Chiropractic vs. Medicine for Acute Low Back Pain- Spine Journal 2010

This post is not meant to pick on any profession. It is meant to educate. I work with many M.D.’s and have M.D. friends.

Pub Med.Gov:  SpineJournal-2010;10:1055-1064.

The Spine Journal, one of the most frequently cited spine research journals in the world, the health care community at large may finally appreciate what the chiropractic profession has known for more than a century: Patients with acute mechanical low back pain enjoy significant improvement with chiropractic care, but little to no improvement with the usual care they receive from a family physician.

Acute low back pain patients demonstrate significantly greater improvement with chiropractic than “usual care.”

The Chiropractic Hospital based Interventions Research Outcomes
(CHIRO) Study:

a randomized controlled study on the effectiveness of clinical practice guidelines in medical and chiropractic management of patients with acute mechanical Low Back Pain

Bishop PB, DC, MD, PhD et al.

Key Points: Chiropractic manipulation resulted in consistently better results.

Another study shows that chiropractic care for low-back pain is significantly superior to usual care from a medical physician.

The study, conducted by researchers at the University of British Columbia in Vancouver, enrolled 92 patients with acute mechanical LBP between the ages of 19 to 59 years.

The study participants were randomly assigned to receive either chiropractic care or usual care from a family medical doctor.

Results revealed that the chiropractic patients had significantly better improvement, compared with medical patients.

This important hospital based study demonstrates that clinical practice guideline consistent care including chiropractic spinal manipulation resulted in consistently better results at 8, 16, & 24 weeks for multiple outcome measures than usual, non-clinical practice guideline consistent care provided by primary care medical doctors in a hospital based spine outpatient clinic.

Even in measures for reduction of back pain, clinical practice guideline consistent care with only acetaminophen and Spinal Manipulation resulted in as much pain reduction as the use of opiods in the usual, non-clinical practiced guideline based care.

Spinal manipulation, an integral part of the clinical practice based guideline care, is an effective, international validated and accepted, mainstream intervention in acute mechanical back pain that when used in conjunction with other validated interventions (acetaminophen, a progressive walking program, avoidance of bed rest and no exercise training in the acute phase) results in better results at 8, 16, and 24 wks of follow-up.

In addition, as noted in the discussion section of the paper, the improved outcomes at the end of the acute phase, as well as, at 24 weeks may increase the likelihood of better long-term outcomes.

This is the subject of a future prospective, longitudinal study which is based on long-term follow-up of the two patient groups in this clinical trial.

Previous published research indicates that the development of chronic and/or recurrent back pain is often preceded by poor outcomes during the acute phase. The improved 16 & 24 week outcomes may predict significantly better outcomes at one year or possibly longer follow-ups. This is a very significant study.

Evidence-based clinical practice guidelines (CPGs) for the management of patients (Pts) with acute mechanical low back pain (AM-LBP) (<4 weeks) have been defined on an international scale as a result of many goverment funded multidisciplinary panels developing evidenced-based guidelines. Multiple trials demonstrate that most AM-LBP Pts don’t receive CPG-based treatment (Tx). This prospective, randomized controlled trial (RCT) is to determine if full CPGs-based care (CPGC) which fulfills 7 of 7 criteria of CPGs results in greater improvement in functional outcomes than primary care physician (PCP)–directed usual care (UC) (consistent with only 2 of 7 CPG criteria) in Tx of AM-LBP. Txs were performed in a hospital-based spine program outpatient clinic.

Patients: 19 to 59 years with 2-4 weeks of AM-LBP.

Outcomes: Roland-Morris Disability Questionnaire (RDQ) baseline at 16 wks (the end of the acute phase), 8 & 24 wks. Short Form-36 bodily pain scale (BP) & physical functioning scale (PF) scores at 8, 16, & 24 wks.

Methods: Pts assessed by a spine physician & randomized to Group 1. CPGC: reassurance, avoidance of passive Tx (bed rest, heat, back supports/corsets/braces), acetaminophen, a progressive walking program, a maximum of 4 wks of chiropractic delivered lumbar spinal manipulation (SM: 2-3x/wk of side posture, high velocity low amplitude technique), no exercise program, & return to work within 8 wks.
Group 2. Primary care physician (PCP) directed usual care (UC).

Results: 36 CPGC & 35 UC Pts completed all follow-ups. Baseline prognostic variables were similar in both groups. Improvement in RDQ scores, was significantly greater in CPGC group than in the UC group. RDQ scores were also greater in the CPGC group at other time points, particularly at 24 weeks (p<.004). Improvements in SF-36 PF scores favored the SC group at all time points; but differences weren’t statistically significant. The evidence-based care group demonstrated significantly greater improvements in reported function through 6 months of follow-up. There were high rates of opioid use (78%) & passive modalities (60%) in PCP ‘‘usual care’’ group, but much less aerobic exercise or SM (6%) used. 78% of Pts in the UC group, vs 0% of CPGC Pts were taking narcotic analgesic meds. This use of narcotic analgesics would normally bias the SF-36 BP scores in favor of the UC group; yet, CPGC Pts showed comparable improvement in BP scores.

Conclusion: There were high rates of opioid use & passive modalities in UC at a university-based hospital. Implementation of CPGC may be truly beneficial to Patients & not just to payers’ strategy to minimize costs.

This is the first RCT assessing the efficacy of full, multimodal, CPG-based therapy for AM-LBP. Two previous studies demonstrated that UC by PCPs are often highly guideline discordant.

Studies demonstrate that PCPs are highly resistant to changing their practice patterns for managing AM-LBP Pts.

This study demonstrates that in AM-LBP of <4 wks of comprehensive CPGC including chiropractic spinal manipulation had great improvement in condition-specific functioning (RDQ scores) at 16 wks, that is throughout the entire duration of the acute phase of the clinical course.

Whether Pts in either Tx group later experience reoccurrences or go on to develop CLBP is the subject of a future study.

The importance of improving Pts outcomes within the acute phase is important because the development of chronic & often refractory LBP is commonly preceded by a poor outcome from the management of the Pts’ AM-LBP.

CPG based care was significantly greater than guidelines-discordant care at 16 wks, & this benefit was maintained at 24 wks.

If you are suffering from: Sports Injuries, Sprains, Strains, Car accident,  Herniated Disc, Disc Bulge, Degenerative Disc Disease, Neck pain, Headaches, Low back pain, of just want to feel better and have better life performance– please call our office in Irvine, California- at 949.857.1888or visit our website at ADJUST2IT to learn more about Functional Fitness Chiropractic, Sports massage, Myofascial Release, Corrective Exercise, Non Surgical Spinal Decompression, Class IV laser,  and Functional Nutrition.

Other good articles:

1.  Chiropractic cost effective-Blue Cross Blue Shield claims analysis-JMPT 2010

2. A New Gatekeeper for Back Pain

3. Chronic Spine pain-Journal of Spine 2003-JMPT 2005

4. Chronic Low Back Pain-Medical Hypotheses Journal 2007

5. Health Related Quality of Life Model

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