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:
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Give adequate information and reassure the patient
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Do not prescribe bed rest as a treatment
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Advise patients to stay active and continue normal daily activities including work if possible
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Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs
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Consider adding a short course of muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
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Consider (referral for) spinal manipulation for patients who are failing to return to normal activities
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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
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Manipulation/mobilisation – Summary of the evidence:
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There is moderate evidence that manipulation is superior to sham manipulation for improving short-term pain and function in chronic low back pain (CLBP)
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There is strong evidence that manipulation and GP care/analgesics are similarly effective in the treatment of CLBP
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There is moderate evidence that spinal manipulation in addition to GP care is more effective than GP care alone in the treatment of CLBP
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There is moderate evidence that spinal manipulation is no less and no more effective than physiotherapy/exercise therapy in the treatment of CLBP
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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.
5. Effectiveness of Manual Therapies – The UK Evidence Report
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.
6. Review of Manual Therapy Evidence
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.
7. Low back pain and sciatica in over 16s: assessment and management
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:
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Consider manual therapy (spinal manipulation, mobilisation or soft tissue
techniques such as massage) for managing low back pain with or without
sciatica, 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.
Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain (2021)
Carlos Gevers-Montoro, 1 , 2 , 3 Benjamin Provencher, 1 , 2 Martin Descarreaux, 1 , 4 Arantxa Ortega de Mues, 3 and Mathieu Piché 1 , 2 , * (2021)
Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labelled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists.
Pain affecting the spine not only has a significant impact on the individual's health and functional ability but also carries considerable costs to the economy and society at large, mostly derived from treatment expenses and work absenteeism. Back and neck pain combined are the number one cause of years lived with disability and the fourth leading cause of years lost to disability globally. At any time, over 11% of the world population suffers from pain in the spine. The prevalence has been increasing over the past decade, particularly among working-age females in high-income countries. Chronic cases where pain lasts for more than 3 months significantly contribute to the increasing burden of spine pain. Likewise, pain affecting the spine affects more than 50% of patients with chronic pain, a condition whose estimated direct and indirect costs are hundreds of billions of dollars. The frequent use of inappropriate and invasive clinical interventions has been suggested as one of the main reasons for this increasing burden.
For the management of LBP, most guidelines recommend SMT, with some discrepancies regarding the circumstances in which it should be administered. For example, the United Kingdom's National Institute for Health and Care Excellence (NICE) guidelines make it imperative that SMT be offered alongside exercise therapy for LBP irrespective of the stage.
For the management of neck pain, recent guidelines recommend the use of SMT based mostly on consensus. In cases of recent onset (acute and subacute) neck pain, SMT is recommended before oral analgesics, although not muscle relaxants. Overall, clinical guidelines currently recommend SMT for the management of neck pain and cervical radiculopathy in combination with other approaches, particularly exercise and patient education.
Evidence-Based Practice and Chiropractic Care (2012)
Ron LeFebvre, MA, DC,1 David Peterson, DC,1 and Mitchell Haas, MA, DC1 (2012)
Evidence-based practice has had a growing impact on chiropractic education and the delivery of chiropractic care.
Over the past 10 to 15 years, evidence-based practice has had increasing influence on the chiropractic profession. A number of events and trends have converged to account for this phenomenon. Starting in the 1990s, a growing body of clinical research has offered support for the application of manual therapy for various musculoskeletal conditions, particularly low back pain. Consequently, manipulation has been included as an effective care option in a number of national and international guidelines on low back pain. Additional research in related fields such as orthopaedic assessment of the spine and extremities, exercise therapy, and biomechanics of the adult spine has also affected the profession. As outcomes research has steadily increased, it has become more common for individual chiropractors to use evidence-based outcome measures.
For basic musculoskeletal injuries and postural syndromes, chiropractors use 4 broad categories of therapeutic interventions: (a) joint manipulation and mobilization, (b) soft tissue manipulation and massage, (c) exercise and physical rehabilitation prescription, and (d) home care and activity modification advice. In addition, nutritional and dietary counseling, physical therapy modalities (eg, heat, ice, ultrasound, electromodalities), and taping/bracing are also used as adjunct procedures.
The goal of evidence-based practice is to incorporate the best-quality evidence into the clinical decision-making process to provide timely, appropriate care. The results of randomized controlled trials (RCTs) on manual therapies have been published in more than 200 peer-reviewed articles, and many of these have been synthesized in systematic reviews and evidence-based guidelines.
Below we present a brief evidence synthesis based predominantly on the United Kingdom Evidence Report by Bronfort et al, currently the most comprehensive review of the evidence for the efficacy of manual therapies. The report was commissioned by the UK General Chiropractic Council in response to media concerns about scope of practice and claims of effectiveness in advertising. The report summarized the scientific evidence regarding the effectiveness of manual treatment as a therapeutic option of the management of 26 musculoskeletal and non-musculoskeletal conditions. The authors based their conclusions on the results of systematic reviews of randomized controlled trials, widely accepted evidence-based guidelines, and randomized controlled trials not yet included in the former.
Low back pain
Spinal manipulation is an effective care option for acute, subacute, and chronic low back pain. Massage was also found to be effective for chronic low back pain. Notably, these finding were based, in part, on the clinical practice guidelines developed for the American Pain Society and the American College of Physicians. Chou et al recommended these treatments in addition to medical care. The most recent meta-analysis was supportive in finding clinically meaningful differences in aggregate between manipulation and other treatment alternatives. A 2010 Cochrane review suggested that there is moderate evidence that exercise can prevent recurrences of back pain, although there was conflicting evidence as to its effectiveness as a primary treatment. Based on fewer studies than on exercise or manipulation, a Cochrane systematic review found benefit of massage for patients with subacute and chronic nonspecific low back pain, especially when combined with exercise and education. Research on most conservative treatments for low back pain, including drug therapy, have reported only modest benefits. It remains to be seen whether this is due to the limited effectiveness of the interventions or the heterogeneity of patient populations. Research continues in an attempt to identify potential responder and non-responder subgroups currently under the generic label of nonspecific low back pain. Potentially better results can also be linked to combination therapies and interdisciplinary approaches.
Neck Pain
Spinal manipulation was found to be effective for acute and subacute neck pain. Effectiveness was also found for acute whiplash when spinal manipulation is combined with exercise. Spinal manipulation was shown to be effective for chronic neck pain when combined with exercise. However, a new study suggests the efficacy of spinal manipulation alone in patients with associated cervicogenic headache. Massage is also effective for chronic neck pain. An influential systematic review on this topic was conducted by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain.
Mid Back Pain
The evidence to date is inconclusive in a favourable direction for the use of thoracic spinal manipulation for mid back pain. This is because there has been only 1 small placebo-controlled trial to date. On the other hand, thoracic spinal manipulation has been shown to be efficacious for the care of neck pain. The trends in the data thus suggest spinal manipulation for mid back pain is a promising therapy requiring further trials.
Headaches
Spinal manipulation is an effective option for migraine and cervicogenic headaches. The evidence was found inconclusive for tension-type headaches. There is little information available on other types of headache. A Cochrane systematic review by Bronfort et al is notable.
Extremity Conditions
Manipulation of extremity joints is used for a variety of conditions. However, there are fewer trials than for back pain, neck pain, and headaches. Effectiveness was found for shoulder girdle pain, adhesive capsulitis, lateral epicondylitis, hip and knee osteoarthritis, patellofemoral pain syndrome, and plantar fasciitis. Inconclusive evidence in a favorable direction was observed for rotator cuff pain, shoulder pain, carpal tunnel syndrome, ankle sprains, Morton’s neuroma, hallux limitus, and hallux abductor valgus. The only definitive negative finding was for ankle fracture rehabilitation, while several other forms of post surgical rehabilitation had inconclusive evidence leaning in the negative direction.
Non-musculoskeletal Conditions
There was positive evidence for spinal manipulation for only 1 non-musculoskeletal condition, cervicogenic dizziness. The evidence for the effectiveness of spinal manipulation was negative for asthma and dysmenorrhea; the addition of spinal manipulation to diet was also ineffective for hypertension. Evidence was inconclusive for pneumonia, stage 1 hypertension, pre-menstrual syndrome, nocturnal enuresis, and otitis media.
Safety
Manual therapies including spinal manipulation are generally safe. Side effects tend to be benign: minor and self-limiting with short duration (e.g., mild post-manipulation soreness). Severe complications have been associated with spinal manipulation but are extremely rare. For example, cauda equina syndrome can be as rare as 1 in 100 million following lumbar manipulations. Cassidy et al reviewed approximately 100 million person-years of records to evaluate stroke risk associated with cervical spinal manipulation and medical care. The authors concluded that the risk was extremely small and there was no excess risk from chiropractic care compared with medical care for neck pain and headaches. They hypothesized that the equivalent risk for chiropractic and medical care suggests that a stroke prodrome can lead to care seeking for these conditions. It is unlikely that manipulation of the neck is causally related to stroke.
Evidence-based practice has made significant inroads into the chiropractic profession by expanding clinical research into interventions commonly employed by chiropractors and by graduating more Evidence-based practice savvy practitioners. The most common conditions treated by chiropractors are back pain, neck pain, and headaches. The best available evidence supports manipulative therapy as a reasonable option for many of these complaints. Manipulative therapy also holds potential value for the treatment of a variety of extremity conditions. Chiropractic practice is far broader than spinal manipulation alone, typically including other evidenced-based interventions such as massage, exercise therapy, and activity modification advice.