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.

In 1990, the British Medical Journal 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 used Maitland 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).

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 medical specialists.

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.

Since 1995, The New England Journal of Medicine has 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 statistical significance.

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 contraindicated. 

John 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.