Back Pain Research

Effectiveness of Chiropractic for Back Pain


At the beginning of his book, The Back Pain Revolution, the British orthopedic surgeon Gordon Waddell wrote: Back pain is a 20th century medical disaster.Waddel G. The Back Pain Revolution. Churchill Livingstone, Edinburgh, 1998

Most of the chiropractic research that has been done to date has been documenting the success chiropractic has had in helping people with back pain. There is now a massive amount of research that has been done into back pain and this research has been summarized in Government Guidelines from many countries including Australia.

Back Pain Guidelines from Denmark (1999)

Manual Therapy is generally recommended for patients with acute pain and functional; limitations, for exacerbations, as one element of a broader strategy for chronic low back pain problems, as an element of conservative care for many people with nerve root irritation/disc problems Therapies not recommended methods are, corsets, traction and ultrasound/laser/short wave therapy. If the 10,000 patients treated annually for disc herniation received good conservative care approx 7,500 would not require surgery or hospitalization. Manniche C et al. Low-back Pain: Frequency Management and Prevention from an HAD Perspective. Danish Health Technology Assessment 1999; 1(1)

American Back Pain Guidelines (AHCPR)

Two treatment options where recommended for patients with non-specific back pain, spinal manipulation and non-prescription medications. Bigos S, Bowyer O, Braen G et al. (1994) Acute Low Back Pain in Adults. Clinical Practice Guidelines No14. AHCPR Publication No. 950642. Rockville, MD; Agency for Health Care Policy and Research, Public health Service, U.S. Department of Health and Human Services.

UK Clinical Guidelines for the Management of Acute Low Back Pain

A professional association sponsored these guidelines for general medical practitioners. They reviewed and accepted the findings (US Guidelines) and had this to say: consider manipulative treatment within the first six weeks They recommended manipulative treatment because of its effectiveness in terms of pain relief, better activity levels and higher patient satisfaction. The also said, …..the risks of manipulation for low back pain are very low provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner. This review also emphasized the importance of early activation in the management of LBP. Waddell G, Feder G et al (1996) Low Back Pain Evidence Review, London: Royal College of General Practitioners

Effectiveness and Cost Effectiveness of Chiropractic Care for LBP: The Manga Report

Faced with out of control health care costs for which low back pain was a major contributor the Ontario government commissioned health economists to provide a report on, The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain.

This report became know as the Manga Report. They had this to say: In our view, the constellation of evidence of: (a) the effectiveness and cost effectiveness of chiropractic management of low back pain. (b) the untested, questionable or harmful nature of many current medical therapies. (c) the economic efficiency of chiropractic care of low-back pain compared with medical care. (d) the safety of chiropractic care. (e) the higher satisfaction levels expressed by patients of chiropractors, together offers an overwhelming case in favour of much greater use of chiropractic services in the management of low-back pain. There should be a shift in policy to encourage and prefer chiropractic services for most patients with low-back pain … a very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the worker’s compensation system. Manga P, Angus D et al (1993) The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain, Pran Manga and Associates, University of Ottawa, Canada The cost of chiropractic care compared to medical care for similar conditions in the US.

The Cost of Chiropractic Compared to Medical

Researchers compared health insurance information between chiropractic and medical patients (N=395,641) and concluded: “Patients receiving chiropractic care experienced significantly lower health care costs on the order of $1000 each over the 2-year period than those who received only medical care Stano M (1993) A Comparison of Health Care Costs for Chiropractic and Medical Patients JMPT 16:291/299

The Second Manga Report Commissioned by the Ontario Chiropractic Association in 1998.

There is now considerable empirical support for the cost-effectiveness and the safety of chiropractic management of musculoskeletal disorders, so much so that doubling the proportion of the Ontario public who visit chiropractors for these problems from 10% to 20% will lead to direct annual savings of $348 million to the Ontario health care system and indirect savings of $1.85 billion per year. The report recommended achieving this by reducing the co-payment expected from patients by increasing the government contribution from $10 to $20 per consultation. The average consultation cost was $30.Manga P Angus D (1998) Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs, Attaining Better Health Outcomes and Improving the Publics Access to Cost-Effective Health Services, University of Ottawa, Ontario, Canada

Chronic Back Pain

The strongest evidence is on acute pain patients but a 1997 study supported the use of chiropractic for chronic low back pain and said… (There is now) strong evidence of the effectiveness of manipulation for patients with chronic low–back pain Van Tulder MW, Koes BW, Bouter LM Conservative Treatment of Acute and Chronic Nonspecific Low-Back Pain, Spine 1997;22:2128-2156.

Low Back Pain Information Articles

Lower Back Trauma

R. C. Schafer Rehabilitation Monograph Series ~ Chapter 24

By Richard C. Schafer, D.C., FICC

Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet. Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.

Management of Chronic Low Back Pain in Active Individuals

Curr Sports Med Rep 2010 (Jan); 9 (1): 60–66

The best available evidence currently suggests that in the absence of serious spinal pathology, nonspinal causes, or progressive or severe neurologic deficits, the management of chronic LBP should focus on patient education, self-care, common analgesics, and back exercises. Short-term pain relief may be obtained from spinal manipulative therapy or acupuncture. For patients with psychological comorbidities, adjunctive analgesics, behavioral therapy, or multidisciplinary rehabilitation also may be appropriate. Given the importance of active participation in recovery, patient preference should be sought to help select from among the recommended treatment options.

Chiropractic Management of Low Back Disorders: Report From a Consensus Process

J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651–658

A broad-based panel of experienced chiropractors was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for patients with low back pain, based on both the scientific evidence and their clinical experience.

J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659–674

As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Spinal Manipulation for Low-Back Pain

National Center for Complementary and Alternative Medicine (NCCAM)

Low-back pain is a common condition that can be difficult to treat. Spinal manipulationThe application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems, including chiropractic medicine, massage, and naturopathy. is among the treatment options used by people with low-back pain in attempts to relieve pain and improve functioning. It is performed by chiropractors and other health care professionals such as physical therapists, osteopaths, and some conventional medical doctors. This fact sheet summarizes the current scientific knowledge about the effects of spinal manipulation on low-back pain.

A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-back Pain in a National Health Service Outpatient Clinic

J Alternative and Complementary Medicine 2008 (Jun); 14 (5): 465–473

At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group than for the pain-clinic group. Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group. This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a sub-population of patients with chronic low-back pain (CLBP)

Prospective Case Series on the Effects of Lumbosacral Manipulation on Dysmenorrhea

J Manipulative Physiol Ther 2008 (Mar); 31 (3): 237–246 ~ FULL TEXT

This prospective case series suggests the possibility that menstrual pain associated with primary dysmenorrhea may be alleviated by treating motion segment restrictions of the lumbosacral spine with a drop table technique. The research team needs to conduct a well-designed feasibility trial to further evaluate the effectiveness of this specific spinal manipulative technique for primary dysmenorrhea.

Diagnosis and Treatment of Low Back Pain

Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491 ~ FULL TEXT

You will enjoy these recommendations from the Oct 2, 2007 issue of theAnnals of Internal Medicine. Their ONLY recommendation for active treatment of acute low back pain is spinal adjusting (manipulation)

Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline

Annals of Internal Medicine 2007 (Oct 2); 147 (7): 492–504 ~ FULL TEXT

Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.

Pathophysiological Model for Chronic Low Back Pain Integrating Connective Tissue and Nervous System Mechanisms

Medical Hypotheses 2007 (Jan); 68 (1): 74–80 ~ FULL TEXT

Although chronic low back pain (cLBP) is increasingly recognized as a complex syndrome with multifactorial etiology, the pathogenic mechanisms leading to the development of chronic pain in this condition remain poorly understood. We hypothesize that pain-related fear leads to a cycle of decreased movement, connective tissue remodeling, inflammation, nervous system sensitization and further decreased mobility. In addition to providing a new, testable framework for future mechanistic studies of cLBP, the integration of connective tissue and nervous system plasticity into the model will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise). You will also enjoy Dr. Dan Murphy’s Key Points.

Is Comorbidity in Adolescence a Predictor for Adult Low Back Pain? A Prospective Study of a Young Population

BMC Musculoskelet Disord 2006 (Mar 16); 7: 29 ~ FULL TEXT

Your chiropractic care may be working out “kinks” in your lower back that have been around a lot longer than you realize. This new study of 10,000 Danish residents shows a link between adolescent and adult low back pain (LBP). Researchers studied twins born between 1972 and 1982 by sending out questionnaires in 1994 and again in 2002. The outcomes showed that a high percentage of those who had LBP in 1994 still suffered from LBP in 2002. They also found that those with persistent LBP were 4.5 times more likely than the average person to have future LBP episodes!

Hormonal and Reproductive Factors Are Associated with Chronic Low Back Pain and Chronic Upper Extremity Pain in Women — The MORGEN Study

Spine 2006 (Jun 1); 31 (13): 1496–1502

Although LBP is suggested to be linked to hormonal and reproductive factors in women, results from previous studies are inconclusive. For this reason, a cross-sectional study of 11,428 Dutch women aged 20-59 years was accomplished. Multivariate logistic regression models were used to examine associations between hormonal and reproductive factors (independent variables) and, respectively, chronic LBP, chronic UEP (upper extremity pain) and combined chronic LBP/UEP. Past pregnancy, young maternal age at first birth, duration of oral contraceptive use, and use of estrogens during menopause were associated with chronic LBP, while young age at menarche was associated with chronic UEP. Irregular or prolonged menstruation and hysterectomy were associated both with chronic LBP and chronic UEP. No positive associations were found for current pregnancy and number of children.

Cost Effectiveness of Physical Treatments for Back Pain in Primary Care

British Medical Journal 2004 (Dec 11); 329 (7479): 1381 ~ FULL TEXT

We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with “usual care” in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain. [1] Read both British Medical Journal articles about the UK BEAM Trial now.

The British Medical Research Council (MRC) Trial Finds Adding Spinal Manipulation and Exercise to GP Care Provides Relief for Back Pain

The British Medical Research Council (MRC)

A Medical Research Council (MRC) trial to assess the effectiveness of adding different treatments to “best care” in general practice for patients with lower back pain has found that spinal manipulation, in the form of chiropractic, osteopathy, or manipulative physiotherapy, followed by a programme of exercise, provides significant relief of symptoms and improvements in general health. The results of the trial are published online today, Friday 19 November, in the British Medical Journal.

Post Partum and Beyond: Managing Back Pain in Women

Dr. Diane Benizzi DiMarco ~ FULL TEXT

The post partum patient retains a higher risk for potential injury as compared to the patient who has not endured pregnancy or has not been pregnant for an extended period of time. Fertilization propels the release of estrogen, progesterone and relaxin, hormones essential to the growth and development of the embryo and fetus. These hormones that are essential to the pregnancy cause global relaxation to the ligaments and muscles in the female pregnant patient. A conglomerate of anatomical changes created by the global laxity in muscles and ligaments compromises the stability of the spine.

Chiropractic Spinal Manipulation for Low Back Pain of Pregnancy: A Retrospective Case Series

J Midwifery Womens Health 2006 (Jan); 51 (1): e7–10

Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0-13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1-5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.

Effects of a Managed Chiropractic Benefit on the Use of Specific Diagnostic and Therapeutic Procedures in the Treatment of Low Back and Neck Pain

J Manipulative Physiol Ther 2005 (Oct); 28 (8): 564–569

For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Palmer Research Center Conducting Several Clinical Trials on Back Pain

The Palmer Center for Chiropractic Research is currently studying back pain through several groundbreaking clinical trials at its research clinic. About 500 people from throughout the Quad-City region who suffer from back pain are being recruited to participate in two separate clinical trials, expected to last up to 18 months. Both studies are funded through federal grants totaling $2.4 million.

A Randomized Clinical Trial Comparing Chiropractic Adjustments to Muscle Relaxants for Subacute Low Back Pain

J Manipulative Physiol Ther 2004 (Jul); 27 (6): 388–398

Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing Global Impression of Severity Scale (GIS).

J Manipulative Physiol Ther 2004 (Oct); 27 (8): 509–514

This study demonstrated two important points: (1) Chiropractic is effective for chronic low back pain (LBP), and (2) that ongoing supportive care can reduce disability levels, as measured by the Oswestry Low Back Pain Disability questionnaire.

Dose-response for Chiropractic Care of Chronic Low Back Pain

Spine J 2004 (Sep); 4 (5): 574–583

There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.

A Practice-Based Study of Patients With Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-Week to 48-Month Follow-up

J Manipulative Physiol Ther 2004 (Mar); 27 (3): 160–169

This study found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients’ first year of symptoms.

Safety of Spinal Manipulation in the Treatment of Lumbar Disk Herniations: A Systematic Review and Risk Assessment

J Manipulative Physiol Ther 2004 (Mar); 27 (3): 197–210

An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million. The apparent safety of spinal manipulation, especially when compared with other “medically accepted” treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.

FCER Critiques 2 LBP Articles in Annals of Internal Medicine

J Manipulative Physiol Ther 2004 (Mar); 27 (3): 197–210

The June 3, 2003 issue of Annals of Internal Medicine featured two studies which questioned the clinical and cost-effectiveness of spinal manipulation. The first is titled Spinal Manipulative Therapy for Low Back Pain: A Meta-Analysis of Effectiveness Relative to Other Therapies. The second study is titled A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain. After careful review of these articles, Anthony L. Rosner, Ph.D., Director of Research for the Foundation for Chiropractic Education and Research (FCER), authored critical responses on behalf of the chiropractic profession. In addition to sharing his understanding of what constitutes research of clinical utility, Dr. Rosner has been able to apply his knowledge of the better research offering significant support for spinalmanipulation, helping the chiropractic profession and the public recognize potentially flawed conclusions.

Low Back Pain: What Is The Long-term Course? A Review of Studies of General Patient Populations

Eur Spine J 2003 (Apr); 12 (2): 149–165

The results of the review showed that the reported proportion of patients who still experienced pain after 12 months was 62% on average (range 42-73%)…the percentage who experienced relapses of pain was 60% (range 44-78%), and the percentage who had relapses of work absence was 33% (range 26-37%)…The results of the review show that, despite the methodological variations and the lack of comparable definitions, the overall picture is that LBP does not resolve itself when ignored. Future research should include subgroup analyses and strive for a consensus regarding the precise definitions of LBP.

Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up

SPINE Journal 2003 (Mar 15); 28 (6): 525–531

Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. Immediately after the 2–month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work (P < 0.01), a relative difference that was maintained throughout the follow-up period.

The Not-So-Hidden Costs of Back Pain

SPINE Journal 2003 (Mar 15); 28 (6): 525–531

Some “experts”–ironically, those outside the chiropractic profession–have attempted to describe back pain as a harmless, self-limiting condition that requires only rest and time for resolution, despite evidence to the contrary. If that’s the case, how do these experts explain the results of a study published in the Jan. 1, 2004 issue of Spine?

A Prospective Study of Back Belts for Prevention of Back Pain and Injury

JAMA 2000 (Dec 6); 284 (21): 2727–2732 ~ FULL TEXT

In the largest prospective cohort study of back belt use, adjusted for multiple individual risk factors, neither frequent back belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain.


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