Welcome to Class Act, a new feature of Clinical Correlations. Class act will feature posts written by NYU 3rd and 4th year medical students. These posts will focus on evidenced based answers to clinical questions related to patients seen by our students in the clinics or on the wards. Prior to publication, each commentary is thoroughly reviewed for content by a faculty member. Enjoy…
Commentary by Brian Liem, MSIV
A 52 year old male with no medical problems presents to your clinic with a 10 year history of chronic intermittent back pain. Over the past few months, his pain has increased in severity and frequency. Radiological examination reveals degenerative changes in the lumbar spine, particularly at L4-L5. Would the patient benefit from chiropractic intervention?
Low back pain is the 5th leading reason for medical office visits in the US and is the leading cause of work-related disability.1 Fifty-six percent of office visits for back pain are to family practitioners and internists, 25 percent to orthopedic surgeons, 7 percent to neurosurgeons, and 4 percent to neurologists, and the rest to chiropractors and other healthcare professionals.2 While the standard practice for treating lower back pain is generally with activity modification, analgesics and physical therapy, spinal manipulative therapy, otherwise known as chiropractic care, has gained popularity throughout the years.
From a chiropractor’s perspective, low back pain is a function of restricted movement in the spine. In spinal manipulation, practitioners apply high velocity manual loading to the spine using short or long leverage methods in order to increase spine mobility.3 Many patients with chronic low back pain will seek chiropractic care, but what is the evidence that chiropractic care is even effective in treating low back pain?
One randomized control study in UK of 1334 patients compared treatment of low back pain with “best care” in general practice to spinal manipulation added to “best care.” At three months post-treatment, those patients who were given the additional spinal manipulation had improved Roland Morris disability scores.4 At twelve months there continued to be improvements, although less dramatic.
However, in a meta-analysis of 39 randomized control trials comparing spinal manipulation to commonly used, but not necessarily proven, therapies (i.e.: analgesics, back school (diathermy), physical therapy, light massage, bed rest, topical gels, corsets), spinal manipulative therapy was found only to be superior to sham therapy or therapies judged to be ineffective or even harmful.5 Researchers found no evidence that spinal manipulation was more effective than standard treatments for low back pain.
Despite the above meta-analysis findings, patients may still believe that they achieve greater relief from chiropractic interventions than from standard medical treatment. In a study of 681 low back pain patients at UCLA, receiving either chiropractic or medical care, it was found that compared with medical care-only patients, chiropractic patients were much more likely to perceive improvements in their low back symptoms.6 This study, however, found that at 18 months post treatment, there was no statistically significant reduction in clinical outcomes, as measured by pain score and disability, between the two groups.
With the literature in mixed support of chiropractic care for low back pain, perhaps the question is not whether spinal manipulative therapy is effective in treating this condition, but, rather, in which subset of patients it is likely to benefit? In a randomized control trial of 131 patients in San Antonio, Texas, it was found that patients who received spinal manipulation in addition to exercise benefited more than those who received exercise therapy alone if they met certain criteria.7 This criteria included: 1) symptoms for fewer than 16 days 2) No symptoms distal to the knee 3) At least one hypermobile segment in the lumbar spine 3) At least one hip with more than 35 degrees of internal rotation 4) A score below 10 on the Fear-Avoidance Beliefs Questionnaire.
Taking the above studies together, at this time chiropractic care can be considered a safe and moderately effective treatment of low back pain. However there is not sufficient evidence to conclude that it achieves better outcomes than standard care.
1. Bigos, SJ, Battie, MC. The impact of spinal disorders on in industry. In: The Adult Spine: Principles and Practice, Frymoyer, JW (Ed), Raven Press, New York 1991. p.147.
2. Hart, LG, Deyo, RA, Cherkin, DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine 1995; 20:11.
3. Cherkin, DC, Sherman, KJ, Deyo, RA, Shekelle, PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med 2003; 138:898.
4. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 2004; 329:1377.
5. Assendelft, WJ, Morton, SC, Yu, EI, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003; 138:871.
6. Hurwitz, EL, Morgenstern, H, Kominski, GF, et al. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine 2006; 31:611.
7. Childs, JD, Fritz, JM, Flynn, TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004; 141:920.
Image courtesy of Gray’s Anatomy