Reviewing chiropractic to treat back pain

Dr. Peter Stanton has commented before on this blog. He’s a board certified chiropractic orthopedist practicing in Burke, Virginia and graciously sent a list of studies that support chiropractic for back pain.

I listed the two studies first and the two reviews next.

Clinical trials
Author: Koes, 1992

• 256 patients with non-specific back and neck complaints of at least six weeks’ duration
• Improvement was larger with manipulative (chiropractic) therapy vs physiotherapy after 12 months’ follow up.
• Manipulative therapy gave larger improvements in physical functioning. The global perceived effect after 6 and 12 months was similar for both treatments.

Overall, after a year, patients treated with manipulation did better than those treated with physiotherapy.

Meade, 1995

• 741 adults with low back pain
• Chiropractic vs hospital outpatient management
• Improvement in all patients at 3 years was ~29% more in patients treated by chiropractors.

Consider this: the reported results were based on returned questionnaires from the patients. Failure to return a questionnaire automatically rated the patient as a treatment failure. Since fewer patients in the outpatient group returned their questionnaires, this group had a greater “failure” rate than they might have had if all the questionnaires were returned. Despite this potentially confounding variable, the researchers concluded that after 3 years, patients treated with manipulation did better.

Review articles
van Tulder, 1997

• Systematic review of studies
• Strong evidence for effectiveness of manipulation, back schools (education), and exercise therapy for chronic low back pain, especially short term

Consider this: The reviewers complain about the lack of well-designed clinical trials. I say, “Get over it.” Based on what we know, chiropractic comes out pretty good in this review.

Bronfort, 2004

• Studies of back and neck pain published in English, Danish, Swedish, Norwegian, and Dutch were reviewed
• Moderate evidence that spinal manipulation is similar to prescription non-steroidal anti-inflammatory drugs (NSAIDs)
• Effective short term compared with placebo and general practitioner care
• Effective long term compared to physical therapy
• Limited-to-moderate evidence that spinal manipulation is better than physical therapy and home back exercise in the short and long term
• Limited evidence that spinal manipulation is superior to sham manipulation in the short term
• Superior to chemonucleolysis for disc herniation in the short term

Consider this: Yea, the studies aren’t great, but the authors step up and conclude, “recommendations can be made with some confidence regarding the use of spinal manipulation therapy ? as a viable option for the treatment of both low back pain and neck pain.”

The bottom line?
Based on the available information, chiropractic for back pain is not a panacea — no surprise there. At the same time, it would be wrong to conclude that it’s useless. Based on the evidence, that would show bias. For a condition where there is no consensus on the best therapy, chiropractic can make a positive contribution .

Maybe the Mayo Clinic makes the best recommendation. “In most cases of injury or strain, there’s no magic cure. It simply takes time for your back to heal. Back pain lasts just as long if you go to a chiropractor, if you go to a physical therapist, or if you seek no treatment at all. But treatment of some type ? either chiropractic or conventional ? might make you more comfortable as you wait for your back to heal.”

2/15/07 21:15 JR