MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

It is no secret to regular readers of this blog that chiropractic’s effectiveness is unproven for every condition it is currently being promoted for – perhaps with two exceptions: neck pain and back pain. Here we have some encouraging data, but also lots of negative evidence. A new US study falls into the latter category; I am sure chiropractors will not like it, but it does deserve a mention.

This study evaluated the comparative effectiveness of usual care with or without chiropractic care for patients with chronic recurrent musculoskeletal back and neck pain. It was designed as a prospective cohort study using propensity score-matched controls.

Using retrospective electronic health record data, the researchers developed a propensity score model predicting likelihood of chiropractic referral. Eligible patients with back or neck pain were then contacted upon referral for chiropractic care and enrolled in a prospective study. For each referred patient, two propensity score-matched non-referred patients were contacted and enrolled. We followed the participants prospectively for 6 months. The main outcomes included pain severity, interference, and symptom bothersomeness. Secondary outcomes included expenditures for pain-related health care.

Both groups’ (N = 70 referred, 139 non-referred) pain scores improved significantly over the first 3 months, with less change between months 3 and 6. No significant between-group difference was observed. After controlling for variances in baseline costs, total costs during the 6-month post-enrollment follow-up were significantly higher on average in the non-referred versus referred group. Adjusting for differences in age, gender, and Charlson comorbidity index attenuated this finding, which was no longer statistically significant (p = .072).

The authors concluded by stating this: we found no statistically significant difference between the two groups in either patient-reported or economic outcomes. As clinical outcomes were similar, and the provision of chiropractic care did not increase costs, making chiropractic services available provided an additional viable option for patients who prefer this type of care, at no additional expense.

This comes from some of the most-renowned experts in back pain research, and it is certainly an elaborate piece of investigation. Yet, I find the conclusions unreasonable.

Essentially, the authors found that chiropractic has no clinical or economical advantage over other approaches currently used for neck and back pain. So, they say that it a ‘viable option’.

I find this odd and cannot quite follow the logic. In my view, it lacks critical thinking and an attempt to produce progress. If it is true that all treatments were similarly (in)effective – which I can well believe – we still should identify those that have the least potential for harm. That could be exercise, massage therapy or some other modality – but I don’t think it would be chiropractic care.


References

Comparative Effectiveness of Usual Care With or Without Chiropractic Care in Patients with Recurrent Musculoskeletal Back and Neck Pain.

Elder C, DeBar L, Ritenbaugh C, Dickerson J, Vollmer WM, Deyo RA, Johnson ES, Haas M.

J Gen Intern Med. 2018 Jun 25. doi: 10.1007/s11606-018-4539-y. [Epub ahead of print]

PMID: 29943109

14 Responses to Chiropractic for back or neck pain? Not nearly as good as some seem to believe

  • Or to put it another way, chiropractic did no worse than other care paths.
    No care path seems to much alter the natural history of back pain.
    It’s a shame, but that’s the way it is

    But other care paths do not necessarily come packaged with anti-vaccine beliefs and other assorted idiocy.

  • IMHO the greatest harm of chiropractic is is promulgation of irrational, anachronistic non-evidence based concepts which were originally dreamt up specifically to be ‘different from medicine’ (D.D.Palmer) and which have led to charlatans and quacks claiming to be ‘doctors’ and even wanting to be regarded as ‘primary care physicians’ without actually going to the trouble and effort of qualifying as such.

    Chiropractors are masquerading as that which they are not and attempting to steal the professional status of MDs.
    They know that perfectly well. The chiropractic colleges were set up for that purpose.
    Why are they not colleges of medicine?

    The medical profession was created and regulated as such precisely so that patients, particularly those who were gullible and vulnerable, could be protected from unqualified practitioners.
    Inventing a new ‘profession’ harms medicine, and patients.

    Surely, that is to be deprecated.

    Chiropractors should get their tanks off the lawns of the real colleges of medicine.

    • In other words, “playing doctor”.

    • The medical profession was created and regulated as such precisely so that patients, particularly those who were gullible and vulnerable, could be protected from unqualified practitioners.

      May I assume that you have not read David Wootton’s Bad Medicine?

  • Dealing with primarily with a chronic condition with an end point at 6 months?

    “Conventional management commonly includes nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, and opioids, which are of modest benefit and are associated with serious toxicities.6,7”

    “Among the referred patients, the mean number of visits with the chiropractor, based upon EHR data, was 4.0 (SD 4.4; median = 3, IQR = 0–7).”

  • After reading the paper, the main thing that strikes me is that the study is underpowered to show any difference in outcomes between the groups, which indeed the authors admit, though not in so many words. The best that they were able to say is that “clinical outcomes were generally similar”, although when we look at the confidence intervals for every one of their outcome measures we can’t really say whether even this is a meaningful conclusion to draw.

    The non-randomised design of the trial does not eliminate bias, and I suppose it is possible that bias in one direction masked a true difference in the opposite direction.

    Indeed, looking at the characteristics of the patients, it seems that those in the control group were more depressed, had had their pain for longer, had had more treatments for it prior to the study, and were more likely to be involved in litigation, and yet they did no worse than those in the treated group (inasmuch as we are able to tell given the limited numbers).

    They conclude “We found no statistically significant difference between the two groups in either patient-reported or economic outcomes.” They could conclude that with only one patient in each group, and in neither case would it actually tell us very much.

    I don’t really think it is possible to draw any conclusions from this study, other than to note that this type of pain seems to improve after three months regardless, and perhaps that it might be more informative to repeat it with larger numbers.

  • I’m not even sure one can conclude that pain improved in the control group without knowing when “usual care” ceased. Was it even detailed in the study?

  • “Under-powered” matters more when one is looking for some subtle, though likely genuine, difference between a test and a control group. Looking for an infrequent but worrying hazard would be undermined by a low-powered study.

    As with so much SCAM, if the effects matched the practitioners’ claims for them, where they assert case upon case of successful outcomes, even a small study should yield a screamingly obvious effect.

    The fact that SCAMsters defend their art by fiddling about in the statistical margins is sufficient in itself to invalidate their main claims.

  • By the way, if the RECAPTCHA process gets any harder I’m going to be unable to prove I am human.

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