Spinal Manipulation and Low Back Pain Historical Review and Recent Updates

In 1985, Professor Emeritus of Orthopedics and Director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada, Dr. W. H. Kirkaldy-Willis and his colleague Dr. J. D. Cassidy, presented the results of chiropractic spinal manipulation in 283 patients with chronic, disabling, treatment resistant low back pain. Their study was published in the journal Canadian Family Physician, and titled:

Spinal Manipulation in the Treatment of Low back Pain

These authors state:

“Spinal manipulation, one of the oldest forms of therapy for back pain, has mostly been practiced outside of the medical profession.”

“Over the past decade, there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.”

“Most family practitioners have neither the time nor inclination to master the art of manipulation and will wish to refer their patients to a skilled practitioner of this therapy.”

“The physician who makes use of this resource will provide relief for many patients.”

Drs. Kirkaldy-Willis and Cassidy note that less than 10% of low back pain is due to herniation of the intervertebral disc or entrapment of spinal nerves by degenerative disc disease. They also explain the physiology of spinal manipulation by claiming that it improves the physiology of pain transmission using Melzack and Wall’s 1965 Gate Theory of Pain. Apparently, segmental spinal adjusting (manipulation) improves segmental motion, resulting in a neurophysiological sequence of events that closes the pain gait, inhibiting muscle spasm and pain. They state:

“The central transmission of pain can be blocked by increased proprioceptive input.” Pain is facilitated by “lack of proprioceptive input.” This is why it is important for “early mobilization to control pain after musculoskeletal injury.”

Drs. Kirkaldy-Willis and Cassidy present the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled (“Constant severe pain; disability unaffected by treatment.”) These patients were given a “two or three week regimen of daily spinal manipulations by an experienced chiropractor.”

These authors considered a good result from manipulation to be:

1) “Symptom-free with no restrictions for work or other activities.”

2) “Mild intermittent pain with no restrictions for work or other activities.”

81% of the patients with referred pain syndromes subsequent to joint dysfunctions achieved the “good” result.

48% of the patients with nerve compression syndromes, primarily subsequent to disc lesions and/or central canal spinal stenosis, achieved the “good” result.

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In 1990, Dr. T W Meade and colleagues published a study in the British Medical Journal titled:

Low back pain of mechanical origin:
Randomized comparison of chiropractic and hospital outpatient treatment

This study involved 741 Patients aged 18-65. The patients were treated by chiropractors, who used chiropractic manipulation in most patients, or by the hospital staff who most commonly used Maitland mobilization or manipulation, or both. The outcomes were assessed by noting changes in the score on the Oswestry pain disability questionnaire and in the results of tests of straight leg raising and lumbar flexion. These authors state:

“Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.”

“A benefit of about 7 percentage points on the Oswestry scale was seen at two years.”

“The benefit of chiropractic treatment became more evident throughout the follow up period.”

“Secondary outcome measures also showed that chiropractic was more beneficial.”

“For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management.”

“The benefit is seen mainly in those with chronic or severe pain.”

If all back pain patients without manipulation contraindications were referred for chiropractic instead of hospital treatment, there would be a significant annual treatment cost reduction, a significant reduction in sickness days during a two year poeriod, and a significant savings in social security payments.

“There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic.”

“The results leave little doubt that chiropractic is more effective than conventional hospital outpatient treatment.”

“The effects of chiropractic seem to be long term, as there was no consistent evidence of a return to pretreatment Oswestry scores during the two years of follow up, whereas those treated in hospital may have begun to deteriorate after six months or a year.”

“Chiropractic was particularly effective in those with fairly intractable pain-that is, those with a history of severe pain.”

“Whatever the explanation for the difference between the two approaches, however, this pragmatic comparison of two types of treatment used in day to day practice shows that patients treated by chiropractors were not only no worse off than those treated in hospital but almost certainly fared considerably better and that they maintained their improvement for at least two years.”

The editors of the journal The Lancet reviewed the June 2, 1990 British Medical Journal article by Meade [immediately above], and noted:

The article “showed a strong and clear advantage for patients with chiropractic.”

The advantage for chiropractic over conventional hospital treatment was “not a trivial amount” and “reflects the difference between having mild pain, the ability to lift heavy weights without extra pain, and the ability to sit for more than one hour, compared with moderate pain, the ability to lift heavy weights only if they are conveniently positioned, and being unable to sit for more than 30 minutes.”

“This highly significant difference occurred not only at 6 weeks, but also for 1, 2, and even (in 113 patients followed so far) 3 years after treatment.”

“Surprisingly, the difference was seen most strongly in patients with chronic symptoms.”

“The trial was not simply a trial of manipulation but of management” as 84% of the hospital-managed patients had [physiotherapy] manipulations.

“Chiropractic treatment should be taken seriously by conventional medicine, which means both doctors and physiotherapists.”

“Physiotherapists need to shake off years of prejudice and take on board the skills that the chiropractors have developed so successfully.”

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The journal Spine is the top ranked orthopedic journal and is the official journal for publication by the world’s top 14 orthopedic societies. In 2003, Lynton Giles and Reinhold Muller published a study titled:

Chronic Spinal Pain:
A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation

This was a 9-week clinical trial involving 115 patients with chronic neck and/or back pain. The drugs used in this study were either Celebrex or Vioxx (COX-2 inhibitors). The spinal manipulation was specific adjustments delivered by a chiropractor. All patients were evaluated using standard measurement outcomes, including the Oswestry Back Pain Disability Index (Oswestry), the Neck Disability Index (NDI), the Short-Form-36 Health Survey questionnaire (SF-36), visual analog scales (VAS) of pain intensity and ranges of movement. These authors state:

“The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).”

“Manipulation achieved the best overall results, with improvements of 50% on the Oswestry scale, 38% on the NDI, 47% on the SF-36, and 50% on the VAS for back pain, 38% for lumbar standing flexion, 20% for lumbar sitting flexion, 25% for cervical sitting flexion, and 18% for cervical sitting extension.”

There is “insufficient evidence for the use of NSAIDs to manage chronic low back pain, although they may be somewhat effective for short-term symptomatic relief.”

“The results of this efficacy study suggest that spinal manipulation, if not contraindicated, may be superior to needle acupuncture or medication for the successful treatment of patients with chronic spinal pain syndrome.”

“In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

In January 2005, these same authors published the data on the 12-month follow-up status of these patients. These results were published in the Journal of Manipulative and Physiological Therapeutics, and titled:

Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes

This follow-up study on these patients involved reapplying the same instruments (Oswestry Back Pain Index, Neck Disability Index, Short-Form-36, and Visual Analogue Scales). These authors state:

“In patients with chronic spinal pain syndromes, spinal manipulation, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.”

Both the 9-week findings and the extended follow-up results are consistent with others who conclude that “those treated by chiropractic derived more short-term and long-term benefit and satisfaction than those treated by hospital therapists.”

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In October 2007, the comprehensive, and authoritative

Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain

was published in the journal Annals of Internal Medicine. An extensive panel of qualified experts constructed these clinical practice guidelines. These experts performed a review of the literature on the topic and then graded the validity of each study. The literature search for this guideline included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society.

In these Guidelines, it is noted that when medication and self-care is inadequate for back pain that clinicians should “consider the addition of nonpharmacologic therapy with proven benefits.” The Guidelines suggested spinal manipulation as one such nonpharmacologic therapy.

Following these Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain, an article reviewing the evidence for nonpharmacologic therapies for the treatment of back pain was presented, and titled:

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

 This article, also published in the Annals of Internal Medicine, October 2007, is probably the most comprehensive review of the literature concerning non-drug therapies used in the treatment of low back pain, citing 188 references.

These authors note that there are many nonpharmacologic therapies available for treatment of low back pain. They therefore assessed the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).

In this review, of the 17 treatments assessed, the only non-drug treatment that has proven evidence to benefit acute, subacute, and chronic back pain is spinal manipulation. Manipulation was defined as “Manual therapy in which loads are applied to the spine using short- or long-lever methods. High-velocity thrusts are applied to a spinal joint beyond its restricted range of movement.”

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On October 12, 2009, Mercer Health and Benefits released a study titled:

Do Chiropractic Services for the Treatment of Low Back and Neck Pain Improve the Value of Health Benefits Plans?

An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending

As noted, Mercer Health and Benefits produced this analysis. A Google Internet search of Mercer states:

“Mercer is a leading global provider of consulting, outsourcing and investment services. Mercer works with clients to solve their most complex benefit and human capital issues, designing and helping manage health, retirement and other benefits. It is a leader in benefit outsourcing. Mercer’s investment services include investment consulting and multi-manager investment management. Mercer’s 18,000 employees are based in more than 40 countries. The company is a wholly owned subsidiary of Marsh & McLennan Companies, Inc., which lists its stock on the New York, Chicago and London stock exchanges.”

Physicians Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD, MPH, authored this Mercer report.

Dr. Niteesh Choudhry is from Harvard Medical School where he is an Assistant Professor of Medicine and an Associate Physician in the Division of Pharmaco-epidemiology and Pharmaco-economics. He is also associated with the Hospital Program at Brigham and Women’s Hospital. Dr. Choudhry’s research focuses on patterns of use and adherence to medications for common chronic conditions, such as coronary artery disease, hyperlipidemia and diabetes.

Dr. Choudhry attended McGill University and then received his M.D. and did his residency training in Internal Medicine at the University of Toronto. He served as Chief Medical Resident for the Toronto General and Toronto Western Hospitals and was also Director of the Medical Clerkship Program at the Toronto General Hospital. He received his Ph.D. in Health Policy from Harvard University, with a concentration in statistics and the evaluative sciences, and was a Fellow in Pharmaceutical Policy Research at Harvard Medical School. He practices inpatient general internal medicine at Brigham and Women’s Hospital and is actively involved in resident education.

Dr. Arnold Milstein is from Mercer Health and Benefits in San Francisco, California where he is the Medical Director at Pacific Business Group on Health, the largest employer health care purchasing coalition in the US, where he is the National Health Care Thought Leader. His work focuses on improving managed care programs for large purchasers and government.

Dr. Milstein’s 40 book chapters and published articles have centered on managed care program design. Dr. Milstein is Mercer’s chief physician and national thought leader who earned the Elliott M. Stone Award of Excellence in Health Data Leadership from the National Association of Health Data Organizations (NAHDO) at its annual meeting in Alexandria, VA, on October 15, 2009.

Dr. Milstein holds a medical degree from Tufts University and a master’s degree in health services planning from the University of California, Berkeley. He received a bachelor’s degree in economics from Harvard University. He is an Associate Clinical Professor at the University of California, San Francisco Medical Center and a Worldwide Partner at Mercer.

This report by Drs. Choudhry and Milstein is twelve pages in length and cites 18 references from the National Library of Medicine PubMed database. A complete copy of the report can be accessed at www.f4cp.org.

The Executive Summary of the report makes the following points:

1) “Low back and neck pain are extremely common conditions that consume large amounts of health care resources.”

2) “Chiropractic care, including spinal manipulation and mobilization, are used by almost half of the US patients with persistent back-pain seeking out this modality of treatment.”

[This is an important point. It indicates that patients seek chiropractic treatment primarily for the management of chronic spinal musculoskeletal conditions. It is established that these chronic problems are both expensive and problematic because they do not spontaneously resolve and those suffering from these chronic complaints tend to seek help from multiple healthcare providers].

3) “The peer-reviewed scientific literature evaluating the effectiveness of US chiropractic treatment for patients with back and neck pain suggest that these treatments are at least as effective as other widely used treatments.”

4) “Chiropractic care is more effective than other modalities for treating low back and neck pain.”

5) “Our findings in combination with existing US studies published in peer-reviewed scientific journals suggests that chiropractic care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefit plans.”

Drs. Choudhry and Milstein note that vast scientific literature has

evaluated the cost effectiveness of chiropractic treatment for patients with

common types of back and neck pain, which support these conclusions:

“Chiropractic care is at least as effective as other widely used therapies for low back pain.”

“Using data from high-quality randomized controlled European trials and contemporary Unites States based average unit prices payable by commercial insurers, we project that insurance coverage for chiropractic coverage for chiropractic physician care for low back and neck pain for conditions other than fracture and malignancy is likely to drive improved cost-effectiveness of United States care.”

“In combination with the existing United States-based literature, our findings support the value of health insurance coverage of chiropractic care for low back and neck pain at average fees currently payable by Unites States commercial insurers.”

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Most recently (2010), Francesca Cecchi and colleagues from the University of Florence, Italy, published a study comparing spinal manipulation to back school and physiotherapy in the treatment of chronic back pain. Their study was published in the journal Clinical Rehabilitation, and titled:

Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain:
A randomized trial with one-year follow-up

This study compared 3 groups in the treatment of chronic low back pain: spinal manipulation, back school and individual physiotherapy. The study used 210 patients that were randomized and followed at intervals for 12 months.

GROUP ONE: The back school consisted of 15 one-hour sessions (5 days a week for 3 weeks). The first five hours consisted of group discussions on back physiology and pathology, with reassurance on the benign character of common low back pain, and with education in ergonomics at home and in different occupational settings. The next 10 hours included relaxation techniques, postural and respiratory group exercises, and individually tailored back exercises.

GROUP TWO: The individual physiotherapy groups consisted of 8 patients and two therapists together for 15 one-hour sessions (5 days a week for 3 weeks). These patients were also given individual physiotherapy which included passive and assisted mobilization, active exercise, 2 massage treatments of the soft tissues, and proprioceptive neuromuscular facilitation with emphasis on patient education and active treatment.

GROUP THREE: The spinal manipulation was performed by one of two physicians who were trained in physical medicine. The entire spine was assessed statically and dynamically. “Treatment was aimed at restoring the physiological movement in the dysfunctional vertebral segment(s) and consisted of vertebral direct and indirect mobilization and manipulation, with associated soft tissue manipulation, as needed.” These patients received 4–6 weekly sessions of 20 minutes each for a total of 4–6 weeks of treatment (80–120 minutes of treatment altogether) [meaning one visit per week for 4-6 weeks]. Manipulations were ended after the physician determined there were “no more dysfunctional vertebral segments to be manipulated.”

These authors made the following conclusions:

“Spinal manipulation and vertebral mobilization are widely used in clinical practice, and there is evidence of the effectiveness of spinal manipulation both in the acute and in the subacute or chronic phase of low back pain.”

“No significant difference in Roland Morris Disability score was found between back school and individual physiotherapy on discharge and at the three follow-ups. On the contrary, spinal manipulation showed a significantly lower disability score on discharge and at the three follow-ups when compared with either other intervention.”

“When compared with either back school or individual physiotherapy, spinal manipulation did not show any significant difference in pain relief on discharge, while at the three follow-ups pain intensity was significantly lower in the spinal manipulation group.”

“The reduction in the Roland Morris Disability score was significantly greater in the spinal manipulation group when compared with both back school and individual physiotherapy groups, and also the reduction in the pain rating scale was significantly greater in the spinal manipulation group when compared with both back school and individual physiotherapy groups.”

“When compared with either other intervention, spinal manipulation showed a significantly less frequent report of low back pain related use of drugs at all three follow-ups.”

“In this pragmatic clinical study we compared the short- and long-term effects of three recommended treatments for chronic, non-specific low back pain in a selected outpatient population. Spinal manipulation provided more functional improvement than either physiotherapy intervention, at discharge and all across follow-ups. Further, pain relief at follow-ups was also significantly more relevant in spinal manipulation patients. Low back pain recurrences and reduction of pain-related use of drugs were also most striking for the spinal manipulation group.”

The total amount of time devoted to treatment was much less for the manipulation group than either physiotherapy intervention groups (80–120 minutes vs. 15 v. 900 minutes).

The authors were “confident that individual physiotherapy’s costs were altogether higher than back school’s, since duration, frequency and number of sessions were the same, but the therapist:patient ratio was 1:4 in back school and 1:1 in individual physiotherapy.”

“Spinal manipulation was associated with best results both in terms of pain and function.”

“Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.”

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The studies presented here (1985- 2010) indicate that there exists substantial and continuing evidence that spinal manipulation is safe, effective, cost effective and offers long-term clinical benefits to those suffering from acute an chronic low back pain syndromes.

References

W.H. Kirkaldy-Willis and J. D. Cassidy; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.

T W Meade, Sandra Dyer, Wendy Browne, Joy Townsend, A 0 Frank; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300, June 2, 1990, pp. 1431-7.

Chiropractors and Low Back Pain; The Lancet; July 28, 1990, p. 220.

Lynton G. F. Giles, DC, PhD; Reinhold Muller, PhD; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; 28(14):1490-1502.

Reinhold Muller, PhD, Lynton G.F. Giles, DC, PhD; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005, Volume 28, Number 1.

Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS; Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society; Annals of Internal Medicine; Volume 147, Number 7, October 2007, pp. 478-491.

Roger Chou, MD, and Laurie Hoyt Huffman, MS; Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society And American College of Physicians Clinical Practice Guideline; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.

Choudhry N, Milstein A. Do Chiropractic Services for the Treatment of Low Back and Neck Pain Improve the Value of Health Benefits Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending. Mercer Health and Benefits, October 12, 2009.
www.f4cp.org.

Cecchi C, Molino-Lova R, Chiti M, Pasquini G, Paperini A. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: A randomized trial with one-year follow-up. Clinical Rehabilitation. 2010; 24; 26.

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