Evidence for chiropractic
There is a range of evidence to indicate that chiropractic care is safe and effective. This evidence includes:
This MRC-funded study estimated the effect of adding exercise classes,spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to “best care” in general practice for patients consulting with back pain. All groups improved over time. Exercise improved disability more than “best care” at three months. For manipulation there was an additional improvement at three month sand at 12 months. For manipulation followed by exercise there was an additional improvement at three months and at 12 months. No significant differences in outcome occurred between manipulation in NHS premises and in private premises. No serious adverse events occurred.
Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.
Summary of recommendations for treatment of acute non-specific low back pain:
- Give adequate information and reassure the patient
- Do not prescribe bed rest as a treatment
- Advise patients to stay active and continue normal daily activities including work if possible
- Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs
- Consider adding a short course of muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
- Consider (referral for) spinal manipulation for patients who are failing to return to normal activities
- Multidisciplinary treatment programmes in occupational settings may be an option for workers with sub-acute low back pain and sick leave for more than 4 – 8 weeks
Manipulation/mobilisation – Summary of the evidence:
- There is moderate evidence that manipulation is superior to sham manipulation for improving short-term pain and function in chronic low back pain (CLBP)
- There is strong evidence that manipulation and GP care/analgesics are similarly effective in the treatment of CLBP
- There is moderate evidence that spinal manipulation in addition to GP care is more effective than GP care alone in the treatment of CLBP
- There is moderate evidence that spinal manipulation is no less and no more effective than physiotherapy/exercise therapy in the treatment of CLBP
- There is moderate evidence that spinal manipulation is no less and no more effective than back-schools in the treatment of CLBP
Recommendation: Consider a short course of spinal manipulation/mobilisation as a treatment option for CLBP.
This review, by Bronfort et al, was published in the journal Chiropractic & Osteopathy in 2010. Commentaries by Professor Scott Haldeman and Professor Martin Underwood accompany the report. In summary, the report demonstrates robust randomised controlled trial (RCT) evidence that the care offered by chiropractors is effective for a wide range of conditions including back pain, neck pain, pain associated with hip and knee osteoarthritis and some types of headache.
In 2011, the RCC commissioned an independent review of manual therapy evidence by Warwick University (‘the Warwick Review’) in order to update a similar review presented in the UK evidence report (see 6 above) and to extend the range of evidence considered to include non-randomised studies. In addition to confirming the findings of the UK evidence report, ratings changed in a positive direction from inconclusive to moderate (positive) evidence ratings in three cases: manipulation/mobilisation [with exercise] for rotator cuff disorder, spinal mobilisation for cervicogenic headache and mobilisation for miscellaneous headache. New moderate (positive) evidence was identified for soft tissue shoulder disorders not reported in the UK evidence report. In addition, moderate (positive) evidence was identified for the use of massage to support cancer care.
NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Its evidence-based guidelines on the management of over 16s with low back pain, with or without sciatica, includes the following recommendation:
Consider manual therapy (spinal manipulation, mobilisation or soft tissuetechniques such as massage) for managing low back pain with or withoutsciatica, but only as part of a treatment package including exercise, with or without psychological therapy.
The guideline explains that mobilisation and soft tissue techniques are performed by a wide variety of practitioners; whereas spinal manipulation is usually performed by chiropractors or osteopaths, and by doctors or physiotherapists who have undergone additional training in spinal manipulation. Manual therapists often combine a range of techniques in their approach and may also include exercise interventions and advice about self-management.