Chiropractic Benefit Challenged
abstract & commentary
Source: Cherkin DC, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for treatment of patients with low back pain. N Engl J Med 1998;339:1021-1029.
In this study from the university of washington, 321 patients aged 20-64 years presented to their primary care physician with non-specific back pain of more than seven days duration. They were randomly assigned to either the McKenzie method of physical therapy, chiropractic manipulation, or minimal intervention by providing an educational pamphlet on the causes and prevention of low back pain. Patients with sciatica were excluded. Physical therapy and chiropractic sessions were limited to nine over a one-month period, with follow-up over a total of two years. The degree of back pain was measured on an 11-point scale and the level of dysfunction assessed on the 24-point Roland Disability Scale.
No significant difference emerged between the chiropractic and physical therapy group at one month, although the chiropractic group appeared to have slightly less severe symptoms than the booklet group (P = 0.02). Differences in the degree of dysfunction among the three groups were small and approached significance only at one year, with slightly greater dysfunction in the booklet group (P = 0.05). No significant differences appeared in the number of days of reduced activity, work, or in recurrent back pain. About 75% of patients in the physical therapy and chiropractic groups were satisfied with their care, compared with about 30% in the booklet group. The mean costs of care over a two-year period were $437 for the physical therapy group, $429 for the chiropractic group, and $153 for the booklet group. Cherkin and associates conclude that patients with low back discomfort had similar benefits and costs from physical therapy and chiropractic manipulation, and they were only marginally better than those patients receiving the minimal intervention of an educational booklet at a fraction of the cost.
Commentary
Back pain is a significant health issue in primary practice and neurology because of its high prevalence and associated healthcare costs. Many patients self-refer to chiropractors for complaints of back pain, as well as other health issues, as "family chiropractic care centers" emerge, claiming to treat back disorders plus a variety of other conditions. An accompanying study concludes that chiropractic manipulation is worthless against childhood asthma (Balon J, et al. N Engl J Med 1998;339:1013-1020). Most physicians shudder when presented with chiropractic theory of general ill health created by spinal malalignments treatable by spinal adjustments. Neurologists have also encountered the catastrophic complications of carotid or vertebral artery dissection and devastating strokes following cervical spine manipulation.
Cherkin et al demonstrate that chiropractic manipulation is no more effective than a popular form of physical therapy in patients with low back pain. Indeed, providing an educational booklet about low back pain provided almost as much relief. The main difference between the groups was that patients receiving any form of hands-on therapy had a much higher satisfaction rate with their care. Whether these treatments are worth the additional costs is open to future debate.
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