Ladies and Gentleman,
Although this is an old thread, I felt that as a practicing Doctor of Chiropractic that a response to this “selective literature review” is necessary.
After reading literally hundreds of these studies over the years, I becomes apparent that many are biased and not randomized, double-blinded, controlled studies. The most negative tend to be cherry picked reviews of poorly conceived trials and bear no merit.
To our credit as chiropractors there are a number of excellent, peer-reviewed, independent clinical trials conducted by respected researchers that completely refute the findings of this particular study and present compelling evidence of the efficacy of chiropractic care contrary to what this review purports.
I will summarize a few of these landmark studies and provide article citations:
1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (U.S. Department of Health and Human Services) -1994.
The following conclusions were made in this landmark study:
* Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
* Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.
Other interesting finds included:
# The risk of serious complications from lumbar spinal manipulation is rare;
# There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
# The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.
2. The Appropriateness of Spinal Manipulation for Lower Back Pain. Shekelle PG, et al. RAND Corporation, Santa Monica, California - 1992.
Findings:
This study, conducted by the prestigious RAND Corporation, marks the first time representatives of the U.S. medical community have gone on record stating that chiropractic is an appropriate treatment for certain low back pain conditions. A second, all-chiropractic panel's ratings show agreement with the multidisciplinary panel that spinal manipulation is appropriate for specific kinds of low back pain.
3. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain. Pran Manga and Associates. University of Ottawa, Canada - 1993.
The Canadian Government report concluded with the following findings:
• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by nonchiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;
• In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:
o the effectiveness and cost effectiveness of chiropractic management of low back pain
o the untested, questionable or harmful nature of many current medical therapies
o the economic efficiency of chiropractic care for low back pain compared with medical care
o the safety of chiropractic care
o the higher satisfaction levels expressed by patients of chiropractors.
Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.
(* it is no coincidence that in this decade there was one case of vertebral artery dissection and subsequent mortality attributed to chiropractic manipulation in Canada that sparked a huge battle between the medical establishment and the chiropractic profession. One of their suggestions was the inclusion of chiropractic privileges in Canadian hospitals. Obviously this did not sit well with the medical establishment and the fight to destroy the image of chiropractic began. It mirrors similar litigation in Wilk, et. Al vs. the AMA in this country where the chiropractic profession prevailed in proving that the AMA conspired to contain, control and eliminate the practice of chiropractic.
In the ensuing melee Dr. Scott Haldeman, a medical physician AND a chiropractor investigated and his findings were thus:
http://www.cmaj.ca/cgi/content/full/165/7/905
There are over 4500 licensed chiropractors in Canada. The likelihood that a chiropractor will be made aware of an arterial dissection following cervical manipulation is approximately 1:8.06 million office visits, 1:5.85 million cervical manipulations, 1:1430 chiropractic practice years and 1:48 chiropractic practice careers. This is significantly less than the estimates of 1:500 000–1 million cervical manipulations calculated from surveys of neurologists.7,8,9 These data also confirm the conclusions of a recent review of the literature in which patients at risk for this complication could not be identified.10
4. Chiropractic Evaluation Study Task III Report of the Relevant Literature. MRI Project No. 8533-D. MacDonald MJ, Morton L. For Department of Defense, OCHAMPUS, Aurora, Colorado - 1986.
This study examined clinical trials published in the professional literature between 1930 and 1981.
The researchers concluded that:
* manual therapy was superior to placebos,
* there was greater mobility following manipulation,
* the duration of treatment was shorter for the manipulated groups,
* there was improved lateral flexion and rotation after manipulation,
* the numerous case studies throughout the literature report the satisfaction of chiropractic patients with the outcome of treatments.
As you can see there is another side to this coin and valid research to support the wide inclusion of chiropractic care as portal-of-entry providers specifically for low back pain. There are several more progressive hospitals in this country where DC’s enjoy privilege and I hope this trend will continue. Until then we can only ‘fight the good fight’, produce more clinical trails to present the overwhelming truth about the efficacy and safety of manipulation and raise our heads above the unfounded that bias we as a profession experience on a daily basis from the allopathic profession.
In closing I have a response to the authors comment about the potential risk to benefit of manipulation. Of course there are minimal risks of minor insult involved in the practice of chiropractic and there are rare occurrences of more severe outcomes in the literature. We do not deny that. If there is a risk of grave iatrogenic injury from manipulation as delivered by Doctors of Chiropractic, why is my 1 million/ 3 million malpractice insurance policy premium renewed at a current rate of about $1,200 per annum?
Could the answer to the outcome of this literature review be professional economics and territorial perseverance?
Lastly I thank David for this keen observation:
[quote=David Smith;9174]
On a personal level relating to back injury. An extremely painful back injury which the NHS could do nothing for, over several months, was resolved in one treatment by a private practitioner using vigorous manipulation.
This is another fault with so called evidence based treatment it makes conclusions about expected outcomes for large groups but not individuals. This may be useful as a guide for the financial managment of clinical procedures but not as a guide to whatis best for the presenting patient.
This will get some "backs" up
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