New Study Finds Chiropractic Care Superior to Family Physician-directed Usual Care
SOURCE: Spine J. 2010 (Oct 2) [Epub ahead of print]
Bishop PB, Quon JA, Fisher CG, Dvorak MF.
International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada. paul.bishop@vch.ca
This newly published (Oct 2) study in Spine Journal compared family physician-directed usual care with evidence-based clinical practice guidelines (CPGs) (which includes reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar chiropractic spinal manipulative care, and return to work within 8 weeks) on patients with acute low back pain. [1]
Evidence-based clinical practice guidelines (CPGs) for the management of patients with acute mechanical low back pain (AM-LBP) have been defined on an international scale. Multicenter clinical trials have demonstrated that most AM-LBP patients do not receive CPG-based treatments. To date, the value of implementing full and exclusively CPG-based treatment remains unclear. To determine if full CPGs-based study care (SC) results in greater improvement in functional outcomes than family physician-directed usual care (UC), a two-arm, parallel design, prospective, randomized controlled clinical trial using blinded outcome assessment was designed. Treatment was administered in a hospital-based spine program outpatient clinic. Patients were assessed by a spine physician, then randomized to SC (reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar CSMT, and return to work within 8 weeks), or family physician-directed UC, the components of which were recorded.
Primary outcomes involved improvement from baseline in Roland-Morris Disability Questionnaire (RDQ) scores at 16 weeks. Secondary outcomes involved improvements in RDQ scores at 8 and 24 weeks; and in Short Form-36 (SF-36) bodily pain (BP) and physical functioning (PF) scale scores at 8, 16, and 24 weeks.
RESULTS: Ninety-two patients were recruited, with 36 SC and 35 UC patients completing all follow-up visits. Baseline prognostic variables were evenly distributed between groups. The primary outcome, the unadjusted mean improvement in Roland-Morris Disability scores, was significantly greater in the chiropractic group than in the UC group (p=.003). Regarding unadjusted mean changes in secondary outcomes, improvements in Roland-Morris scores were also greater in the chiropractic group at other time points, particularly at 24 weeks (p=.004). Similarly, improvements in SF-36 PF scores favored the chiropractic group at all time points; however, these differences were not statistically significant.
CONCLUSIONS: This is the first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP. Compared to family physician-directed UC, full CPG-based treatment including spinal manipulative care (CSMT) is associated with significantly greater improvement in condition-specific functioning.
This re-confirms the findings of the UK BEAM Trial, published in the British Medical Journal in 2004. [2] Most patients with acute back pain improve over time, but adding spinal manipulation followed by exercise to standard care moderately improves results. The UK BEAM trial team (page 1377) randomised 1334 patients with low back pain to additional exercise classes, spinal manipulation, or manipulation followed by exercise or to “best care” in general practice. Manipulation, with or without exercise, improved symptoms more than best care (medical care) alone after three and 12 months. However, analysis of the cost utility of different strategies shows that manipulation alone probably gives better value for money than manipulation followed by exercise (page 1381).
The Low Back Pain and Chiropractic Page contains numerous other studies, dating back to the early 1990s, that demonstrate the vast superiority (and safety) of chiropractic management for low back pain.
You may also want to review the editorial titled:
End Medical Mis-Management of Low Back Pain
as it encapsulates many of those same findings.
REFERENCES:
1. Findings from the: “United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial”
British Medical Journal 2004 (Dec 11); 329 (7479): 1381 ~ FULL TEXT
2. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain
Spine J. 2010 Oct 2. [Epub ahead of print]
Thanks, Dr. Painter, for sharing.
Looking forward to your Memphis Seminar Nov 13th.
RESPONSE from Frank
Thanks Rhena…I’m looking forwards to it too!
Very nice reading!
Greetings from Denmark
Overall, this study is important not only to chiropractic but also family physicians. The familiy physicians/practitioners I have spoken with would prefer that these NMS pts. be seen by physical medicine practitioners.They don’t have the time and usually the best training to deal with these pts. You can bet the physical therapy community has looked at this study to further rationalize their quest to dominate manipulation. We need to embrace this study and consider the pros and the possible cons. Studies like this will give us Best Practice evidence for chirpractic care. I feel our strategy must be a strategy of not bad mouthing but “kill them” with kindness.
Thanks Karl
The major reason I like this article is that it points out very clearly that what we do is evidence-based, while most of what they do isn’t.
As for PTs, some States have already ruled that manipulation is outside their scope of practice. We do need to emphasize that DCs take 1200 or more hours (and most of it closely supervised) in spinal manipulation, and that PTs (and even osteopaths) don’t get even a tiny fraction of those hours.
There’s a VAST difference between an MD or a PT taking a weekend class in manipulation (as documented in The Back Letter) and being enrolled in a 15-week class, where you are supervised (and get constant feedback) throughout that whole semester-long process. That’s how WE learn it.
Who would you prefer to have adjust you?
I read this a week ago and had a hard time pulling out the important data. Thanks for your highlights making it easier (at least for me) to understand.
What a great comment “. . . manipulation alone probably gives better value for money than manipulation followed by exercise.”
All my decisions are about value. Good to know I’m providing it.
It is a good to see that there is finally some research showing the benefits of our profession are giving the patient what they really need as stated in the summary “first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP.” Perhaps some of the politicians will see the importance of having more than one specified system of treatment.
[…] New Study Finds Chiropractic Care Superior to Family Physician-directed Usual Care Recent CommentsChiropractors Directory on Why Do Spinal Surgery Rates Continue To Rise?karl on New Study Suggests That Back Surgery Fails 74% of the TimeDR.RICH on New Study Suggests That Back Surgery Fails 74% of the TimeJohn on Chiropractic Care – Global Strategic Business ReportCategories […]
Good health care professionals are lifetime learners. They want to keep up with the literature and adopt what is best for their patients, families, and themselves. That being said, I agree with Frank. PT’s and MD’s simply don’t have enough training to perform spinal manipulation properly and safely.
A good read. Nice to know that what I am providing is showing better results in the studies.
[…] New Study Finds Chiropractic Care Superior to Family Physician-directed Usual Care […]
In the spirit of Karl’s comment about “killing them with kindness” above, I think the discussion shouldn’t so much center on what treatment is superior or not, as what defines superiority is only tightly controlled in clinical trials…but on what’s best for the individual–e.g what they want to get out of the clinical experience. I think if informed consent about tx options actually took place on a level playing field, chiropractic care would be the first choice for many. Just from the side effects of pharmaceutical alone!
RESPONSE from Frank
Dr. Ziska,
I agree that in comparison, spinal adjusting is vastly safer than drugs for symptom management.
I believe our biggest challenge will be how to communicate the superiority of chiropractic SMT to PT-provided SMT. At present, most PTs have considerably less hours devoted to SMT than DCs do. I wonder how that will change as doctorate level PTs enter the market. I guess it’s time to review their curricula to see how many SMT hours those programs provide.
It would be great if family physicians referred to chiropractors. Seems like they prefer Physical Therapists for some reason.
Really good to see studies like this…The body is a concert and the spine is the conductor.
This is the kind of evidenced-based information that the public needs to be made aware of. Medical doctors may be aware of such studies, but may still choose to keep their patients in the dark about treatment options that don’t involve pharmaceutical drugs.