In the past few weeks I have shared some powerful examples of research supporting the efficacy and safety of chiropractic care in relation to low back pain (see Chiropractic Strengthening Spinal Health, April 30). I have also recently outlined the importance of weighing up the pros and cons of spinal surgery for low back pain, which is oftentimes far less effective than we are led to believe (Will Surgery Fix it?, April 30).
Through sheer coincidence a recent review by researchers at Murdoch Universityiin Australia did not find evidence to support or refute whether chiropractic interventions provide a clinically meaningful difference in low back pain or disability, compared to other interventions. Although this specific paper found that chiropractic care minimally improved acute and sub-acute low back pain and did not improve chronic low back pain, several points need to be made in regards to their findings:
- Firstly the authors note that the number of chiropractic treatments may not have been sufficient to make a difference in follow-up outcomes. In other words, if patients have limited treatment for long-standing and recurring problems, it is not surprising their improvement will be minimal. This would seem to be true. Diagnostically chiropractors look for the root cause of an individual’s problem rather then simply addressing presenting symptoms. The root cause of the problem may be (evident on xray) a weak link for some years. Chiropractic addresses whole body function and focuses on what is overloading an individuals´ spine and nervous system. By enabling the nervous system to function freely of interference the body’s own healing mechanisms function optimally.i Excitingly, this may leap frog people beyond the daily grind of illness and symptoms and into the realm of expressing their true health potential.
- The researchers findings are not uniformly supported by other recent studies. In contrast, another reviewii published this year found high quality evidence that spinal mobilization and massage is effective for subacute and chronic low back pain, and moderate quality evidence that it is effective for acute low back pain. Another study from the United Statesiii found substantial pain relief for chronic low back pain patients receiving chiropractic care for 3 weeks. And a review by Lawrenceiv found solid evidence to support the use of spinal mobilisation in reducing symptoms and improving function for patients with acute, subacute and chronic low back pain.chronic low back pain as acute or subacute low back pain. This review found that there was as much, or more evidence supporting the use of spinal manipulative therapy in patients with
- The review looked only at comparisons between chiropractic (combined with therapies such as massage and heat and cold), and other treatments such as exercise programs and anti-inflammatories. Significantly, no comparisons were made with surgery. Considering that from 1991 to 2002 the number of surgical procedures on the spine increased from approximately 200,000 to approximately 1 million in the United States alone, examining the relative merit of surgery versus more conservative approaches such as chiropractic is criticalv. Failed back surgery syndrome (FBSS) is a major public health problem, affecting up to 40% of patients undergoing surgical treatment for back pain in the United States. (Failed Back Surgery Syndrome 1). Being invasive, surgery carries with it significant physical risk, and is also a substantial financial cost to health care systems. Chiropractic on the other hand has been shown to be safe, effective and highly cost effectivevi.
- The other treatment options (such as anti-inflammatory use) that were compared with chiropractic in the review need to be considered in the context of safety and effectiveness. Despite their common usage, it is important to remember that anti-inflammatories are capable of serious effects such as gastrointestinal reactions, kidney dysfunction, decreased platelet function, and allergic reactions. Around 15% to 20% of patients taking anti-inflammatories develop peptic ulcer and about 3% of this group go on to experience hemorrhage or gut perforationvii. There is also the issue of effectiveness. A review of studies on anti-inflammatory use for low back painviii found only short-term effectiveness for patients with low back pain, but less or no effectiveness for patients with low back pain with sciatica and nerve root symptoms. In fact one clinical study has found that a course of Chiropractic care was 250 times safer than a course of anti-inflammatory drugs.ix
- Finally, it has been recognized that the design of certain studies may make them unable to demonstrate the actual clinical effects seen in practice. Bronfort et alx state that evidence from randomized controlled trials and systematic reviews of them may not be capable of determining whether a treatment is effective or not. In other words, when a therapy is studied and broken-down in such a manner, the complexity of the human interaction is lost and the findings may no longer reflect what is going on in clinical practice. A whole systems approach that more accurately represents the entire clinical encounter could enhance future research.
The importance of patients continuing to invest into their health through chiropractic, lifestyle changes and wholesome habits cannot be overstated, especially when health problems have become chronic. In fact when chiropractic is truly understood as both holistic and health-enhancing it becomes clear just how important it is for everyone, regardless of symptoms, to be investing in their health.
We are fortunate as a society to have so many therapeutic options and choices available to us. We are also blessed that more and more research is elucidating the effects of these many therapeutic approaches. A potential downside to this vast amount of information however, is the difficulty of assessing what to choose, when and why. Fortunately, the strong research showing that Chiropractic is safe, highly effective and cost-efficient gives us all a powerful reason for its embrace.
[ii]Association of Chiropractic Colleges – Position Paper No 1 JMPT 1996;19:634-7.[ii] Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3
[iii] Haas M, Groupp E, Kraemer DF. Dose-response for chiropractic care of chronic low back pain.The Spine Journal 4 (2004) 574–583
[iv] Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M,
Updyke W, Mootz R, Triano JJ, Hawk C. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. Journal of Manipulative and Physiological Therapeutics 2008 November/December
[v]North RB, Kidd D, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery 2007 61:361–369
[vi] Manga P, Angus DE, Papadopoulos C, William MHA, Swan R, Comm B. The Effectiveness and Cost-Effectiveness Of Chiropractic Management Of Low Back-Pain Funded by the Ontario Ministry of Health August, 1993
[vii] Shekelle PG, Brook RH. A Community-Based Study of the Use of Chiropractic Services American Journal of Public Health 1991;81:439-442
[viii] Gupta S, Tarkkila P. Complications of Opioids and Nonsteroidal Antiinflammatories in Chronic Nonmalignant Pain Techniques in Regional Anesthesia and Pain Management 1998 Vol 2, No pp 112-118
[ix] Dabbs,V.,& Laurettti, W.J.. A Risk Assessment of Cervical Manipulation vs NSAIDS for the Treatment of Neck Pain. Journal of Manipulation and Physiological Therapeutics, 18(8), 530-536.
[x] Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3