fibromyalgia
• etc

… and non-musculoskeletal conditions:
• pre-menstrual syndrome
• pneumonia in older adults
• nocturnal eneuresis in children
• hypertension
• otitis media (ear infections) in children
• etc

Spinal manipulation was not any more effective than sham manipulation for:
• asthma
• colic/incessant crying in children

The research supported safety and appropriateness of spinal manipulation for all these conditions. Also, “that the incidence of serious side effects such as a stroke following chiropractic care is extremely rare and is probably not related to manipulation in most patients but due to the fact that patients develop neck pain or headaches as a result of a dissection of a vertebral artery that progresses through the natural history of dissection to stroke irrespective of the clinician the patient consults”.
In summary, about 90% of chiropractic practice is supported by scientific evidence at the most rigorous Randomized Control Trial level. The 10% of unsupported practice (not practised by the majority of chiropractors) hails from the fundamentalist, pre-scientific era of chiropractic philosophy.

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