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Complementary and Alternative
Medicine: Fair and Balanced
vs. hospital treatment for back pain
medical literature supports the position that chiropractic is a
reasonable treatment alternative for any patient in whom manipulation
is not contraindicated.
By John Russo, Jr./Vicus.com
(25 March 2000) -- One
sign of the frustration that allopathic
medicine has with available traditional treatment options for low
back pain is found in a series of studies published in peer-reviewed
medical journals over the past decade that assessed
alternative-medicine options for its management. Here is a review of
these studies and their implications for chiropractic
physicians, as well as for patients with low back pain.
Chiropractic vs. hospital
In 1990, the
published a comparison of chiropractic vs. hospital outpatient
treatment for low back pain of mechanical origin. Meade and colleagues
from the Epidemiology and Medical Care Unit, Northwick Park Hospital,
Harrow, Middlesex, concluded that for patients with low back pain, in
whom manipulation is not contraindicated, chiropractic almost
certainly confers worthwhile, long-term benefits in comparison with
hospital outpatient management. The benefit is seen mainly in those
with chronic or severe pain. Therefore, application of chiropractic
should be considered.
In this study, 741
patients (aged 18 to 65 years) with no contraindications to
manipulation and who had not been treated within the past month were
randomly assigned to treatment. Chiropractors used chiropractic
manipulation in most patients, while the hospital staff most commonly
mobilization, manipulation, or both. Outcomes were based on
changes in the Oswestry
pain disability questionnaire scores and in the results of tests
of straight-leg raising and lumbar flexion.
In the study, patients
with chronic or severe back pain benefited the most from chiropractic
care. A benefit of about seven percentage points on the Oswestry scale
was seen at two years and became more evident throughout the follow-up
period. Secondary outcome measures also showed that chiropractic was
more beneficial than hospital outpatient treatment.
These same researchers
published a follow-up comparison in this population of patients. At
three years, their conclusions confirmed the findings of the earlier
report. When chiropractic or hospital therapists treated patients with
low back pain as they would in day-to-day practice, those under
chiropractic care derived more benefit and long-term satisfaction than
those treated in hospitals (Meade et al., 1995).
The experience in the
In 1998, Shekelle and
colleagues at the West Los Angeles VA Medical Center noted that recent
practice guidelines recommended spinal manipulation for some patients
with low back pain. Since concerns had been raised about the
appropriate use of chiropractic care, they decided to conduct a
retrospective review of chiropractic office records against preset
criteria for appropriateness that were developed from a systematic
review of the literature and a nine-member panel of chiropractic and
Based on a review of more
than 1,000 patient records, they concluded that the proportion of
chiropractic spinal manipulations judged to be congruent with
appropriateness criteria was similar to proportions previously
described for medical procedures. Thus, the findings provide some
reassurance about the appropriate application of chiropractic care.
Comparisons to other
forms of treatment
Since 1995, The
New England Journal of
published two articles comparing costs and alternative treatments for
back pain. One, a prospective observational study of outcomes and the
cost of care among primary care practitioners, chiropractors and
orthopedic surgeons revealed that although outcomes were similar,
primary-care practitioners provided the least expensive care for acute
low back pain. Satisfaction however, was greatest among patients
treated by chiropractors (Carey et al., 1995).
In another prospective
study of more than 300 adults, when chiropractic care was compared
to physical therapy or minimal intervention (provision of an
educational booklet), the chiropractic group had less severe symptoms
than the minimal intervention group at four weeks (p=0.02).
Differences in symptoms among patients in the physical therapy group
and those in the minimal intervention group did not achieve a
The use of back-pain
medication of any type during the first month of the study, compared
with baseline data, decreased significantly (p<0.05) in the
chiropractic treatment group (82% to 18%) compared to the physical
therapy group (84% to 27%) and minimal intervention group (77% to
32%). In addition, 18% of the patients in the minimal intervention
group visited a health-care provider during the first month of the
study, compared with 8% in the chiropractic group and 9% in the
physical therapy group. Although not stated in the article, this
action could be assumed to be a break in protocol.
After one year,
differences in the extent of dysfunction in the minimal intervention
group was significantly greater (p=0.05) compared with the other
groups, although further statistical analysis showed this difference
to be insignificant. The authors concluded that both chiropractic care
and physical therapy were expensive compared with dispensing booklets,
and they wondered whether the "limited benefits" of these
treatments were worth the additional costs (Cherkin et al., 1998).
In the Cherkin study,
considering the confounding variables (concurrent drug use and
additional medical care) reported, particularly in the minimal
intervention group, it is impossible to determine comparative effects
of the primary treatments. However, based on the high level of
defections from the minimal intervention group, it is unlikely that
these patients were satisfied with their care.
In 1994, the Federal
Agency for Health Care Policy and Research (now known as the Agency
for Healthcare Research and Quality, or AHRQ, pronounced
"arc"), released guidelines for the treatment of acute low
back pain. The guidelines recommended spinal manipulation -- either
osteopathic or chiropractic -- over more typical forms of physical
therapy (including traction, diathermy,
transcutaneous electrical nerve stimulation [TENS] and ultrasound).
While the specific physiologic effects of spinal manipulation were
largely unknown, these guidelines acknowledged that the methods used
often meet with positive results. National treatment guidelines in
Canada and England also recommend chiropractic manipulation as
first-line therapy for neck and back pain.
Chiropractic is not a
panacea for either acute or chronic low back pain. However,
considering the widespread nature of the condition, the socioeconomic
expense and the lack of superior alternative treatments, the medical
literature supports the position that chiropractic is a reasonable
treatment alternative for most patients in whom manipulation is not
Russo, Jr., PharmD is senior vice president of medical
communications at Vicus.com. He is a pharmacist and medical writer
with more than 20 years of experience in medical education.
TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The
outcomes and costs of care for acute low back pain among patients seen
by primary care practitioners, chiropractors, and orthopedic surgeons.
The North Carolina Back Pain Project. N
Engl J Med
1995 Oct 5; 333(14):913-7.
DC, Deyo RA, Battíe M, Street J, Barlow W. A comparison of physical
therapy, chiropractic manipulation, and provision of an educational
booklet for the treatment of patients with low back pain. N
Engl J Med
1998 Oct 8; 339(15):1021-9.
TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of
mechanical origin: Randomised comparison of chiropractic and hospital
outpatient treatment. BMJ
1990 Jun 2; 300(6737):1431-7.
TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic
and hospital outpatient management for low back pain: Results from
extended follow up. BMJ
1995 Aug 5; 311(7001):349-51.
PG, Coulter I, Hurwitz EL, Genovese B, Adams AH, Mior SA, Brook RH.
Congruence between decisions to initiate chiropractic spinal
manipulation for low back pain and appropriateness criteria in North
1998 Jul 1; 129(1):9-17.