Chiropractic v. Physical Therapy For Back Pain

There are 18 chiropractic colleges in the United States:

Cleveland Chiropractic College – Kansas City, KS
D’Youville College –  Buffalo, NY
Life Chiropractic College West – Hayward, CA
Life University – Marietta, GA
Logan University – Chesterfield, MO
National University of Health Sciences – Lombard, IL
New York Chiropractic College – Seneca Falls, NY
Northwestern Health Sciences University – Bloomington, MN
Palmer College of Chiropractic – Davenport, IA
Palmer Chiropractic College, Florida – Port Orange, FL
Palmer Chiropractic College West – San Jose, CA
Parker University – Dallas, TX
Sherman College – of Chiropractic  Spartanburg, SC
Southern California University of Health Science – Whittier, CA
St. Petersburg College – St. Petersburg, FL
Texas Chiropractic College – Pasadena, TX
University of Bridgeport – Bridgeport, CT
University of Western States – Portland, OR

In contrast, there are 227 Physical Therapy Schools in the United States.

Some of the chiropractic colleges are Universities that grant academic degrees in addition to the Doctor of Chiropractic degree (DC). Others only grant Doctor of Chiropractic degrees.

Since the 1970s, the federal government has controlled chiropractic education in the United States. The United States Department of Education oversees chiropractic education by recognizing the Council for Chiropractic Education (CCE) (1):

“CCE maintains recognition by the United States Department of Education as the national accrediting body for Doctor of Chiropractic Programs and chiropractic solitary purpose institutions of higher education.”

All of the 18 chiropractic colleges in the United States are accredited by the CCE.

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Both chiropractors and physical therapists treat acute pain and chronic pain problems, including those of the spine. Both chiropractors and physical therapists are educated in the clinical application of physical therapy modalities. Some physical therapists are also trained in spinal manipulation. Physical therapist Jan Lucas Hoving, PT, PhD, and colleagues, note (2):

“Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.”

The article by Hoving and colleagues was published in the Annals of Internal Medicine, and titled (2):

Manual Therapy, Physical Therapy, or Continued Care by a
General Practitioner for Patients with Neck Pain:
A Randomized Controlled Trial

In this study, the authors compared the effectiveness of manual therapy, physical therapy, and care by a general practitioner in the treatment of spinal pain, using a randomized controlled trial design. The study involved 183 patients. These authors concluded:

“Manual therapy scored consistently better than the other two interventions on most outcome measures.”

“In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”

“The success rates for manual therapy were statistically significantly higher than those for physical therapy.”

“Manual therapy scored better than physical therapy on all outcome measures…”

“Range of motion improved more markedly for those who received manual therapy or physical therapy than for those who received continued care.”

“The postulated objective of manual therapy is the restoration of normal joint motion, was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”

“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care.”

“Manual therapy seems to be a favorable treatment option for patients with neck pain.”

“Primary care physicians should consider manual therapy when treating patients with neck pain.”

Interestingly, in this study whose primary authors are physical therapists, they found that manual manipulative therapy was superior to physical therapy in the management of neck pain.

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The core of chiropractic clinical practice is spinal manipulation. Spinal manipulation is the use of the vertebrae (usually the transverse and/or spinous process) as a lever to influence tissue integrity and improve the movement parameters of spinal articulations. When this goal is accomplished, a neurological sequence of events is established that closes the “pain gate,” resulting in reduced pain and improved function (3).

Pain is a huge problem in the United States. Acute pain comes and goes, depending on circumstances and activities. In contrast, chronic pain is an ongoing, frustrating and debilitating problem. Of the 238 million adults in the United States, approximately 116 million live with chronic pain (4, 5).

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The recent, comprehensive, and authoritative Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain were published in the October 2007 issue of the journal Annals of Internal Medicine. An extensive panel of qualified experts constructed these clinical practice guidelines after 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. The results were presented in two publications (6, 7):

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
October 2007, Volume 147, Number 7, pp. 478-491

AND

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

The following chart summarizes these guideline’s conclusions. It is noteworthy that the only therapeutic intervention they found acceptable for acute, sub-acute, and chronic low back pain was spinal manipulation (7):

The Following Chart Summarizes The Treatment Benefit
For Low Back Pain

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In 1985, Dr. Kirkaldy-Willis, a Professor Emeritus of Orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada, published an article in the journal Canadian Family Physician (8). In this study, the authors 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, presumably including physical therapy, and they were all totally disabled. 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:

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

OR

“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 herniation and/or central canal spinal stenosis, achieved the “good” result.

Dr. Kirkaldy-Willis attributed this clinical outcome to Melzack and Wall’s 1965  “Gate Theory of Pain.” He noted that the manipulation improved motion, which improved proprioceptive neurological input into the central nervous system, which in turn blocked pain. Dr. Kirkaldy-Willis concluded:

“The physician who makes use of this [manipulation] resource will provide relief for many back pain patients.”

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In 1990, Dr. TW Meade and colleagues published the results of a randomized comparison of chiropractic and hospital outpatient treatment in the management of low back pain. This trial involved 741 patients and was published in the prestigious British Medical Journal (9). It was titled:

Low Back Pain of Mechanical Origin:
Randomized Comparison of Chiropractic and
Hospital Outpatient Treatment

The patients in this study were followed for a period between 1–3 years. Nearly all of the chiropractic management involved traditional joint manipulation. Key points from the authors include:

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

“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.”

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

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

Important for this discussion, 84% of the hospital patients were treated with physical therapy and physical therapy manipulation. This observation led to an editorial follow-up in a different journal, Lancet, the following month, which stated (10):

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

Low Back Pain of Mechanical Origin:
Randomized Comparison of Chiropractic and
Hospital Outpatient Treatment

The study “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.”

The authors of the Meade study note that if all back pain patients without manipulation contraindications were referred for chiropractic instead of hospital treatment, there would be significant annual treatment cost reductions, a significant reduction in sickness days during two years, and a significant savings in social security payments.

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In 1996, a study from the University Department of Orthopaedic Surgery, Bristol, UK, was published in the journal Injury, titled (11):

Chiropractic Treatment of Chronic ‘Whiplash’ Injuries

This retrospective study was undertaken to determine the effects of chiropractic spinal manipulation in a group of 28 patients who had been referred with chronic ‘whiplash’ syndrome. The authors defined spinal manipulation as:

“Spinal manipulation is a high-velocity low-amplitude thrust to a specific vertebral segment aimed at increasing the range of movement in the individual facet joint, breaking down adhesions and stimulating production of synovial fluid.”

The severity of subjects’ symptoms was assessed before and after treatment using the Gargan and Bannister (1990) classification:

The Gargan and Bannister Whiplash Classification

The 28 patients in this study had initially been treated with anti-inflammatories, soft collars and physiotherapy. These patients had all become chronic, and were referred for chiropractic at an average of 15.5 months (range was 3–44 months) after their initial injury. Ninety six percent (27/28) of the study subjects were classified as category C or D symptoms at the time of initial chiropractic treatment.

Following chiropractic 93% of the patients had improved: 16/28 (57%) by one symptom group and 10/28 (36%) by two symptom groups. These authors state:

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”

Complications from cervical manipulations are rare, and when they are reported in the literature, they often “arose as a result of spinal manipulation performed by non-chiropractors, who had been misrepresented in the literature as being trained chiropractors.”

Once again, spinal manipulation appears to result in a positive clinical outcome when compared to physical therapy in the treatment of a common musculoskeletal pain syndrome.

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On September 17, 2016, researchers from the University of Montreal, Laval University, and the University of Toronto released an early publication (epub) in the Journal of Occupational Rehabilitation titled (12):

Association Between the Type of
First Healthcare Provider
and the Duration of Financial Compensation
for Occupational Back Pain

The objective of this study was to compare the duration of financial compensation and the occurrence of a second episode of compensation for back pain among injured workers patients seen by three types of primary healthcare providers (physicians, chiropractors, and physiotherapist). The authors note that most Canadian worker’s compensation boards provide injured workers direct access to physicians, chiropractors, and physiotherapists, but:

• • physicians can prescribe medication and diagnostic imaging
  • chiropractors can prescribe X-rays but no medication
  • physiotherapists cannot prescribe diagnostic imaging or medication

The authors adjusted for covariables, specifically controlling for “sex, age, community size, language, union membership, employer’s doubts regarding the work-relatedness of the injury, physical demands, gross earnings, previous similar injury, previous 100% wage compensation, the nature of the injury and the body part affected.”

The study used a cohort of 5,511 injured workers who received compensation in Ontario, CAN. They were followed for a period of 2 years.

Three outcomes were analyzed:

• • The duration of the first episode of 100% wage compensation
  • The duration of the first episode of any wage compensation (full or partial)
  • The occurrence of a second episode of compensation for the same claim during the follow-up period

These authors note:

• • At any given point, the prevalence of back pain is about 9% of the population.
  • The lifetime prevalence is about 85%.
  • “Back pain is the most common occupational injury in Canada and the United States.”
  • “Back pain causes more years of life with disability than any of the other 291 conditions studied.”

Summary of Outcomes

The median numbers of days of the first episode of full wage compensation were 7.0 for chiropractic, 8.0 for physician, and 19.0 for physiotherapists.

The median number of days of partial wage compensation was 8.0 for chiropractic, 10.0 for physician, and 25.0 for physiotherapists.

The percentage of workers who completed their first episode of any wage compensation and required a second compensation episode, 15.0% for chiropractic, 16% for physician care seekers, and 23% physiotherapist care.

These authors made these comments:

“Physiotherapists showed the longest duration of compensation, and chiropractors showed the shortest.”

Over the first 149 days, the “workers who first sought care from a chiropractor had a significantly greater hazard of ending their compensation episode compared with the workers who first consulted a physician and those who first consulted a physiotherapist.”

“The workers who first sought care from a physiotherapist had significantly higher odds of having a second episode of compensation compared with the workers who first consulted a physician.” [Relative increased risk by 49%]

“The workers who first sought care from a chiropractor did not have significantly different odds of having a second episode of compensation compared with the workers who first consulted a physician.” [Reduced relative risk by 17%]

“When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones.”

“Physiotherapists were associated with higher odds of a second episode of financial compensation.”

“In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care.”

“We found that the workers who sought chiropractic care experienced shorter durations of compensation.”

“The physiotherapy patients experienced longer compensation durations and more second episodes of compensation.”

“Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest.”

“The physiotherapy patients were also more likely to experience a second episode of compensation. Our results raised concerns regarding the use of physiotherapists as gatekeepers of Ontario’s worker’s compensation system.”

“These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.”

These authors also found that compared to medical care, both chiropractic care and physiotherapy care reduced use of diagnostic imaging, surgery and opioids. This study would argue that chiropractic spinal manipulation is very effective in the treatment of low back pain, especially in comparison to other treatment approaches. It would also support the argument, as a consequence of its superior treatment outcomes, that chiropractic should be the gatekeeper for the worker’s compensation system.

REFERENCES

1. www.cce-usa.org; accessed October 11, 2016
2. Hoving JC, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, Mameren H, Devillé WLJM; Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain; A Randomized Controlled Trial; Annals of Internal Medicine; May 21, 2002; Vol. 136; No. 10; pp. 713-722.
3. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
4. Foreman J; A Nation in Pain; Healing Our Biggest Health Problem; Oxford University Press; 2014.
5. Pho K; Pain Management: Education is Key; USA Today; September 19, 2011; p. 9A.
6. 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; Annals of Internal Medicine; Volume 147, Number 7, October 2007, pp. 478-491.
7. Roger Chou, MD, and Laurie Hoyt Huffman, MS; Nonpharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.
8. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
9. Meade TW, Dyer S, Browne W, Townsend J, Frank OA; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300, June 2, 1990; pp. 1431-1437.
10. …; Chiropractors and Low Back Pain; Lancet; July 28, 1990; p. 220.
11. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic treatment of chronic ‘whiplash’ injuries; Injury; November 1996; Vol. 27; No. 9; pp. 643-645.
12. Blanchette AM, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I; Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain; Journal of Occupational Rehabilitation; September 17, 2016 [epub].

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