Low-back pain sufferers can seek relief from any number of health professionals, orthopedists, physical therapists and osteopaths among them.
Many choose chiropractors, which typically combine spinal manipulation with such treatments as exercise, massage, heat or electrical stimulation. This approach modestly is successful in reducing pain of recent onset and improving disability, at least for a few weeks, according to a new Cochrane review. However, the review found no evidence that chiropractic works significantly better than care provided by other clinicians.
Lead author Bruce Walker, a doctor of chiropractic at the Murdoch University School of Chiropractic and Sports Science in Australia, said that the studies analyzed here were “pragmatic,” in that “they reflect the reality of practice, which usually involves combined interventions and not just one.”
This kind of study cannot identify which particular treatment or treatments worked, “but from a consumer’s point of view, that matters little, if the care they get is safe and effective,” he said.
“If consumers have acute or subacute [lingering for several weeks] back pain they can have some confidence that if they go to the chiropractor they’ll see some improvement,” although the results are not essentially different from what they might find elsewhere, Walker said.
This review appears in the latest issue of The Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
Walker and his colleagues (one is also a chiropractor) analyzed 12 randomized controlled trials that included 2,887 participants. Each study compared combined chiropractic interventions to some other therapeutic approach to low-back pain.
The review labeled interventions “chiropractic” when the reviewers judged them to be so and when licensed chiropractors performed them. These regimens drew from a broad spectrum of physical, mechanical, thermal, exercise-based, nutritional and educational options; and 10 of the 12 studies included spinal manipulation.
The comparison treatments were equally diverse (and often overlapped with the chiropractic medley): massage, heat and cold, exercise, physiotherapy, analgesics, lumbar support, spinal manipulation and education.
The reviewers grouped studies by how long the condition had persisted. Three studies involving acute and subacute low-back pain (up to 12 weeks duration) found that in the short-term (within one month after the study began), pain improved in patients treated both with chiropractic and comparison treatments. Benefits were somewhat greater in the chiropractic group, but the difference was not “clinically significant,” the reviewers said.
The one study that considered long-term results (six months after treatment initiation) found no difference between treatment groups.
Four studies that considered disability in acute and subacute patients found chiropractic worked significantly better than alternatives in the short term, but one study that followed patients out for six months found no difference.
Studies involving chronic (12 weeks or more duration) low-back pain found no significant difference between chiropractic and comparison groups in pain relief or disability after up to six months of treatment (three studies) or in the longer term (one study).
While the overall analysis failed to show significant advantages to chiropractic, some individual studies did. Walker pointed to one that compared chiropractic care in private practice to physical therapy in an outpatient hospital.
The generally small treatment effects seen in the reviewed studies, Walker suggested, could reflect the mixed origins of the condition. “Low-back pain is a symptom, not a diagnosis,” he said. ”Maybe it’s a big call to expect things like spinal manipulation to help all low-back pain….If we could divide symptoms into subsets with different causes, we might be able to direct treatment better.”
Roger Chou, M.D., of the Oregon Evidence-Based Practice Center and Health and Science University of Oregon, described the review as different from most in its attention to “who’s doing the intervention, rather than the intervention itself… The authors tried to make the case that it’s more like real life that way and I think that’s a valid point.”
The problem is interpreting evidence from such broad sources, he said. “The interventions are so different — some combine chiropractic with a heating pad; some add exercise therapy or ultrasound — it seems difficult for me to make sense of how all these studies can be combined.”
He would draw the conclusion that “the effective intervention is probably manipulation and, for the most part, you don’t get a lot more benefit from throwing additional things on,” said Chou, who is on the Cochrane Back Review Group, but was not involved with the creation of this review.
The overall quality of the studies they reviewed was not good, the authors said: Weaknesses in experimental design made the risk of bias substantial in all but three. They said that this does not invalidate the results, but suggests it is highly probable that future research might reach different conclusions.
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Walker BF, et al. Combined chiropractic interventions for low-back pain (Review). Cochrane Database of Systematic Reviews. Issue 4, 2010.