“Chronic low-back pain -
The single most expensive cause of pain and disability in working age adults”
The Spine Journal (2008) 8 (1):1-278
In the journal of the North American Spine Society there is a comprehensive review of ‘Chronic low-back pain’ and evidence for and against the numerous methods of managing patients with this condition.
Currently there are several influential clinical guidelines about this sort of stuff such as the Ontario Workers’ Safety and Insurance Board of Canada’s guidelines and in Europe the European Back Pain Guidelines which are all available online. In the UK the British Medical Research Council sponsored the BEAM Trial which has shown “convincingly that both manipulation alone and manipulation followed by exercise provide cost-effective additions to best care (for low-back pain patients) in general practice”
However this review is different with each form of management being tackled by another health care expert, so the review of manipulation under anaesthesia is done by chiropractors. The editors are critical of what they call a supermarket response to low-back care where patients are offered a range of untested treatments (with over 200 different forms of care available in the USA) and even those with the most evidence, such as chiropractic still have questions that must be asked. Every year there appear to be more treatments available with strong and commercial advocates but with generally limited scientific evidence.
This does present a problem because the gold standard would be high-quality randomized controlled trails (RCT) but the cost of conducting these is, as the report states, “beyond the realm of possibility”. So, we are left using evidence-informed care rather than evidence-based care. Though there are more randomized controlled trails examining chiropractic care than any other chronic low-back intervention.
The best available evidence today is not materially different from the recommendations in the Practice Guidelines on Acute Low-Back Pain in Adults published in the US by the Agency for Health Care Policy and Research (AHCPR) in 1994. The reviews support the findings of this work and add that “a reasonable approach to CLBP would include education strategies, exercise, simple analgesics, a brief course of manual therapy in the form of spinal manipulation, mobilization or massage, and possibly acupuncture”. And, tellingly, that these treatments should be preferred to more complex or invasive approaches.
These reviews are available, free, on www.science-direct.com/science/journal/15299430 and click on Vol.8 Issue 1.
The one covering chiropractic is really useful. It has a history of chiropractic, a description of the examination and treatments in practice today and is seen as being an excellent authority for all concerning chiropractic especially referring medical doctors. A couple of telling lines:
“Spinal manipulative therapy (SMT) or spinal mobilization is superior to usual medical care for patient improvement”
“For pain reduction “SMT with strengthening exercises is similar to prescription NSAIDs with exercise in both the short-term and long-term”
High-dose SMT is superior to low-dose SMT "for pain reduction in the short term”
And from the 9 trials where there were patients with chronic and acute low-back pain the evidence was good that:
SMT is superior to usual medical care alone
SMT/MOB is superior to physical therapy and to home exercise in the long-term
Now this is a change from the old approach where it was recognised that chiropractic was effective in treating acute low-back pain as this now demonstrates that chiropractic is effective in treating chronic as well as acute low-back pain.
One of the key advantages of SMT over drug and surgery lies in respect to harm. The review noted that the only likely side effects of SMT are minor, temporary and typically do not interfere with activities of daily living – a major advantage over spinal surgery I'd argue.
