When you see the word, Chiropractor, there are a number images that people conjure up; both positive and negative. One of the most common images is the image of back pain. Back pain is one of the most common ailments that people come in to see me at my chiropractic office. Spinal manipulation is often used in my treatments, in addition to Active Release Techniques, acupuncture and corrective exercises.
This blog is a continuation of a blog post seeking out the evidence of the above image. Though I have not found the specific statements in the research regarding the effectiveness of manipulation on lower back pain here is what the evidence says in the literature.
I would like to comment on some of the findings you will read in this post. When a conclusion is made that says that there is no evidence that the treatment is superior to other forms of treatment this doesn’t mean that it is not effective. What it does mean is that it is equally as effective as those treatments. That’s a good thing. It means it is a viable option for care for back pain.
Check out some of the research. Read the highlights, read the entire abstract or seek out the full paper. If you have questions seek out further information or just ask and I’ll try and find that information for you.
Chiropractor and Athletic Therapist in Winnipeg
Lower Back Pain
Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis.
Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain.
To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB.
RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time).
Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence.
Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy.
Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.
Overall, studies have shown that spinal manipulation is one of several options—including exercise, massage, and physical therapy—that can provide mild-to-moderate relief from low-back pain. Spinal manipulation also appears to work as well as conventional treatments such as applying heat, using a firm mattress, and taking pain-relieving medications.
In 2007 guidelines, the American College of Physicians and the American Pain Society included spinal manipulation as one of several treatment options for practitioners to consider when low-back pain does not improve with self-care. More recently, a 2010 Agency for Healthcare Research and Quality (AHRQ) report noted that complementary health therapies, including spinal manipulation, offer additional options to conventional treatments, which often have limited benefit in managing back and neck pain. The AHRQ analysis also found that spinal manipulation was more effective than placebo and as effective as medication in reducing low-back pain intensity. However, the researchers noted inconsistent results when they compared spinal manipulation with massage or physical therapy to reduce low-back pain intensity or disability.
Researchers continue to study spinal manipulation for low-back pain.
Researchers are investigating whether the effects of spinal manipulation depend on the length and frequency of treatment. In one study funded by NCCAM that examined long-term effects in more than 600 people with low-back pain, results suggested that chiropractic care involving spinal manipulation was at least as effective as conventional medical care for up to 18 months. However, less than 20 percent of participants in this study were pain free at 18 months, regardless of the type of treatment used.
Researchers are also exploring how spinal manipulation affects the body. In an NCCAM-funded study of a small group of people with low-back pain, spinal manipulation affected pain perception in specific ways that other therapies (stationary bicycle and low-back extension exercises) did not.
A Cochrane review of combined chiropractic interventions for low-back pain.
Cochrane systematic review of randomized controlled trials.
To determine the effects of combined chiropractic interventions on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with low-back pain (LBP).
SUMMARY OF BACKGROUND DATA:
Chiropractors commonly use a combination of interventions to treat people with LBP, but little is known about the effects of this care.
We used a comprehensive search strategy. All randomized trials comparing combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies were included. At least two authors selected studies, assessed bias risk, and extracted data. Descriptive synthesis and meta-analyses were performed.
We included 12 studies involving 2887 LBP participants. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of subpopulations with LBP. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (standardized mean difference [SMD] -0.25 [95% CI: -0.46 to -0.04] and MD -0.89 [95%CI: -1.60 to -0.18]) compared with other treatments, but there was no significant difference in long-term pain (MD -0.46 [95% CI -1.18 to 0.26]). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 [95% CI: -0.70 to -0.02]). However, the effect was small and studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and studies that had a mixed population of LBP.
Combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.
Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain.
To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.
The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened.
Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure.
DATA COLLECTION AND ANALYSIS:
Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).
Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.
There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.