text_1: Study Questions Chiropractic’s Impact on Back Pain
text_2: The article focused on a recent systematic review of the effectiveness of spinal manipulation for chronic low back pain. The Cochrane Collaboration review found that this popular treatment leads to rapid short-term pain relief and improvement in function. But the magnitude of the treatment effect was modest at best. And manipulation did not provide a “clinically significant” advantage over other common treatments for chronic low back pain, according to this review. The HealthDay article made a key observation about chronic back pain: that there is no “silver bullet” for it. And it provided a brief but fair description of the systematic review and the evidence it considered. Our reviewers could have gone either way on several of the graded criteria, so the 4-star final score may be a bit deceiving. What were some of the shortcomings of this article? The article had a misleading title: “Study Questions Chiropractic’s Impact on Back Pain”. This systematic review looked at the effects of manipulation as practiced by multiple professions rather than the impact of chiropractic per se. Since the review concluded that manipulation is a viable treatment for chronic back pain, one can argue that it supports rather than questions this manual therapy. It might have been useful to ask an impartial expert how the new review on manipulation compares with other recent reviews of the evidence in this area. And how manipulation compares with other effective treatments for chronic back pain. Readers of this article might well have come away with the impression that all treatments for chronic back pain offer similar results. This is not the case. Of the 200 or so therapies for chronic back pain in the medical marketplace, no treatment consistently offers a major benefit. Only a few have been proven to provide a moderate benefit for chronic back pain. The most influential U.S. guideline found only six treatments, including manipulation, where there was “good” evidence of a “moderate benefit” for chronic back pain (See Chou et al., 2007; Chou et al., 2009). An influential British review concluded that three general approaches (exercise, manual therapy including manipulation, and acupuncture) provide roughly equal benefit in the early management of persistent back pain. (See NICE, 2009). So the new review on manipulation is reasonably consistent with the larger evidence picture. It would have been useful if the article could have highlighted this point—since it offers an important message for people with chronic back pain. Based on this body of evidence, they shouldn’t be expecting heroic cures. Rather, they should look for validated treatments that can help them stay comfortable and active—and that align with their values, expectations and tolerance for risk. References: Chou R et al., Diagnosis and treatment of low back pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,  Annals of Internal Medicine, 2007; 147:478-491. Chou R et al., Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain, Spine, 2009; 34(10): 1066-67. NICE, Early management of persistent non-specific low back pain; 2009; see http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf                                      Spinal manipulation is one of the most popular treatments for low back pain in the United States and many other nations. The 2007 National Health Interview Survey concluded that roughly 8.6% of U.S. adults—close to 20 million individuals—utilized chiropractic or osteopathic manipulation. Despite its popularity, spinal manipulation is still commonly referred to as a “complementary/alternative” therapy rather than a mainstream treatment. Though it enjoys considerable support in systematic reviews and guidelines, spinal manipulation remains somewhat controversial and is not widely available in primary care medical settings. It does not enjoy completely consistent support from insurance companies. So determining the optimal role of manipulation in the management of chronic low back pain—in both chiropractic and conventional medical settings— is an important priority.