Chiropractic vs. Medicine for Acute LBP: No Contest. What a surprise.

February 5, 2011
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I don’t normally use research studies to make a point, but as skeptics are very fond of them and have been ignoring this one, I thought I would give it a mention. Skeptics like Edzard |Ernst were widely quoted in the media in 2007 when a study showed spinal manipulation performed by unskilled practitioners (physiotherapists not chiropractors)was not very effective for low back pain. This study  is reviewed in the prestigious journal Spine. These researchers come to a very different conclusion than  Professor Ernst about chiropractic, spinal manipulation and back pain.

I would ask skeptics to consider why chiropractic might be beneficial for people suffering from low back pain.  Note I said “beneficial” there is no cure for back pain, spinal joint dysfunction is not a disease, its a functional problem that effects nerve and muscle function, the dysfunction needs to be corrected and maintained.

Chiropractic benefits  because chiropractors correct vertebral subluxation dysfunction in the lumbar spine and pelvis, if chiropractic works on pain transmission from nerves in the low back, it works on nerves from the thoracic spine and cervical spine. If chiropractic works on pain it works on cortisol levels in the blood and helps the immune system.

Acute low back pain patients demonstrate significantly greater improvement with chiropractic than "usual care."

This Article is From The latest edition of Dynamic Chiropractic

With the publication of the Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study in The Spine Journal, one of the most frequently cited spine research journals in the world,2 the health care community at large may finally appreciate what the chiropractic profession has known for more than a century: Patients with acute mechanical low back pain enjoy significant improvement with chiropractic care, but little to no improvement with the usual care they receive from a family physician.

Published in the December 2010 edition of The Spine Journal, the study found that after 16 weeks of care, patients referred to medical doctors saw almost no improvement in their disability scores, were likely to still be taking pain drugs and saw no benefit with added physical therapy – and yet were unlikely to be referred to a doctor of chiropractic.

The study is "the first reported randomized controlled trial comparing full CPG [clinical practice guidelines]-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC [usual care] in the treatment of patients with AM-LBP (acute mechanical low back pain)." (Evidence-based clinical practice guidelines have been established for acute mechanical low back pain in many countries around the world, but sadly, most primary care medical doctors don’t follow these guidelines.) Researchers found that "treatment including CSMT [chiropractic spinal manipulative therapy] is associated with significantly greater improvement in condition-specific functioning" than usual care provided by a family physician.

Study Parameters

The Chiropractic Hospital-based Interventions Research Outcome (CHIRO) initiative was "designed to evaluate the outcomes of spinal pain patient management strategies that involve a component of chiropractic assessment and/or spinal manipulative therapy, administered in a hospital-based spine program outpatient clinic." The study utilized the CHIRO framework "to examine the effectiveness of current evidence-based CPG-recommended treatments for patients with AM-LBP pain."

CPG "study care" (SC) was compared with the usual care (UC) provided by family physicians. Patients were first seen by a spine physician and then randomly assigned to either the SC group or the UC group.

Patients in the SC group received acetaminophen, a "progressive walking program" and up to four weeks of lumbar chiropractic spinal manipulative therapy. The manipulative therapy was provided "using conventional side-posture, high-velocity, low-amplitude techniques" to the lumbar region only, and only by a chiropractor.

Patients assigned to the UC group were referred back to their family physician, who was "simply advised to treat at their own discretion." Patients in this group received treatment from "a variety of professionals including family physicians, massage therapists, kinesiologists, and/or physiotherapists."

All care was provided at a hospital-based spine program outpatient clinic. The primary outcome measure was the Roland-Morris Disability Questionnaire (RDQ), administered at the beginning of care and at 16 weeks, when acute low back pain is considered to become chronic. The RDQ was also administered at eight and 24 weeks.

Other Important Findings

After 16 weeks, "78% of patients in the UC group were still taking narcotic analgesic medications on either a daily or as needed basis." (Only 6 percent of this group received chiropractic care.)

Condition-specific improvement after 16 weeks "clearly favored the SC group, with mean RDQ improvement scores of 2.7 in the SC group compared with only 0.1 in the UC group (p=.003)."

While the difference in improvement "was not quite significant at 8 weeks," it was found to be "clearly significant at 24 weeks of follow-up (0.004)."

Both groups showed improvement in bodily pain and physical functioning, but "patients in the UC group uniquely showed no improvement whatsoever in back-specific functioning (RDQ scores) throughout the entire study period."

The inclusion of NSAIDs and manipulation/mobilization performed by physical therapists were no more effective in treating patients than family doctors who offered patients advice and acetaminophen. The study found: "[T]he addition of NSAIDs and a form of spinal manipulative therapy or mobilization administered by a physiotherapist to the lumbar spine, thoracic spine, sacroiliac joint, pelvis, and hip (compared with a detuned ultrasound as placebo manipulative therapy), to family physician ‘advice’ and acetaminophen were shown to have no clinically worthwhile benefit when compared with advice and acetaminophen alone." [Italics ours]

The study criticizes a 2007 report that had derided the efficacy of spinal manipulation by pointing out that the older report based its conclusions on the outcomes of therapies performed by non-chiropractors. The 2007 study concluded that patients "do not recover more quickly with the addition of diclofenac or spinal manipulative therapy."3 By contrast, the CHIRO study noted: "Although spinal-manipulative therapy is currently administered by many different healthcare professionals, including: chiropractors, osteopaths, orthopedic surgeons, family physicians, kinesiologists, naturopaths, and physiotherapists, the levels of training and clinical acumen vary widely. The study design used by Hancock, et al., therefore, differs from our study because [their study] did not use chiropracticspinal manipulation, and current guideline based care does not endorse any forms of spinal manipulation administered by any other practitioners." [Italics ours]

References

  1. Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Spine Journal, 2010;10:1055-1064. www.ncbi.nlm.nih.gov/pubmed/20889389
  2. Brunarski D. "Impact of the Chiropractic Literature." Dynamic Chiropractic, Dec. 2, 2010;28(25).
  3. Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, Spindler MF, McAuley JH. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet, 2007 Nov 10;370(9599):1638-43. www.ncbi.nlm.nih.gov/pubmed/17993364
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  1. Sedentary posture and back pain
  2. Cortical Neuroplasticity With Spinal Manipulation, Exercise, Injury and Pain
  3. The GCC vision for chiropractic
  4. How can Edzart Ernst be considered an expert on clinical Chiropractic?
  5. Effects of acupuncture largly due to placebo. So what as long as it helps some women through childbirth.
  6. Professor Edzard Ernst discovers the biopsychosocial model of health care 40 years after George Engle.
  7. Whats the difference between confirmation bias and just being biased.
  8. The chiropractic profession has not been very effective at defending itself from sceptics
  9. These are my comments on the article professor Edzard Ernst had published in the New Scientist last summer about chiropractic.
  10. Despite the damage done by the BCA the chiropractic profession should not seek “legitimacy” through the biomedical model

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  • http://www.chiropracticlive.com Richard Lanigan

    This is what I find most depressing about our profession. We have an opponent like Ernst who obviously loves being in the limelight, does not appear to be a science intellectual. The GCC gave him a platform in 2006 and fail to give him a grilling about the conclusions he was drawing from his research and his failure to discuss cause. http://www.chiropracticlive.com/gcc-fiddles-while-edzard-ernst-burns/

    Have been doing a spot of Moron bating on twitter this morning. Blue Wode could not take it any more. Called me a quack, dont get upset when these people call you names. Water off a DUCKS back was my response, I was rather pleased with that.

  • http://www.chiropractorswarwick.co.uk Stefaan A.L.P. Vossen

    I think this is wonderful. I await with abaited breath…
    Stefaan

  • A N Other

    About 1 week ago I e-mailed Prof Ernst and asked him the following question:

    So, would you say most low back pain research is flawed by the fact that researchers don’t view the musculoskeltal system has a whole and therefore when they do a study using a single modality (mobilisation) to see its effect on low back pain, they don’t take into account the heterogenous population that the study is testing i.e. they are subgroups within the low back pain population, who wouldn’t respond to mobilisation of their low back for low back pain?

    He has yet to reply.

  • http://www.chiropractorswarwick.co.uk Stefaan A.L.P. Vossen

    I personally think the matter runs even deeper than that in that it simply is bad science and fraudulent editorialism for any one to comment on efficacy in the way Ernst has done. This, in my opinion is the source of appearance of bias and the reason I cannot take him seriously as a commentator on efficacy of treatment modalities. Commenting on what the reasearch says means starting with “the research says” and the second part of the sentence should at least reflect the parameters of the study evaluated. Prof Ernst’s commentary runs far wider than the parameters allow and he knows it (at least I have challenged him enough on the issue). As he chooses not to engage with the matter I can only assume that the decision to do so is conscious…
    Regards,
    Stefaan

  • http://www.chiropracticlive.com Richard Lanigan

    Professor Ernst latest on Pulse announces that “compared to other treatments, the effect of spinal manipulation on pain and function is not clinically relevant. They also found weak evidence to suggest that the effects of spinal manipulation are mainly due to placebo. As pain is very much an emotional response in the brain to abnormal sensory imput this is hardly a surprising finding for clinicians.
    Steffan has been harassing Professor Ernst for moths about the cause of back pain and to explain how he can make pronouncements of efficacy without knowing what has caused the back pain. Ernst is very opinionated on what works, however he seems to have no idea about what causes acute back pain or how pain is expressed by the brain.
    Factors like sedentary lifestyle, trauma, pathology, posture, weak core muscles etc etc are major causes of acute back pain, however before researchers like Professor Ernst can draw meaningful conclusions about what is an effective intervention they need to understand the cause better. If someone has back pain because they are over weight and sit at a computer all day, you might as well recommend whiskey for them as spinal manipulation.
    Ernst shows little interest in understanding cause and is happy to parrot negative information to his followers, rather than champion some original research into the subject.What we do know is that acute pain become chronic if not managed properly in the acute stage, joints degenerate and develop arthritis.
    Spinal joint dysfunction has a physiological role in the production of spinal pain and muscle spasm. However its unlikely to be the only cause. Spinal manipulation can help dysfunctional joints function better, but wont do much if someone has a knife in their back.
    Edzard Ernst may believe that joint function/subluxation has no role in back pain and can just as well be “treated” with NSAIDs, opiates or for that matter whiskey. The millions of people who have benefited from spinal care know different.

  • http://www.chiropracticlive.com Richard Lanigan

    This posting cover some of your questions http://www.chiropracticlive.com/its-a-bit-premature-for-zeno-and-gcc-to-write-obituary-of-vertebral-subluxation/

    The medical understanding is what you have described. I would look at Gatermans explanation which makes more sense Spinal joint dysfunction ranging from hyomobiliy to hypermobility the extremes at both ends being contained indications for spinal adjustment/manipulation, (Fusion and partial dislocation) Gatterman has covered all the research that you ask about. Palpation skills seem to be good when people check their own findings not as good when others check. My office is being pained at the moment, next week I will dig out my books and send you some studies.

    I dont dispute what you are saying, however in activities involving a high level of skill sometimes you have to accept some people are crap at it and some are very good at it. The regualtor wants to be abel to say every one is the same. They are not and thats just another one of the lies the GCC is prosecuting chiropractors for. Every Chiropractor knows Stephen Hughes is one of the top people in his field, yet the GCC has been punished for saying this on his website. http://www.chiropracticlive.com/stephen-hughes-has-specialist-knowledge-in-chiropractic-care-of-children-it-is-an-absolute-disgrace-that-he-has-been-admonished-by-the-general-chiropractic-council/

  • Austin

    I can understand that there is this feeling of ‘them’ and ‘us’ when talking about ‘researchers’ and ‘skilled clinicians’, in saying that the researchers are striving for answers which are measurable – rather than anecdotal heresay opinions. There are a lot of reseacrhers who are clinicans who are attempting to find answers to help best practice.

    It would be great to see studies whereby the palpation skills are tested to further advocate the use of chiropractic therapy. This really needs to be done to help reducing scepticism in this field. Please do guide me to research that has been done on this already, although I have searched.

    The term subluxation has me somewhat confused, as this is defined as a partial dislocation in some professions. Is there any research to show that this has occured on radiography? Any studies that demonstrate correlation between palpation findings and radiography findings?

  • http://www.chiropracticlive.com Richard Lanigan

    absolutely, chiropractic is very much an Art and very much dependent on the skill of the practitioner. I have have discussed this with Andy Lewis from quackometer. I am happy to be tested by anybody on my palpation skills to detect spinal joint dysfunction /subluxation and be compared with a other skilled experienced chiropractors.

    Tiger Woods golf ability was developed by practice everything else is secondary to his skill level. Students or researchers are not going to be as skilled as an experienced practitioner.

  • Austin

    A point that I feel are worth querying in relation to this post:

    It is very interesting that you state ‘Chiropractic benefits because chiropractors correct vertebral subluxation dysfunction’.

    I am curious to know how this ‘subluxation’ can be identified reliably. Perhaps the chiropractic skills are really an art and not a science when considering the incredibly poor inter-clinician and intra-clinician reliability of the accuracy of palpation and indeed notable variance amongst clinicians?

    Let me know you academic viewpoints on these please, no opinions or rash comments please.

  • Fedup

    Garland that may be so, but it is evidence based medicine!!!

  • Garland

    See the lead article in the current issue of Dynamic Chiropractic. Medicine in the US kills someone every 3 minutes.

  • Garland

    Let’s think about this: Edzard |Ernst’s opinion vs. Spine. Not much to think about really. Ernst is an idiot and the skeptics would buy water front property in Arizona if the research showed there was water there.

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