Cleveland Chiropractic CollegeKansas City

EDITOR'S LOG

Using Research to Defend and Promote Chiropractic

By Daniel Redwood, DC

(pdf) (197.8 KB)

If the public is to be better educated about the benefits of chiropractic care, chiropractors must be the ones to do the educating. Research is the strongest tool we have to promote our healing art to those unfamiliar with its value and to defend it from unwarranted attacks. We owe it to our patients, our profession, ourselves and future generations to know the facts so that we can share them far and wide.

This does not mean that every practicing DC needs to become a full-time scholar, familiar with the details and nuances of the approximately 100 randomized clinical trials on spinal manipulation. It does mean that to be effective chiropractic ambassadors, we all need a good grasp of the overall picture, along with working knowledge of a small number of studies, reviews and guidelines that will allow us to most effectively deliver our message. And we need to stay up-to-date as new studies emerge.

For much of our history, prior to dawn of the modern era of chiropractic research in the 1970s and 1980s, chiropractors had no choice but to rely completely on powerful true stories about the patients we had helped in our offices. These individual stories still matter and can legitimately be shared with others as part of our outreach. But in this evidence-based era, we must only use these anecdotes as the spice rather than the main course. Otherwise, we risk losing many opportunities to strengthen our case through strategic use of the increasingly broad and deep body of evidence researchers have made available to us. We best honor their work by sharing it widely, forcefully and accurately.

What Can We Accurately Claim?

Low Back Pain

How do we spread a positive message about chiropractic while remaining faithful to the facts, neither overstating nor understating the research data? Let’s start with the condition seen most often by chiropractors—low back pain (LBP).

Can we legitimately claim that spinal manipulation (used here as a synonym for “chiropractic adjustment”) is “of proven benefit” for low back pain? To answer this question, we need to ask a preliminary question: what kind of evidence is sufficient? To persuade those who are not already supporters of chiropractic (particularly other health professionals in our communities and policy makers in government and industry), we need to see at least a modest number of positive randomized controlled trials (RCTs), and ideally the endorsement of spinal manipulation in systematic reviews and/or evidence-based practice guidelines.

For low back pain, we surpassed this threshold at least 15 years ago. There are now several dozen RCTs on spinal manipulation for low back pain, the majority of which show a significant benefit from spinal manipulation, the mainstay (but not the entirety) of chiropractic care. More often than not in these clinical trials, manipulation has outperformed comparison therapies or a placebo. Since at least the mid-1990s, when the U.S. Agency for Healthcare Policy and Research released its landmark guidelines on acute low back pain,¹ which identified spinal manipulation as the only doctor-delivered method shown to both relieve pain and improve function, it has been clear that any evidence-based guidelines process must recognize the effectiveness of spinal manipulation for low back pain. While guidelines^2,3 from chiropractic organizations like the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) are among our profession’s most important initiatives and merit our strong support, guidelines prepared by non-chiropractors carry more weight in our interactions with those outside the profession because they can more readily withstand accusations of bias, however unjustified these might be.

At this time, the strongest single fact we can cite in support of the effectiveness of spinal manipulation is that the 2007 low back pain guidelines,⁴ jointly prepared by the American College of Physicians and the American Pain Society identify spinal manipulation as a method “of proven benefit” for acute, subacute and chronic low back pain. While the ACP-APS guidelines recognize several “nonpharmacologic” methods as effective for subacute and chronic cases, (intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, and progressive relaxation), only spinal manipulation is also recognized as effective for acute low back pain.

In this cost-conscious time, DCs should also know that a recent review⁵ on the cost-effectiveness of methods endorsed in the ACP-APS guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, and that there was insufficient evidence to reach a conclusion about its cost-effectiveness for acute cases. To put this into context, the review also found that there was no evidence at all on the cost-effectiveness of medications for low back pain of any duration. When facing questions about chiropractic’s cost-effectiveness, this fact should always be noted.

Chiropractors should also be aware that the ACP-APS guidelines also include some recommendations with which we disagree (e.g., prioritizing pain medications as a first-line, “self-care” approach that should precede referral for spinal manipulation). Nonetheless, the fact that the widely-recognized ACP-APS guidelines conclude that manipulation has proven effectiveness carries a “final verdict” kind of power that we should all be ready to quote early and often.

While the ACP-APS guidelines may be our strongest calling card in policy settings, there is great power in also being able to share some of the dramatic specifics from individual studies. With so many studies on low back pain available, individual DCs may differ as to which two or three to have handy. I still often quote the early studies by Kirkaldy-Willis and Cassidy⁶ and Meade^7,8 (both involving orthopedic surgeons who found chiropractic care extraordinarily effective). Others on my personal highlight reel are the large and influential UK BEAM study,^9,10 which demonstrated both effectiveness and cost-effectiveness; and the smaller Wilkey et al trial¹¹ on chronic LBP, performed inside the British National Health Service, where chiropractic yielded five times as much improvement on disability measures as that achieved by conventional medical care.

In addition, every chiropractor worldwide should be familiar with the award-winning 2010 study by Bishop and colleagues,¹² which showed that guidelines-based care including chiropractic spinal manipulation was far more effective than “usual care” from family practice MDs, while also showing that typical medical care was poorly adherent to guidelines, with 78% of medical patients receiving prescriptions for narcotics (such as Tylenol 3 with Codeine), which are not guideline-endorsed.

Low Back Pain with Sciatica

An important subset of low back pain cases involves disc-related sciatica. The research on this is far less extensive than for low back pain without leg pain, but two major RCTs have demonstrated very positive responses to chiropractic care. The Santilli et al trial,¹³ written by three MDs about care delivered by chiropractors, found that acute lumbar disc syndrome responded far better to spinal manipulation than to sham manipulation, while the McMorland et al study¹⁴ (with a DC as lead author and three neurosurgeons as co-authors) found that 60% of patients who would otherwise have been sent for microdiskectomy were able to achieve equivalent outcomes through chiropractic, and thus able to avoid surgery. Anytime you are confronted with an assertion that chiropractic may be appropriate for low back pain but not if sciatica is involved (as still happens frequently, in person and in print), citing the Santilli and McMorland studies is the strongest response.

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"For much of our history, prior to dawn of the modern era of chiropractic research in the 1970s and 1980s, chiropractors had no choice but to rely completely on powerful true stories about the patients we had helped in our offices. These individual stories still matter and can legitimately be shared with others as part of our outreach. But in this evidence-based era, we must only use these anecdotes as the spice rather than the main course. Otherwise, we risk losing many opportunities to strengthen our case through strategic use of the increasingly broad and deep body of evidence researchers have made available to us. We best honor their work by sharing it widely, forcefully and accurately.”