CHIROPRACTIC: Two Studies Dispute Treatment Efficacy
"Chiropractors are no more effective than physical therapists in treating lower back pain, and are ... only marginally successful at easing their patients' symptoms," according to a study published in today's New England Journal of Medicine. A second study in the same issue concludes that spinal manipulation "provides 'no benefit' for children with mild or moderate asthma," a conclusion that challenges chiropractors' treatment of nonmusculoskeletal conditions. The study findings are "fueling an already fiery debate about" the cost-effectiveness and efficacy of alternative practitioners (Tye, Boston Globe, 10/8). According to the Los Angeles Times, the back pain study calls into question "the main reason people go to chiropractors" (Monmaney, 10/8).
Back Pocket Pain
The first study, led by researchers from the University of Washington, tracked 321 adults with lower back pain through two years of either chiropractic manipulation, physical therapy or minimal intervention. The control group receiving only minimal intervention were provided with an educational booklet, but received no physical intervention. The researchers found that "there were no significant differences" in reported dysfunction "between the physical therapy and chiropractic groups." They also reported "no significant differences" in recurring back pain, number of days of reduced activity, or the amount of lost work attributed to back pain. The researchers concluded that patients receiving physical interventions "had only marginally better outcomes that those receiving the minimal intervention of an educational booklet." However, the differences in cost were substantial. Over the two-year study period, the cost to those in physical therapy was $437, for those visiting a chiropractor, $429, and for those receiving an educational booklet, $153. The authors conclude, "Whether the limited benefits of these treatments are worth the additional costs is open to question" (Cherkin et al., New England Journal of Medicine, 10/8 issue).
The second chiropractic study investigated the benefit of spinal manipulation for children with asthma. The researchers measured the peak expiratory flow for eighty children divided into two groups -- one group received chiropractic treatment while the control group received simulated chiropractic care. While patients in both groups reported an increase in "quality of life," researchers found "no significant differences between the groups" in regard to a change in expiratory flow. The authors conclude, "In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit" (Balon et al., 10/8 issue).
The New England Journal contains an accompanying editorial by Dr. Paul Shekelle of the West Los Angeles Veterans Affairs Medical Center. Shekelle wrote that while "spinal manipulation is a somewhat effective symptomatic therapy for some patients with acute low back pain ... [w]hat is in dispute is the efficacy of spinal manipulation in relation to other therapies." Citing the back pain study's finding of "no appreciable difference in outcomes" between spinal manipulation and minimal intervention, he also questioned the cost-effectiveness of chiropractic services. He wrote, "I conclude that chiropractic care for low back pain, at least as practiced in the United States, costs more than the usual supportive medical care delivered by [HMOs]." Shekelle concluded, "The challenge for chiropractors is to demonstrate that they can achieve this benefit at a cost that patients or health insurers are willing to bear" (10/8 issue).
"I am surprised really that this rose to the level of warranting publication in the New England Journal," asserted Jerome McAndrews, American Chiropractic Association spokesperson. He charged that the back pain study was "highly limited" and excluded patients "commonly and effectively treated by chiropractors, including pregnant women and people who have had back surgery." McAndrews said he feared the study would prompt a "chilling backlash" against chiropractors by managed care plans (Boston Globe, 10/8). Furthermore, an ACA statement contends that the physical therapy method used for comparison in the study is in fact incorporated into some forms of chiropractic treatment and, as such, the study design does not accurately convey the differences between the two treatments. In addition, the ACA argues that chiropractic therapy incorporates manipulation, stretching and patient education, it would be reasonable to expect less favorable outcomes by extracting only one treatment strategy for use in comparison (ACA release, 10/7). Responding to the study conclusion that minimal intervention is as cost-effective as other approaches to back pain, Dr. Robert Crocker, spokesperson for the New York State Chiropractic Association, said, "I'm sure the physical therapists would agree with us that the millions of people who consult and pay for care would certainly not think it could be replaced by a pamphlet."
A Maturing Profession
McAndrews "said his group was pleased the asthma report had been published and that more studies are ongoing." One of the researchers involved in the asthma study, Dr. Jeffrey Balon of the Canadian Memorial Chiropractic College, noted that his research was financed by four chiropractic groups. "It shows we're maturing as a profession. We are capable of carrying on multi-discipline research at a high level and are not afraid to publish the results," he said (Kerr, Newsday, 10/8). Click here to listen to a National Public Radio report on the NEJM studies.