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

Chronic back pain is often a difficult condition to treat. Which option is best suited?

A review by the US ‘Agency for Healthcare Research and Quality’ (AHRQ) focused on non-invasive nonpharmacological treatments for chronic pain. The following therapies were considered:

  • exercise,
  • mind-body practices,
  • psychological therapies,
  • multidisciplinary rehabilitation,
  • mindfulness practices,
  • manual therapies,
  • physical modalities,
  • acupuncture.

Here, I want to share with you the essence of the assessment of spinal manipulation:

  • Spinal manipulation was associated with slightly greater effects than sham manipulation, usual care, an attention control, or a placebo intervention in short-term function (3 trials, pooled SMD -0.34, 95% CI -0.63 to -0.05, I2=61%) and intermediate-term function (3 trials, pooled SMD -0.40, 95% CI -0.69 to -0.11, I2=76%) (strength of evidence was low)
  • There was no evidence of differences between spinal manipulation versus sham manipulation, usual care, an attention control or a placebo intervention in short-term pain (3 trials, pooled difference -0.20 on a 0 to 10 scale, 95% CI -0.66 to 0.26, I2=58%), but manipulation was associated with slightly greater effects than controls on intermediate-term pain (3 trials, pooled difference -0.64, 95% CI -0.92 to -0.36, I2=0%) (strength of evidence was low for short term, moderate for intermediate term).

This seems to confirm what I have been saying for a long time: the benefit of spinal manipulation for chronic back pain is close to zero. This means that the hallmark therapy of chiropractors for the one condition they treat more often than any other is next to useless.

But which other treatments should patients suffering from this frequent and often agonising problem employ? Perhaps the most interesting point of the AHRQ review is that none of the assessed nonpharmacological treatments are supported by much better evidence for efficacy than spinal manipulation. The only two therapies that seem to be even worse are traction and ultrasound (both are often used by chiropractors). It follows, I think, that for chronic low back pain, we simply do not have a truly effective nonpharmacological therapy and consulting a chiropractor for it does make little sense.

What else can we conclude from these depressing data? I believe, the most rational, ethical and progressive conclusion is to go for those treatments that are associated with the least risks and the lowest costs. This would make exercise the prime contender. But it would definitely exclude spinal manipulation, I am afraid.

And this beautifully concurs with the advice I recently derived from the recent Lancet papers: walk (slowly and cautiously) to the office of your preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.

 

21 Responses to The AHRQ review of spinal manipulation for chronic back pain: more bad news for chiropractors

  • “Recent guidelines from the CDC4 in the United States and the Canadian Guidelines for Opioid Use in Chronic Non-Cancer Pain21 recommend nonopioid treatment as preferred treatment for chronic pain. Further, American College of Physicians guidelines recommend nonpharmacological therapies over medications for chronic back pain.12 Our findings support the feasibility of these guidelines by showing that there are nonpharmacological treatments for chronic pain that have evidence of sustained effectiveness after the completion of therapy. Importantly, some interventions, such as exercise, multidisciplinary rehabilitation, mind-body interventions, cognitive behavioral therapy and some complementary and integrative medicine therapies such as acupuncture and spinal manipulation also were associated with some sustained effects on function, although evidence beyond 12 months is sparse. At the same time, there was no evidence suggesting serious harms, although data on harms were limited.”

  • Key Messages
    • Interventions that improved function and/ or pain for at least 1 month when used for—

    – Chronic low back pain: Exercise, psychological therapies (primarily cognitive behavioral therapy [CBT]), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR).
    – Chronic neck pain: Exercise, low- level laser, Alexander Technique, acupuncture.
    – Knee osteoarthritis: Exercise, ultrasound.
    – Hip osteoarthritis: Exercise, manual therapies.
    – Fibromyalgia: Exercise, CBT, myofascial release massage, tai chi, qigong, acupuncture, MDR.
    – Chronic tension headache: Spinal manipulation.

    • yes…
      and what does that change in relation to my post
      or perhaps you just wanted to show how good you are at ‘cut and paste’?

  • Wow…all that’s left is the crying. As it involves chiroquackers crying and lying.

  • Let’s see, 98.5% of chiropractors promote physical fitness/exercise on a daily basis, 98.1% promote self-care strategies on a daily basis, 96.8% utilize corrective or therapeutic exercise and 92.3% utilize rehab/stabilization exercises of the spine (Job Analysis). Many clinical guidelines on low back pain include spinal manipulation somewhere within their algorithm along with the above approaches. A few papers even suggest that spinal manipulation may have an additive effect with some of the above.

    • No, what you’re describing there is physical therapy. Tell us, what is it that is unique that chirorpractors do?

      • “Overlap among professions is necessary. No one profession actually owns a skill or activity in and
        of itself. One activity does not define a profession, but it is the entire scope of activities within the
        practice that makes any particular profession unique. Simply because a skill or activity is within one
        profession’s skill set does not mean another profession cannot and should not include it in its own
        scope of practice.” ….National Council of State Board of Nursing.

        • So… what I got out of that, was that chiropractors have the relationship to physical therapists, as nurses to medical practitioners. Is this a mainstream view within chiropractic?

          • no profession owns those therapeutic approaches. If one wishes to know anything unique to a profession one compares scope of practices.

          • “no profession owns those therapeutic approaches” but each profession has to generate at least one useful intervention to merit being called a profession.

          • EE: but each profession has to generate at least one useful intervention to merit being called a profession.

            profession:

            A paid occupation, especially one that involves prolonged training and a formal qualification. Oxford dictionary

            A profession is a type of job that requires advanced education or training. Collins dictionary

            a calling requiring specialized knowledge and often long and intensive academic preparation Merriam Webster

            etc, etc

          • glad you can copy, now try to think.

          • your requirement is not included in any definition. It appears you just made it up.

            “…each profession has to generate at least one useful intervention to merit being called a profession.’

  • Mr (or Ms/Mrs) DC,
    Could you explain why you found chiropractic so attractive to study?
    Why did you not study medicine and then go on to post-graduate study of ‘chiropractic’ (had you still felt so inclined)?
    Why does ‘chiropractic’ regard itself as a profession distinct from medicine?
    What is it ‘chiropractors’ do that doctors could not (if they were shown how – e.g., adjust subluxations)?

    Thank you.

    • Richard,

      You’ve asked that question quite a few times – I hope DC responds, as it’s alway interesting to hear how people end up on their paths.

      I’ve been meaning to ask you the same question. You freely admit to being studied and practiced in the art of deceiving people. Why did you study deception, when there are many other disciplines/arts devoted to clarity of mind, objective observation, etc?

      It’s always seemed like an odd choice for you. I would think your comments and book (you wrote a book, yes?) would only be taken seriously by the most gullible of the gullible…those who would come to the conclusion that the practiced con man is, this time, being straight up (wink wink nudge nudge).

    • RR…Could you explain why you found chiropractic so attractive to study?

      It came down to this question…based upon my information, which profession has the best possible model to prevent spine injury/surgery…i.e. Address MSK dysfunction within a global mindset.

      RR…Why did you not study medicine and then go on to post-graduate study of ‘chiropractic’ (had you still felt so inclined)?

      I didn’t see that a medical degree would be of any benefit towards my goals.

      RR…Why does ‘chiropractic’ regard itself as a profession distinct from medicine?

      Generally, we focus on addressing nonspecific MSK conditions without the direct use of pharmaceuticals.

      RR…What is it ‘chiropractors’ do that doctors could not (if they were shown how – e.g., adjust subluxations)?

      Nothing. MDs could do what i do, but most choose not to (for whatever reasons they may have).

      • DC wrote: “MDs could do what i do, but most choose not to (for whatever reasons they may have).”

        @ DC

        Could the reason be that MDs recognise that there’s an overwhelming lack of evidence for what you (i.e. chiropractors) do and that your industry is mired in quackery?

        • BW…you would have to ask them for their reasons.

          • Here is what one survey found.

            For physical treatments, the application of heat or ice, therapeutic ultrasound, and massage therapy were used by most of the physicians (88.5% [77/87], 55.2% [48/87], and 65.5% [57/87], respectively).

            Physicians performed, or recommended spinal manipulation only 21.8% (19/87) of the time although the guideline recognized manipulation as the only physical treatment with proven efficacy.

            About half of the physicians (45/87) used some form of injection therapy despite evidence demonstrating equivocal results.

            https://triggered.clockss.org/ServeContent?issn=1063-3987&volume=9&issue=10&spage=1015

          • Really? A reference about clinical practice from 2000? Tee hee.

            Why not this one?

            Palmer, D.D. (1910) The Science, Art and Philosophy of Chiropractic Portland, Oregon: Portland Printing House Company

            Much more amusing for this audience.

          • Lipid, if you have a more recent reference that pertains to the topic being discussed, please share it.

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