Low Back Pain: Manipulation Helpful
Each year, about one out of 20 Americans goes to a chiropractor for manipulation, most often as a treatment for back pain. Although the medical profession has long dismissed chiropractic manipulation as quackery, the people have “voted with their feet” and continue–in large numbers–to seek chiropractic care.
Within the last decade, the chiropractic profession has begun to see vindication. In 1987, it won a lawsuit against the American Medical Association and other medical organizations for “systematic long-term wrongdoing and the long-term intent to destroy a licensed profession.”
More recently, the RAND Corporation, the prestigious research agency, was commissioned by two chiropractic organizations to conduct a review of all research exploring the value of manipulative therapy for low back pain. Its report, published last year, produced evidence to support manipulation’s efficacy in treating acute back pain without serious neurological symptoms.
The latest evidence in favor of manipulation is a controlled study conducted in The Netherlands and reported last month in the British Medical Journal (March 7). It involved over 250 people with back and/or neck pain persisting for more than six weeks.
They were randomly assigned to receive either: physiotherapy (exercise, massage, and physical therapy modalities, such as heat, electrotherapy, ultrasound, short-wave diathermy); manipulative therapy; standard treatments from a general practitioner (painkillers and advice about posture, exercise, and bedrest); or placebo, which consisted of an examination and “treatment” with detuned shortwave diathermy and ultra-sound machines.
The study is significant not only because it is randomized (participants can’t choose their treatment) and controlled (includes a placebo group), but also because it is one of the few to follow participants for a long period of time (one year). The investigators wrote: “We conclude that after 12 months’ follow up both manipulative therapy and physiotherapy seem to be more effective than treatment by the general practitioner or placebo treatment. Furthermore, the findings indicate a slightly better result from manipulation therapy compared with physiotherapy.”
Four years ago, another controlled study compared the effects of a single manipulation on 54 people with either long- or short-term pain. It was conducted by Nortin M. Hadler, M.D., and colleagues at the University of North Carolina at Chapel Hill and published in the medical journal Spine. More significant relief was shown for the long-term pain group, that is, those who entered the study with pain that had persisted for two to four weeks. They reported far more rapid improvement from manipulation than their counterparts who had suffered back pain for less than two weeks.
The RAND report states that 94% of all manipulative care is delivered by chiropractors, with osteopathic physicians delivering 4%, and general practitioners and orthopedic surgeons accounting for the remainder. A renewed interest in manipulation on the part of the medical profession is also noted in the RAND report, along with a reference to its long history. It states: “Spinal manipulation as a treatment for musculoskeletal pain has been practiced for centuries, having been described by Hippocrates, Galen, and other Western physicians, as well as in the writings of comparable historical figures in Eastern medical history.”
In the course of putting together this report, the RAND physicians relied on advice and “constructive critique” from a nine-member panel of orthopedic surgeons, osteopathic physicians, and chiropractors.
While manipulation continues to receive validation, the standard medical therapies have not fared so well. One by one, over the last few years, some of the most popular medical treatments for back pain have been proven ineffective, often worsening the problem. Traction, prolonged bedrest, and transcutaneous electrical nerve stimulation are but a few examples. Last year, another popular medical treatment, steroid injections, was shown in a carefully controlled study to be no better than a placebo injection (with salt water).
One reason why such treatments became so widely accepted before being fully assessed was offered in a 1991 New England Journal of Medicine editorial by Richard A. Deyo, M.D., M.P.H. “Up to 85% of patients with low back pain cannot be given a definitive diagnosis, because of the poor associations among symptoms, pathological findings, and imaging results… there is no gold standard for the diagnosis .”
In 1986, Dr. Deyo co-authored a landmark study showing that people suffering low-back pain who were randomly prescribed two days of bedrest missed 45% fewer days of work than their counterparts who were assigned to seven days of bedrest. No other differences in pain and functioning were observed between the two groups. His work has influenced the current medical trend toward “earlier ambulation” and exercise.
While medical science pursues its quest for the most effective treatment, chiropractic care is likely to continue accounting for about two-thirds of all patient visits for back pain.
And what about the dangers of manipulation therapy? The RAND physician/reviewers found 135 case reports of serious manipulation-related complications, including 18 deaths, most of which occurred in the period from 1950 to 1980. It is estimated that tens of millions of manipulations took place during this 3O-year period.
Several months ago, the TV show 20/20 featured the RAND report. lts principle author, Paul G. Shekelle, M.D. responded to a question about the basis for manipulation’s efficacy in treating low-back pain, by saying “There is more evidence for manipulation than there is for many of the things orthopedic surgeons and neurologists have to offer.”