About Chiropractic and Low Back Pain: References and Appendixes

2. Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Archives of Internal Medicine. 1998;158(20):2215-2224.

3. Bronfort G. Spinal manipulation: current state of research and its indications. Neurologic Clinics. 1999;17(1):91-111.

4. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Journal of the American Medical Association. 1998;280(18):1569-157

5. Wolsko PM, Eisenberg DM, Davis RB, et al. Patterns and perceptions of care for treatment of back and neck pain: results of a national survey. Spine. 2003;28(3):292-297.

6. Coulter ID, Hurwitz EL, Adams AH, et al. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine. 2002;27(3):291-296.

7. Vickers A, Zollman C. ABC of complementary medicine. The manipulative therapies: osteopathy and chiropractic. BMJ. 1999;319(7218):1176-1179.

8. Atlas SJ, Nardin RA. Evaluation and treatment of low back pain: an evidence-based approach to clinical care. Muscle and Nerve. 2003;27(3):265-284.

9. Pengel HM, Maher CG, Refshauge KM. Systematic review of conservative interventions for subacute low back pain. Clinical Rehabilitation. 2002;16(8):811-820.

10. Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. Annals of Internal Medicine. 2003;138(11):871-881.

11. Complementary medicine: fact and fiction about chiropractic. Harvard Health Letter. 1999;24(3):1-3.

12. The Council on Chiropractic Education. Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status January 2003. Council on Chiropractic Education Web site. Accessed at www.cce-usa.org on June 16, 2003.

13. Eisenberg DM, Cohen MH, Hrbek A, et al. Credentialing complementary and alternative medical providers. Annals of Internal Medicine. 2002;137(12):965-973.

14. Agency for Health Care Policy and Research. Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research; 1998. AHCPR publication no. 98-N002.

15. Dagenais S, Haldeman S. Chiropractic. Primary Care. 2002;29(2):419-437.

16. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low back pain. Annals of Internal Medicine. 1992;117(7):590-598.

17. Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine. 1997;22(4):435-440.

18. Hufnagel A, Hammers A, Schonle PW, et al. Stroke following chiropractic manipulation of the cervical spine. Journal of Neurology. 1999;246(8):683-688.

19. Jeret JS, Bluth M. Stroke following chiropractic manipulation: report of 3 cases and review of the literature. Cerebrovascular Diseases. 2002;13(3):210-213.

20. Haldeman S, Rubinstein SM. Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. Spine. 1992;17(12):1469-1473.

21. Haldeman S, Rubinstein SM. Compression fractures in patients undergoing spinal manipulative therapy. Journal of Manipulative and Physiological Therapeutics. 1992;15(7):450-454.

22. Hurwitz EL, Morgenstern H, Harber P, et al. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study. Spine. 2002;27(20):2193-2204.

23. Cooper RA, Henderson T, Dietrich CL. Roles of nonphysician clinicians as autonomous providers of patient care. Journal of the American Medical Association. 1998;280(9):795-802.

24. Chiropractic regulatory boards. Federation of Chiropractic Licensing Boards Web site. Accessed at www.fclb.org/boards.htm on June 16, 2003.

25. Hsieh CY, Adams AH, Tobis J, et al. Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine. 2002;27(11):1142-1148.

26. Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine. 1998;339(15):1021-1029.

27. Bronfort G, Goldsmith CH, Nelson CF, et al. Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial. Journal of Manipulative and Physiological Therapeutics. 1996;19(9):570-582.

28. Carey TS, Garrett J, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. New England Journal of Medicine. 1995;333(14):913-917.

29. Pope MH, Phillips RB, Haugh LD, et al. A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine. 1994;19(22):2571-2577.

30. Triano JJ, McGregor M, Hondras MA, et al. Manipulative therapy versus education programs in chronic low back pain. Spine. 1995;20(8):948-955.

31. Meade TW, Dyer S, Browne W, et al. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. BMJ. 1995;311(7001):349-351.

32. Assendelft WJ, Koes BW, van der Heijden GJ, et al. The effectiveness of chiropractic for treatment of low back pain: an update and attempt at statistical pooling. Journal of Manipulative and Physiological Therapeutics. 1996;19(8):499-507.

33. Ernst E. Chiropractic spinal manipulation for back pain. British Journal of Sports Medicine. 2003;37(3):195-196.

34. Ernst E. Chiropractic care: attempting a risk-benefit analysis. American Journal of Public Health. 2002;92(10):1603-1604.

35. Hurwitz EL, Morgenstern H, Harber P, et al. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. American Journal of Public Health. 2002;92(10):1634-1641.

36. Sran MM. Commentary on "Chiropractic spinal manipulation for back pain." British Journal of Sports Medicine. 2003;37:196.

Appendix I
Research Studies of Chiropractic Treatment in Adults with Back Pain
Published from January 1994 through June 2003

Citation: Hurwitz et al., 2002(22)
Description: Randomized clinical trial (RCT) of patients in a managed care organization compared chiropractic cared (with and without any of the following added: heat or cold therapy, ultrasound, electrical muscle stimulation) with conventional medical care (with and without physical therapy added). Participants (652) had acute, subacute, or chronic low back pain with or without leg pain. Back-pain intensity and back-related disability were measured.
Findings: After 6 months of followup, the conventional medical care and chiropractic regimens were found to be comparably effective.

Citation: Hsieh et al., 2002(25)
Description: RCT compared four treatments for subacute low back pain (LBP): "joint manipulation" by a chiropractor, back school (program of counseling and exercises), myofascial therapy, and joint manipulation plus myofascial therapy. Participants (178) had LBP for either >3 weeks but <6 months in a current episode or>2 months within the preceding 8 months for recurrent LBP, and were evaluated 3 weeks and 6 months after treatment.
Findings: No statistically significant differences were found between groups at 3 weeks or 6 months.

Citation: Cherkin et al., 1998(26)
Description: RCT in an HMO setting of 321 adults aged 20-64 with low back pain. Patients received either chiropractic manipulation, physical therapy (PT), or a booklet on self-managing back pain. They were monitored for 2 years and evaluated for bothersomeness of symptoms and level of dysfunction.
Findings: The outcomes for those who received manipulation or PT were better than those who received the booklet, but "only marginally better." There were no significant differences between the manipulation and PT groups. Authors note that manipulation and PT "may slightly reduce symptoms."

Citation: Bronfort et al., 1996(27)
Description: For chronic low back pain, prospective RCT compared (1) chiropractic spinal manipulation therapy (SMT) plus trunk-strengthening exercises with (2) chiropractic SMT plus trunk-stretching exercises and (3) trunk-strengthening exercises combined with an NSAID (drug). Enrollees (174) were measured for low back pain, disability, and functional health status at 5 and 11 weeks.
Findings: Each of the 3 regimens yielded a "similar and clinically important improvement over time that was considered superior to the expected natural history of long-standing chronic low back pain."

Citation: Carey et al., 1995(28)
Description: Prospective observational study on the outcomes of care for acute low back pain by chiropractors, primary care practitioners, and orthopedic surgeons, including how long it took to return to functional status. Participants (1,633) had acute pain of less than 10 weeks' duration.
Findings: Time to recovery was "essentially the same," regardless of which provider provided the care.

Citation: Meade et al., 1995(31)
Description: RCT of 741 patients who came to chiropractic and hospital outpatient clinics in 11 centers, for low back pain. Participants were randomized to receive either chiropractic or hospital-outpatient management. Outcomes were measured mainly with a pain disability questionnaire, at 6 weeks, 6 months, and 1, 2, and 3 years.
Findings: Chiropractic was found to be more effective, especially for those with "short current episodes, a history of back pain, and initially high [pain scale] scores." Benefit was less evident at 2 and 3 years than earlier. Authors noted that further trials are needed, e.g., on specific components of chiropractic.

Citation: Triano et al., 1995(30)
Description: RCT comparing chiropractic spinal manipulation, sham manipulation, and a back education program. Participants (170) had low back pain (lasting 7 weeks or longer or consisting of at least 6 episodes in 12 months) and were evaluated for pain and activity tolerance at enrollment, after 2 weeks of treatment, and after 2 weeks of no treatment.
Findings: Greater improvement was found in the manipulation group than in other groups. Pain relief continued to end of evaluation period.

Citation: Pope et al., 1994(29)
Description: Prospective RCT compared chiropractic spinal manipulation for treatment of subacute low back pain to massage, use of a corset, and TMS (electrical muscle stimulation). Patients (164) were treated for 3 weeks and evaluated through various standardized instruments and examinations.
Findings: Various improvements were seen in all 4 groups. The manipulation group had the most improvement in flexion and pain. However, authors concluded overall that none of the changes in physical outcomes measured was significantly different between groups.

Appendix II
Reviews on Chiropractic Treatment for Back Pain in Adults Published from
October 1996 through June 2003

Citation: Assendelft et al., 2003(10,e)
Description: Meta-analysis of 39 randomized clinical trials of treatments for acute or chronic low back pain in adults. The trials compared spinal manipulation (by chiropractors and other health care providers) with another treatment or control condition (including no treatment, conventional medical care, pain-relieving drugs, physical therapy, exercise, and back school).
Findings: Spinal manipulation was more effective than sham therapy, but no more or no less effective than other treatments. Authors found that the specific profession of the manipulators (including chiropractors) did not affect these results.

(e) This study on spinal manipulation is included because the authors were able to break down the findings according to the profession of the manipulator, including chiropractors.

Citation: Ernst, 2003(33)
Description: General review of the scientific evidence for the effectiveness of chiropractic spinal manipulation for back pain (this review is not limited to low back pain studies).
Findings: Author noted there has been only one systematic review of chiropractic spinal manipulation exclusively (Assendelft et al., 1996, see below), and that, since that study, emerging trial data "have not tended to be encouraging…. The effectiveness of chiropractic spinal manipulation for back pain is thus at best uncertain."

Citation: Assendelft et al., 1996(32)
Description: Systematic review of 8 RCTs of chiropractic for acute or chronic low back pain.
Findings: Authors stated that all studies analyzed had serious flaws in design, execution, and reporting. Studies could not be pooled to reach statistical conclusions because of insufficient data and data quality problems. Authors summarized the available data narratively; concluded they "did not provide convincing evidence for the effectiveness of chiropractic for acute or chronic low back pain"; and noted that better-executed trials are needed in future.

National Center for Complementary and Alternative Medicine(NCCAM)
http://nccam.nih.gov/health/chiropractic/index.htm
National Institutes of Health, U.S. Department of Health and Human Services
NCCAM Publication No. D196 November 2003