9. Methodological
quality
The
included studies were evaluated using the GATE criteria.
The systematic review was of good quality.
The
included studies varied in methodological quality from poor to good. Two
RCTs were of good quality and the other Fair.
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10. Results
The systematic
review (Ernst and Canter 2003) found 12 relevant studies published between
1981 and 2000 which varied in methodological quality 6 fair to good and 4
poor). There was a lot of variation in the population (acute, chronic or
mixed back pain with or without sciatica), in the interventions and
comparisons and follow-up periods. The sample size was below 50 in 5 studies
and unknown in one. Most did not have any power calculations and adequate
follow-up was seen in only 4 studies.
The results
were highly variable as well. Some small or moderate benefit of chiropractic
treatment over comparison treatments was reported in 5 studies. No benefit
was reported in 6 studies and chiropractic was less beneficial than back
school in 1 study. There was no indication that chiropractic treatment was
more effective in any particular type of low back pain (eg acute vs
chronic).
All 4 studies
sham chiropractic treatment as a comparison found chiropractic more
effective.
One out of 4
studies found that chiropractic treatment was more effective than
medication. This one was of poor quality.
No study found
that chiropractic treatment was more effective than massage therapy, TENS,
corset, education, or acupuncture.
Only one of 3
studies demonstrated that chiropractic was more effective than
physiotherapeutic exercise.
The authors
conclude that there is little evidence that chiropractic treatment is an
effective treatment for low back pain or that it is more beneficial than
other treatments.
One of the
RCTs (Hsieh, Adams et al. 2002) which compared 4 treatments (back school,
myofascial therapy, chiropractic and combined myofascial therapy and
chiropractic) in patients with subacute low back pain found no difference
between any group except combined therapy and myofascial therapy at 3 weeks.
However back school, chiropractic and combined therapy were equally
effective at reducing pain and increasing activity scores. There is no way
to demonstrate that the effect of these therapies is different from no
treatment
Twenty-three
patients reported adverse events: 7 in the combined group, 6 in the
chiropractic group, 4 in the myofascial group and 6 in the back school
group. Most of these were short periods of worsening symptoms except one in
the myofascial group experienced tinnitus.
An RCT (Hoiriis,
Pfleger et al. 2004) which compared chiropractic with muscle relaxants and
placebo found a significant reduction in pain for all groups (p<0.0001) over
4 weeks. There was also a significant improvement of pain in the
chiropractic group compared to the control group at both 2 and 4 weeks
(p=0.0301, p=0.0321). There was a significant decrease in the disability
scores for all groups (p<0.001) but no difference between the groups. The
same was found in the depression score. Global impression of severity
decreased significantly for all groups (p<0.0001) and the chiropractic group
improved more than the other two groups (p<0.05).
An RCT (Hurwitz,
Morgenstern et al. 2002)which compared chiropractic treatment with
chiropractic treatment plus physical modalities and medical care and medical
care plus physical modalities in adults with low back pain found all groups
had a significant reduction in pain at all assessment times (p<0.001). There
were no differences between the groups in pain reduction. A similar result
was found in improvement of disability.
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11.
Discussion
of Findings
The
systematic review is complex and confusing however there appears to be some
evidence, although not conclusive, that chiropractic treatment is as effective
as other therapies but this may be due to chance. There is very little evidence
that chiropractic is more effective than other therapies.
One RCT (Hsieh,
Adams et al. 2002) found that for subacute back pain, combined chiropractic and
myofascial therapy was as effective as either therapy alone. This study was of
fair quality and as there was no placebo group, it is difficult to determine
whether these therapies are more effective than no treatment.
One RCT (Hoiriis, Pfleger et al. 2004) found
that for subacute
back pain chiropractic was more beneficial than in
reducing pain than placebo and more beneficial than placebo or muscle relaxants
in reducing a global impression of severity.
An RCT (Hurwitz,
Morgenstern et al. 2002) found that chiropractic treatment and medical care were
similar in their effectiveness. There was a possible small benefit of physical
therapy in reducing disability compared to medical care.
Adverse effects of
chiropractic treatment were only reported in one RCT, these were mainly short
periods of worsening symptoms. However
other reports have
described frequent mild adverse effects as well as more serious complications.
For information about contraindications and possible adverse effects see:
http://www.webmd.com/content/article/4/1680_50518.htm
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12.
Conclusions
There is level 3 evidence that chiropractic treatment is as effective as
other treatments for low back pain.
There is
level 2
evidence that chiropractic treatment helps to reduce acute low back pain
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13. References
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J., S. C. Morton, et al. (2004). "Spinal manipulative therapy for low back
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Chapman-Smith, D.
(2000). The Chiropractic Profession. 2006.
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Hurwitz, E. L., H.
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Maniadakis, N. and
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Date prepared:
1 July 2006
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