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

The objective of this study was to compare chronic low back pain patients’ perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment.

Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data:

  1. The SMT group began long-term management with SMT but no prescribed drugs.
  2. The PDT group began long-term management with prescription drug therapy but no spinal manipulation.
  3. This group employed SMT for chronic back pain, followed by initiation of long-term management with PDT in the same year.
  4. This group used PDT for chronic back pain followed by initiation of long-term management with SMT in the same year.

A total of 1986 surveys were sent out and 195 participants completed the survey. The respondents were predominantly female and white, with a mean age of approx. 77-78 years. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short-Form Health Survey to measure HRQoL.

Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort’s reported concern about PDT (P = .03).

The authors concluded that among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.

The main issue here is that the ‘study’ was a mere survey which by definition cannot establish cause and effect. The groups were different in many respects which rendered them not comparable. For instance, participants who received SMT had higher self-reported physical and mental health on average than those who received PDT. Differences also existed between the SMT and the PDT groups for agreement with the notion that “spinal manipulation for LBP makes a lot of sense”; 96% of the SMT group and 35% of the PDT group agreed with it. Compare this with another statement, “taking /having prescription drug therapy for LBP makes a lot of sense” and we find that only 13% of the SMT cohort agreed with, 95% of the PDT cohort agreed. Thus, a powerful bias exists toward the type of therapy that each person had chosen. Another determinant of the outcome is the fact that SMT means hands-on treatments with time, compassion, and empathy given to the patient, whereas PDT does not necessarily include such features. Add to these limitations the dismal response rate, recall bias, and numerous potential confounders and you have a survey that is hardly worth the paper it is printed on. In fact, it is little more than a marketing exercise for chiropractic.

In summary, the findings of this survey are influenced by a whole range of known and unknown factors other than the SMT. The authors are clever to avoid causal inferences in their conclusions. I doubt, however, that many chiropractors reading the paper think critically enough to do the same.

32 Responses to Spinal Manipulation vs Prescription Drug Therapy for Chronic Low Back Pain. More pseudoscience from the chiro cult

  • Of course some of the limitations that Ernst mentions were suggested as limitations in the study.

    “The overall response rate was 10%, and the PDT and SMTX cohorts had fewer participants than anticipated. Generalizability may be limited due to the low response rate. Additionally, we observed a statistically significant difference in age between respondents and nonrespondents, based on a 1–year difference in mean age; however, this small difference would not likely affect the estimates in a meaningful way. It is possible that respondents in the PDT group had more severe back pain and lower HRQoL at baseline, which may have influenced their responses. Additionally, since this study was survey-based, recall bias may pose an issue; but we have no reason to expect recall to be different between the cohorts. Moreover, participants’ reported HRQoL may be unrelated to prior treatments received for low back pain. As in any observational study, the results may be confounded by unmeasured variables. In this study, treatments received other than SMT or PDT may have confounded the results. Further study is needed to better understand patient beliefs regarding SMT versus PDT for cLBP. ”

    But I do agree it shouldn’t have been published as is, at best (if done at all) it should have been done as a pilot survey. Other than that, pretty much a waste of time to discuss the paper.

    Regardless, I object to Ernst’s titling this blog with the words pseudoscience and cult. Perhaps he should look up the criteria.

  • “The main objective of a pilot survey is to test the research tools including the questions, survey structure, and distribution channels. If done in the right way, it helps you to discover challenges that can affect the main data collection process.”

    https://www.formpl.us/blog/pilot-survey-questionnaire#:~:text=The%20main%20objective%20of%20a,the%20main%20data%20collection%20process.

  • I am a strong opponent to chiropractic. I have arrived at my current mindset through personal experience along with reading and studying medical literature. I am seeing a growing trend with chiropractors omitting the D.C.after their name. Now why would they do that? Chiropractors want to be thought of as the same as a MD. In my opinion this is very dishonest and misleading. My daughter’s best friend has had 5 miscarriages. A chiropractor told her that he can help her from having a miscarriage. This poor woman has lost 5 babies!!! Personally I want to strangle the fellow because I have seen the pain and depression the miscarriages have caused in her life. This is just 1 instance of disreputable chiropractic care. I could give you 5 more that I have experienced/witnessed. It is time for the Chiropractic community to adopt science based chiropractic. This would be a sign of positive change. Has chiropractic practice and brief changed at all since Daniel Palmer invented chiropractic? Not much

    • too much to cover so I will just leave you with this. This is a list I came up with a while back on what to watch out for when choosing a chiropractor. And yes, I got a lot of heat over it.

      This to watch out for regarding chiropractors:

      Anti-vaccination view.
      Repeated use of x rays outside current evidence based standards.
      Advertising claims of spinal manipulation effectiveness for conditions beyond current evidence.
      Use of words like…vitalism, miracles, innate intelligence, universal intelligence, green books, medipractor.
      A heavy reliance on anecdotal and case studies to justify broad based care.
      Adjusting infants due to “birth trauma”.
      Unrealistic long term treatments and use of prepaid treatment plans.
      More emphasis on making money than quality patient care.
      Devaluing science over philosophy.
      Conspiracy theories especially regarding pharmaceutical companies.

  • I have difficulty with 1-10 or 1-5 rating scales on how I feel or other questions.
    It is so subjective.
    After a period of time if I am asked to rate the same condition I cannot remember what I said before.
    I think these subjective ratings should not be the basis for scientific conclusions

    • Pain scales have been validated. But they should not be used as the sole outcome criteria. However, pain is typically one of the main drivers to seek healthcare so it is important to monitor it.

    • I was admitted to hospital with a pathological fracture of my T12 vertebra just over five years ago (a pathological fracture is one that occurs because the bone is already weakened, in this case because I had an undiagnosed cancer with deposits in my spine). The nurses kept asking me how bad my pain was on a scale of 1 to 10. I eventually worked out my own scale, where 0 – 5 didn’t require any additional pain killers and 6 – 10 did. I was quite detailed about it in my own mind:

      0 – no pain
      1 – slight pain if I thought about it
      2 – slight pain, not intrusive
      3 – definite pain but not interfering with any activity
      4 – pain troublesome but tolerable
      5 – pain tolerable only if I kept still
      6 – pain bad enough to warrant an increase in analgesia
      7 – severe pain; I would like analgesia now
      8 – unbearable pain
      9 – pain enough to cause vomiting
      10 – pain enough to cause unconsciousness

      I have seen 9 and 10 in my own patients, though never experienced anything worse than 8 myself. Happily I am one of those individuals who responds well to opiates without experiencing much in the way of side-effects from them.

      After a while I realised that the only thing that the nurses were interested in was whether the pain was better or worse than the last time they had assessed it. The numbers themselves were completely arbitrary.

      Requiring a number on a scale is much more useful than simply asking how bad the pain is, as it forces people to think how bad it is at the moment. However, there is no point in asking anybody how their pain was yesterday, or even half an hour ago, as by and large pain is not something that people remember. If you require a detailed assessment of changes you have to ask them to keep a diary and set an alarm so that they know when to complete it.

      Many times as a junior doctor I have been faced with somebody who simply wanted to impress on me how bad there pain was, without telling me anything about it that would have been useful in making a diagnosis. In particular, people from the Indian sub-continent would simply say “Too much pain, doctor. Too much pain.” I always thought that this was particularly unhelpful, as most people would regard any pain as too much. However, years later I started learning some Hindi prior to a holiday in India (I love travelling, and I find that I get much more out of a trip if I know something of the language), and I discovered that the word for “a lot” and “too much” was the same.

      I didn’t get very far with Hindi, not least because I found it very difficult to pronounce convincingly, with the nasal and non-nasal vowels, and aspirated and non-aspirated versions of each consonant, on top of an accent which required holding my mouth in a very unnatural posture, though clearly many of the words had the same roots as their Greek and Latin equivalents. Also there a lot of people who speak English in India (albeit their own uniquely charming version of it).

  • The commenter who has the DC nom de plume, I am assuming you are a chiropractor. It appears like you are at least trying to be somewhat responsible concerning the myriad of problems the chiropractic establishment has with making false and outrageous claims. One thing I have long been suspicious of is the claim by chiropractors that neck adjustments are safe, and that injuries are 1 in a million or something to that effect. My questions is, how often does the emergency physician ask the person with the vertebral artery dissection if they have visited a chiropractor??
    I believe that there are far more people that have suffered a vertebral dissection than what chiropractors claim. Why in the world anyone would allow a person to crack their neck is beyond me. Even when I was ignorant about Chiropractic, I never let a chiropractor adjust my neck. It seemed scary as shit. I am glad I trusted my instinct.

    • Kate: My questions is, how often does the emergency physician ask the person with the vertebral artery dissection if they have visited a chiropractor??

      I don’t know the answer but I don’t think that’s relevant information when trying to establish causation.

      • How would you establish causation?

      • Kate wrote “My questions is, how often does the emergency physician ask the person with the vertebral artery dissection if they have visited a chiropractor??”

        ‘DC’ replied “I don’t know the answer but I don’t think that’s relevant information when trying to establish causation.”

        Would that be “relevant information” if there existed a chiropractic AE reporting system?

        If there existed a chiropractic AE reporting system then each vertebral artery dissection occurring after a visit to a chiropractor must be entered into the chiropractic AE reporting system. Who would be responsible for collecting and entering this relevant information?

        • Pete: If there existed a chiropractic AE reporting system then each vertebral artery dissection occurring after a visit to a chiropractor must be entered into the chiropractic AE reporting system.

          Wrong (again). It would record a VAD being diagnosed after a visit to a chiropractor.

          • Oh, so tell us ‘DC’, what exactly is an AE?

            And, if there existed a chiropractic AE reporting system, what would it record and report, exactly?

          • My apologies, I failed to detect the usual pathetic attempt at deflation by ‘DC’.

            ‘DC’ wrote “Wrong (again). It would record a VAD being diagnosed after a visit to a chiropractor.”

            Great! Now we know what would be recorded.

            How about answering the who questions, highlighted in the following reiteration:

            Kate wrote “My questions is, how often does the emergency physician ask the person with the vertebral artery dissection if they have visited a chiropractor??”

            ‘DC’ replied “I don’t know the answer but I don’t think that’s relevant information when trying to establish causation.”

            Pete wrote “Would that be ‘relevant information‘ if there existed a chiropractic AE reporting system?

            If there existed a chiropractic AE reporting system then each vertebral artery dissection occurring after a visit to a chiropractor must be entered into the chiropractic AE reporting system. Who would be responsible for collecting and entering this relevant information?”

            Obviously, a chiropractic AE reporting system doesn’t update itself; I wouldn’t expect a patient to update it (especially if the VAD resulted in death); the chiropractor wouldn’t be aware of a VAD being diagnosed UNLESS the emergency physician asked the person with the VAD if they have visited a chiropractor.

            If one is genuinely “trying to establish causation” then all information either is relevant, or it may become relevant, as the investigation progresses.

          • This may answer some of your questions at least from the medical side.

            “Systematic collection of all AEs provides a unique resource of consistent and contemporaneously collected comparison information that can be used at a later date to conduct epidemiologic assessments.”

            https://www.ncbi.nlm.nih.gov/books/NBK208615/

          • @ ‘DC’

            I am quite familiar with AE recording and reporting systems, what they are used for, and what they can and they cannot be used for, thank you. We have seen many comments on this website exemplifying their misuse by anti-vaxxers.

            I was hoping that you would explain their intended purpose and usage from your perspective, in your own words, because in your comments over the years you have expressed a desire to have a chiropractic AE recording and reporting system, for which I applaud you.

  • Pete: I am quite familiar with AE recording and reporting systems, what they are used for, and what they can and they cannot be used for,

    I have my doubts based upon this statement:

    “ If there existed a chiropractic AE reporting system then each vertebral artery dissection occurring after a visit to a chiropractor must be entered into the chiropractic AE reporting system.”

    Regardless, the quote I provided is sufficient for the intended purpose and usage of an AERS.

    • You duck like a quack, as usual. You can’t even use the Reply button 😂

      ‘DC’ wrote “Regardless, the quote I provided is sufficient for the intended purpose and usage of an AERS.”

      Your quote was “Systematic collection of all AEs provides a unique resource of consistent and contemporaneously collected comparison information that can be used at a later date to conduct epidemiologic assessments.”
      https://www.ncbi.nlm.nih.gov/books/NBK208615/

      Yes, but you have not answered my very simple question, which boils down to: Who would be responsible for the “Systematic collection of all AEs” for a chiropractic AERS?

      smoke and mirrors: the obscuring or embellishing of the truth of a situation with misleading or irrelevant information.
      — Oxford Languages

      • It will need to be a multidisciplinary team. If I need to take you by the hand and walk you thru it I will consider it.

        • ‘DC’ wrote “It will need to be a multidisciplinary team. If I need to take you by the hand and walk you thru it I will consider it.”

          ‘DC’ needs to take someone by the hand and walk them thru it because there still isn’t a chiropractic AERS. There never will be, because it’s all smoke and mirrors.

          To summarise:
          Kate wrote “My questions is, how often does the emergency physician ask the person with the vertebral artery dissection if they have visited a chiropractor??”

          ‘DC’ replied “I don’t know the answer but I don’t think that’s relevant information when trying to establish causation.”

          Pete wrote “If one is genuinely “trying to establish causation” then all information either is relevant, or it may become relevant, as the investigation progresses.”

          For those who are not genuinely “trying to establish causation” then it’s duck like a quack, it’s all smoke and mirrors. Six years of petulance.

          Put up or shut up: If you say someone should put up or shut up, you mean that they should either take action in order to do what they have been talking about, or stop talking about it.
          — Cambridge Dictionary

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