J Can Chiropr Assoc. 1993 (Dec); 37 (4): 221–229 ~ FULL TEXT
Pran Manga, PhD, Douglas E Angus, MA, William R Swan, BComm
Low back pain is a ubiquitous and economically costly problem. Unfortunately, the clinical management of low back pain is not yet well understood. Chiropractic management of back pain, long the black sheep of back care, has undergone a transition and is now a more respected and understood alternative to conservative medical care, itself under increased scrutiny due to unsatisfactory outcomes and unacceptable iatrogenic side effects.
The substantial amount of clinical and related research on the effectiveness of manipulation for low back pain is summarized here from a larger study, divided into randomized control trials, case-control trials, meta-analyses and descriptive studies. The chiropractic management of low back pain is found to be a more effective way of dealing with this medical, social and economic problem. It is suggested that greater utilization of chiropractors be encouraged such that the “right people are doing the right things at the right time”.
From the FULL TEXT Article:
Recent estimates indicate that about 10.5 percent of Canada's
GNP is spent on health care services - a proportion second only
to the United States, and the highest in the world for a publicly
funded system. As such, cost containment has become the
cornerstone of virtually all health care policy decisions.
One crucial area of concern - particularly in view of the
pervasive medical, social and economic implications - is the
search for effective management of acute and chronic low back
pain (LBP). We have reviewed the extensive literature on the
epidemiology, prevalence and incidence of LBP elsewhere, 
and thus, offer only a synopsis of those findings here.
In its many manifestations, LBP afflicts at least 80 percent of
the population at some time during their lives. Estimates of the
number of people actually suffering from LBP at the time of a
given survey range from 5 to 30 percent. While estimates of the
incidence and prevalence of LBP may be wide ranging, there
can be no doubt that LBP remains a ubiquitous health problem.
LBP is most common between the ages of 25 and 55, while
the average age for filing a workers' compensation claim falls
between 33 and 35 in both Canada and the United States.
Although some studies have reported a substantial difference in
the occurrence of back pain between males and females, still
others have found little overall differences between sexes. This
is, no doubt, due to an historical trend in gender incidence of
LBP which has been most evident in workers' compensation
statistics. Earlier analyses showed that the incidence and prevalence of LBP was much higher among men than women.
However, with the continued increase in the labour force participation rate for females since World War II, the difference in
rates between men and women has narrowed substantially.
Variations in the occurrence of LBP have also been found
based on age, race, region and educational status. Further,
prevalence has been shown to be higher for people who smoke,
for people with lower levels of education and for people who
have had previous back problems. Finally, there is some support
for the inclusion of anxiety, stress, pregnancy, being separated,
divorced or widowed, and sports activities as other potential
correlates of LBP.
According to Frymoyer and Cats-Baril, "Low back disorders
are extremely prevalent in all societies and probably have not
increased substantially over the past two decades. What has
increased is the rate of disability, the reasons for which are
uncertain".  Obviously, the greater the incidence of disabling
back injuries, the greater the social and economic burden.
An important and essential first step in the process of identifying cost-effective solutions is to establish scientific evidence of
the effectiveness of alternative therapies for LBP. The purpose
of this paper is to review the existing literature and experience
regarding the efficacy and effectiveness of chiropractic, medical, and physiotherapeutic approaches for treating and managing
LBP. Cost-effectiveness issues are dealt with in a larger, more
comprehensive study. 
Effectiveness of chiropractic and other management of low back pain
To assess the effectiveness of a given therapeutic procedure,
"the strongest and only conclusive evidence of effectiveness is
the randomized controlled trial, which in the ordinary clinical
situation is difficult to perform".  Other types of studies - case
control or cohort, descriptive, and literature reviews or metaanalyses
- carry a lower level of proof. Using a methodology
previously employed by the Quebec Task Force on Spinal Disorders,  each study in this review is classified according to the type of research technique used.
Randomized controlled trials (RCTs)
Table 1 [5–36] presents a summary of 31 clinical trials which were
conducted on spinal manipulation for back pain. While there
have been many clinical trials done on the efficacy of manipulation
and other treatment for LBP, there have been questions with
respect to their validity. Hence, certain criteria should be considered
and noted when interpreting the results of a given trial.
These criteria are: randomization, patient attrition, outcome
assessment, equivalent co-intervention, compliance, contamination,
statistical power, demographic description of patients,
clinical description of patients, description of intervention, and
reporting of relevant outcomes.
While the first RCT of spinal manipulation on record was
done in 1974,  the first true controlled efficacy study of chiropractic
therapy for LBP was conducted in 1986 by Waagen et al.
Prior to this study, the authors observed that "any efficacy of
chiropractic therapy can only be inferred from the studies of
manipulative therapy for the treatment of LBP which have been
performed utilizing medical, osteopathic or physiotherapytrained
practitioners of manipulation".  However, because
chiropractors specialize in the delivery of specific spinal adjustments
and receive a longer period of formal training than other
practitioners of manipulation, the authors of this study believed
that it was not possible to extrapolate the results of previous
trials in manipulative therapy directly to chiropractic.
Nineteen patients undertook this trial which lasted two
weeks. They were randomly allocated to one of two groups: one
received a series of chiropractic adjustments (experimental),
and the other (control) received a comparable series of manual
interventions, both provided by trained chiropractors. Assessment
of treatment effect was conducted prior to the first treatment
and at the conclusion of the two-week treatment period by
a group of chiropractors who were not involved in treating the
patients. Eight objective tests of function and a subjective rating
of pain on a Visual Analogue Scale were used. Results showed
that the experimental group had significantly more relief from
pain than control patients immediately after being treated. As
well, after two weeks of treatments the experimental patients, as
a group, exhibited significant overall pain relief whereas this
was not the case in the control group. Experimental patients
improved significantly in the objective measurements of spinal
mobility as well, compared to the control patients. Thus, for the
first time that chiropractic manipulation was properly assessed,
it was found that both subjectively and objectively, chiropractic
therapy was more effective at relieving LBP than a manual
placebo treatment. However, a major drawback of this study
was the small sample size.
In another highly-rated RCT, Ongley et al.  randomized 81
patients with chronic LBP into two groups: one group received
forceful spinal manipulation and injections of a proliferant solution
into soft-tissue structures in order to decrease pain and
disability; the other group received less extensive manipulation
and initial local anaesthesia, and substitution of saline for proliferant,
both treatments carried out by physicians. Effectiveness
of treatment was measured by the patients' subjective
assessment of pain and disability, as well as by an independent
objective evaluation of physical signs. Measurements were
made upon entry to the trial and at ope, three and six months.
Results showed that the experimental group had significantly
greater improvement than the control group at all three points.
Visual analogue pain scores and pain diagrams also showed
significant advantages for the forcefully manipulated group.
The authors concluded that the experimental regimen "is a safe
and effective treatment for chronic LBP that has not responded
to other conservative forms of treatment".
In a very recent Dutch study, Koes et al.  conducted a
randomized controlled trial on the effectiveness of manual
therapy, physiotherapy, and general practitioner treatment for
nonspecific back and neck complaints. They also reported on
the results in a one year follow-up of the trial. In total, 256
patients were allocated into one of the three treatment groups or
a placebo group. They were pre-stratified and randomly allocated
in blocks of eight to either their general practitioner, a
physiotherapist or to a manual therapist. Manual therapy was
limited to manipulation and mobilization of the spine. Physiotherapy
consisted of exercises, massage and physical therapy
modalities (not manipulative techniques). The general practitioner
treatment included prescription medication, home exercises
and bed rest among other modalities. The placebo treatment
(provided by a physiotherapist) used detuned short-wave
diathermy and detuned ultrasound. The principal outcome measures
were severity of the main complaint, global perceived
effect, pain and functional status. Assessments were carried out
at three, six and twelve weeks after the onset of the trial. Results
of this study indicated a more favourable outcome for treatment
with manual therapy or physiotherapy as opposed to medical
treatment. The former two treatments decreased the severity of
complaints more and had a higher global perceived effect compared
to continued treatment by the general practitioner. There
were no differences between physiotherapy and manual therapy
treatments. The basic trend showed that all four groups had
increased improvements at all three follow-up periods. At the
three and six week follow-up, the medical treatment was least
effective, even more so than the placebo. By the twelve week
follow-up, all four study groups showed a large improvement,
while the differences among them had almost disappeared entirely.
The authors concluded that "it seems useful to refer
patients with nonspecific back (and neck) complaints lasting for
at least six weeks for treatment with physiotherapy or manual
therapy".  In the results of the one year follow-up of this study,9
it was concluded that manipulative therapy and physiotherapy
were better than general practitioner and placebo treatment.
Furthermore, manipulative therapy was found to be slightly
better than physiotherapy after one year.
In 1977, the British Chiropractors' Association, citing the
results and controversy over contemporary studies in the U.S.,
appealed to the Medical Research Council (MRC) in the U.K. to
explore the question of chiropractic efficacy. In response to the
pressure, the MRC set out plans for what became the longest and
largest clinical trial of chiropractic effectiveness to date.
The Medical Research Council study published in the British
Medical Journal in 1990,  is based on a prospective randomized
controlled trial in which 741 patients aged 18-65 were
tracked for two years after random assignment to chiropractic
and hospital outpatient clinics in eleven centres. The treatment
alternatives were discretionary, but chiropractors used manipulation
on virtually all patients and the hospital staff (physiotherapists)
used mostly Maitland mobilization and/or manipulation.
The principal outcome measures were changes in the score
on the Oswestry pain disability questionnaire and in the results
of tests of straight leg raising and lumbar flexion. The characteristics
of patients under hospital outpatient care and chiropractic
care were very similar. Outcome measures were taken at weekly
intervals for six weeks, at six months, and then at one and final
at two years after entry. A notable feature of the study was its
full and candid discussion of its design and possible weaknesses.
The results of this randomized clinical trial were that:
(1) chiropractic care conferred significantly long-term benefit in comparison with hospital outpatient treatment;
(2) the advantages of chiropractic management started soon after treatment began;
(3) the effects of chiropractic treatment were long-term, whereas the effects for those treated by hospital staff deteriorated
after six months to a year;
(4) the longer term benefits of
chiropractic care were not due to further chiropractic treatment, since between year one and year two only 17 percent of those initially treated by chiropractors had further chiropractic care, while 24 percent of the hospital group had further hospital treatment; and
(5) the benefit was seen mainly in those patients
with chronic or severe LBP,
Inevitably, there were a number of criticisms as well as
positive commentaries on this clinical trial. The criticisms were
largely minor and included: the use of hospital physiotherapists
who may have been restrained with respect to the number of
treatments rendered; the limitation of the comparison to physiotherapists;
the spontaneous disappearance of some LBP; the
adequacy of the Oswestry scale as an outcome measure; and,
that variables other than treatment modalities may have affected
outcomes. Perhaps the warmest testimonial on the value of the
MRC study came from a renowned researcher who declared the
trial "to be one of the better trials in this field". 
Overall, of the 28 RCT's reviewed, more than two-thirds
concluded that manual manipulation had significant beneficial
outcomes in the treatment and management of LBP, and none of
the studies found that chiropractic made the patient worse off.
Perhaps most interestingly, the more recent - and better -
studies tend to give greater credibility to the effectiveness of
chiropractic manipulation in LBP.
Table 2 [38–42] summarizes six significant case-control studies, all of
which conclude that chiropractic treatment is a comparatively
more effective treatment alternative. For brevity, we do not
discuss each of the studies here, but focus on the best and most
recent of the studies.
Arkuszewski  conducted a clinical trial to assess the efficacy
of manual treatment in LBP. One hundred patients with sciatica
or lumbosacral pain were divided into two groups. Both received
a standard treatment of drugs, physiotherapy and physical
examination twice a week. However, in one group manual
treatment was also applied, in the form of traction, mobilization
and manipulation. To assess efficacy of treatment, six outcomes
were measured: posture, mobility of the spine, severity of pain,
gait, manual and neurological examinations (after treatment and
at six months). Results showed that after the first week of
treatment, improvement was significantly greater in the experimental
group, up to the day of discharge. Even at six months,
improvement of all symptoms was significantly greater in the
manipulated group. "A comparison of the two groups six
months after discharge showed . . . a greater ability to continue
professional employment in the group of patients given manual
treatment. In this group, in addition, the percentage of those
pensioned off for disability was lower". 
As early as 1930, there was evidence in the literature of the
efficacy of manipulation for LBP. Riches  examined the clinical
records of 113 patients who had undergone manipulation of
the back reported over an eight-year period. In addition to
examining clinical data, a questionnaire was sent to those
patients requesting information on the condition of their backs,
length of time taken from work, return of pain, and so on.
Results of the study indicated that in cases of chronic back
and sacroiliac strain, manipulation was successful in about 90
percent of the cases, and success was seen in almost all cases
where there was evidence of existing trauma. The study also
concluded that manipulation did not permanently improve
lumbo-sacral strain, manipulation improved about half the cases
of spinal arthritis, cases of neurotic spine did not respond to
manipulation unless there was an underlying strain, and finally,
that manipulation of the back should not be confined to cases
where mechanical displacement existed. 
Other relevant descriptive studies include those by Mensor, 
Parsons and Cumming,  Potter,  Cassidy et al. [47, 48] and
Mierau et al.  These studies corroborate the value of spinal
manipulation for LBP. Mierau et al.  compared the effectiveness
of spinal manipulative therapy for LBP patients with and
without spondylolisthesis. Data collected from a previous study
showed that the results of manipulative treatment were not
significantly different in those patients with or without lumbar
spondylolisthesis. As such, spondylolisthesis was found not to
be a contraindication to 'skillful' manipulation.
Meta-analysis is a relatively recent approach to reviewing a vast
amount of research and information and finds significant use in
the area of health technology assessment. For example, Brunarski 
reviewed nearly fifty trials to determine where there existed
sufficient evidence to suggest that spinal manipulation was
more effective than medical care in the management of "painful
neuromuscular conditions". He found that in these trials, over
8,300 patients underwent spinal manipulation, and over 80
percent of the trials examined patients who were treated for
LBP. Aggregatively, improvement in the manipulated groups
averaged over 70 percent as compared to 50 percent in the
non-manipulated patients, with acute patients responding comparatively
better. However, both acute and chronic pain patients
"appeared to do consistently better when treated with spinal
manipulative therapy than with other more conventional treatment".
Very recently, Anderson et al.  undertook a meta-analysis of
23 randomized controlled clinical trials of spinal manipulation
to evaluate its effectiveness in the treatment of LBP. The results
demonstrated a consistent (and strong) trend favouring the
greater efficacy of spinal manipulative treatment over other
forms of treatment. The authors determined that "the average
patient receiving spinal manipulation is better off than from
54-85 percent of the patients receiving the comparison treatment,
depending upon the specific outcome variable and the
follow-up time period. . . . Clearly, spinal manipulation was
better than whatever treatment to which it was compared for a
large majority (86%) of the outcomes.... We believe that the
consistently positive small to medium effect sizes noted in this
meta-analysis are real and indicative of clinically meaningful
differences in favour of spinal manipulation for LBP
Other meta-analyses were also examined, including: Greenland
et al.  Ottenbacher and Di Fabio;  Di Fabio;  the
Quebec Task Force on Spinal Disorders;  Curtis;  Koes et
al.;  Shekelle et al.;  and Assendelft et al.  1n the report by
Shekelle et al.,  published by RAND, the medical literature
was reviewed to gain knowledge about the efficacy of spinal
manipulation for LBP. The authors concluded that "support is
consistent for the use of spinal manipulation as a treatment for
patients with acute LBP and an absence of other signs or symptoms
of lower limb nerve-root involvement. Support is less clear
for other indications, with the evidence for some insufficient, . .
. while the evidence for others is conflicting". 
The Canadian Coordinating Office for Health Technology
Assessment (CCOHTA) conducted a review of controlled trials
of manipulation for back pain disorders, with the purpose of
assessing the effectiveness of chiropractic in the treatment of
low back disorders. It concluded that "chiropractor applied
manipulation, in all but one study, was at least as effective in
treating back pain as the alternative treatments described in each
study (these included physiotherapy, massage, electrostimulation,
drug therapy, heat, exercise, education and bed-rest); and
that based on the relatively small number of patients enrolled in
these trials, chiropractor applied manipulation appears to be a
safe treatment offering more immediate relief than other forms
of conservative care". 
Reviews such as the prestigious RAND study, and the recent
CCOHTA study, were also undertaken by medical organizations
such as the North American Spine Society  which concluded
that spinal manipulation and adjustment was an acceptable
and effective treatment for most patients with lumbosacral
disorders. All these reviews add measurably to the growing
credence of spinal manipulation as the therapy of choice for
LBP is pervasive and results in significant medical, social and
economic implications. The approaches for dealing with LBP
have been mainly medical, chiropractic, and physiotherapeutic.
In this paper, we have reviewed the evidence on the effectiveness
of these different alternatives for treating and managing
There are many clinical trials assessing alternative treatment
of LBP. There are also several case-control studies, as well as
meta-analysis and descriptive studies. Our review found many
of the past studies wanting in terms of methodology and scientific
validity. Nevertheless, we believe that despite the weaknesses
and shortcomings, the studies do point to some likely results
vis-a-vis the effectiveness of the alternative therapies for LBP.
We hasten to add, however, that clinical trials with greater
scientific validity need to be undertaken for further understanding
of the effectiveness of alternative therapies for LBP.
In the bulk of the methodologically sound clinical studies,
spinal manipulation applied by chiropractors is shown to be
more effective than many alternative treatments for LBP. The
clinical evidence is corroborated by meta-analysis, case-control
studies and highly-respected clinical guidelines panels. It is
noteworthy that there is no clinical or case-control study that
demonstrates or even implies-that chiropractic spinal manipulation
is unsafe in the treatment of LBP.
The evidence also shows that many traditional medical therapies
for LBP have questionable efficacy, effectiveness and
adequacy, sometimes resulting in severe iatrogenic complications
for the patients. Our reading of the literature suggests that
chiropractic manipulation is (at least) as safe and many times
safer than medical management of LBP and resulted in one
rather curious conclusion. While it is prudent to call for even
further clinical evidence of the effectiveness and efficacy of
chiropractic management of LBP, what the literature revealed to
us is the equally significant need for clinical evidence of the
validity of medical management of LBP. There is also some
evidence in the literature to suggest that manipulation can be
less safe and less effective when performed by non-chiropractic
It appears that the time is right for encouraging greater utilization
of chiropractic services for the management of LBP, especially
in view of the impressive body of evidence on the effectiveness
of such services which we have reviewed in this paper.
Finally, it also is apparent that greater collaboration amongst the
key providers in this area - chiropractors, physicians, and
physiotherapists - is required, particularly if we wish to ensure
that the "right people are doing the right thing at the right time".
The authors gratefully acknowledge the significant contribution
of Costa Papadopoulos. The material for this study was funded
by the Ontario Ministry of Health.
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