Two major studies on chiropractic for low back pain have been published already in 2018. One study was published in the Spine Journal and the other published in JAMA. These studies are significant because of their findings and their research design. The results from the pragmatic trial (Goertz et al) indicate that chiropractic care, when added to usual medical care resulted in moderate short-term treatment benefits in both low back pain (LBP) intensity and disability, demonstrated a low risk of harm, and led to high patient satisfaction and perceived improvement in active-duty military personnel. The results from the other study (Coulter et al) showed that there is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Below, is a summary of the two studies.
Study # 1: Goertz CM, Long CR, Vining RD, Pohlman KA, Walter J, Coulter I. Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial. JAMA Network Open. 2018;1(1):e180105.
Active duty military personnel aged 18-50 with LBP of any duration were allocated in equal proportions to one of two groups: 1) usual medical care (UMC) with chiropractic care or; 2) UMC alone. The trial lasted for 6 weeks and subjects were stratified by site (Walter Reed National Military Medical Center, Naval Medical Center San Diego and Naval Hospital Pensacola).
In this pragmatic trial, UMC in both groups included any care recommended or prescribed by nonchiropractic military clinicians to treat LBP. Options included self-management advice pharmacologic pain management, physical therapy, or pain clinic referral. Participants in the UMC alone group were asked to avoid receiving chiropractic care for the active care period unless directed by their clinician. In both groups, frequency of treatment visits and procedures were determined individually based on the participant’s diagnosis or condition, response to care, and scheduling availability.
Participants in the UMC with chiropractic care group had UMC in addition to as many as 12 chiropractic visits during the active care period. The primary chiropractic procedure was spinal manipulative therapy in the low back and adjacent regions. Treatment decisions regarding
manipulation type, location, and direction were based on patient diagnoses. Other factors included patient preference, prior response to care, paraspinal muscle hypertonicity, spinal joint hypomobility, and imaging findings. Additional therapeutic procedures may have included rehabilitative exercise and other common therapies applied by chiropractors.
Outcome measures were collected at baseline and 2, 4, 6, and 12 weeks after baseline. These included numerical pain ratings, Roland Morris Disability Questionnaire, Global Improvement Ratings, medication use, satisfaction with care.
Results/Key Findings:
- There were 375 patients in each group
- Adjusted mean differences between groups overall were consistently in favor of UMC with chiropractic care compared with UMC alone for the primary outcome variables of LBP intensity and disability at all 3 sites at 6 weeks
- Overall at weeks 6 and 12, participants receiving UMC with chiropractic care, compared with UMC alone, reported significantly lower mean worst LBP intensity within the past 24 hours and symptom bothersomeness
- Participants receiving UMC with chiropractic care had significantly better global perceived improvement at 6 weeks at all sites
- Those receiving UMC with chiropractic care had significantly greater mean satisfaction with care at 6 weeks at all sites
- Those receiving UMC with chiropractic care self-reported significantly less pain medication use than those receiving UMC alone at week 6 (but not at any individual sites)
Study # 2: Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Suttorp Booth M, Herman PM. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018 May;18(5):866-879.
This study was a systematic literature review and meta-analysis. The purpose of this review was to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for the treatment of chronic low back pain. The outcome variables studied were measures self-reported pain, function, health related quality of life, and adverse events. The authors included randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network criteria.
Results/Key Findings:
- 51 trials were included in the systematic review – 9 trials provided sufficient data and were judged similar enough to be pooled for meta-analysis
- The standardized mean difference (SMD) for a reduction of pain was significant after treatment
- The reduction in disability was also significantly improved for manipulation or mobilization compared with other active therapies
- Further analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy
- Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain but not disability
- Bottom line: There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe.
