Effectiveness Studies

The Manga Report
As the largest existing analysis of scientific literature on low back pain, the 1993 Ontario Ministry of Health commissioned study drew international attention when it recommended the management of low back pain be moved from medical doctors to chiropractic doctors.

Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

The researchers also stated that studies on the prevalence and incidence of low back pain suggest that it is the leading cause of disability and morbidity in middle-aged persons, and is by far the most expensive source of workers' compensation costs North America.

The Canadian Government report concluded with the following findings:

• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by non-chiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;
• In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:
• the effectiveness and cost effectiveness of chiropractic management of low back pain
• the untested, questionable or harmful nature of many current medical therapies
• the economic efficiency of chiropractic care for low back pain compared with medical care
• the safety of chiropractic care
• the higher satisfaction levels expressed by patients of chiropractors.

The following recommendations were also included in the report:

• There should be a shift in policy to encourage and prefer chiropractic services for most patients with low back pain;
• Chiropractic services should be fully insured under the Ontario Health Insurance Plan;
• Chiropractic services should be fully integrated into the health care system;
• Chiropractors should be employed by tertiary hospitals in Ontario;
• Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs;
• Chiropractic should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients;
• Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with low back injuries;
• A very good case can be made for making chiropractors the gatekeepers for management of low back pain in the workers' compensation system in Ontario;
• The government should make the requisite research funds and resources available for further clinical evaluations of chiropractic management of low back pain, and for further socioeconomic and policy research concerning the management of low back pain generally;
• Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public finding;
• Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.

1.  The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain. Pran Manga and Associates. University of Ottawa, Canada - 1993.

The Agency on Health Care Policy and Research Study
On December 8, 1994, the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services released Clinical Practice Guidelines for the management of acute low back pain. Their guidelines were developed after extensive study of diagnostic and treatment methods for acute low back pain.

The guidelines were created by the AHCPR panel to provide primary care clinicians with information and recommended strategies for the assessment and treatment of acute low back problems. The AHCPR panel was made up of 23 members consisting of medical doctors, chiropractic doctors, nurses, experts in spinal research, physical therapists, an occupational therapist, a psychologist, and a consumer representative.

The following conclusions were made in this landmark study:

• Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
• Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.

Other interesting finds included:

• The risk of serious complications from lumbar spinal manipulation is rare;
• There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
• The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.

1.  Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (U.S. Department of Health and Human Services) -1994.

The Rand Corporation Study - Members of the Medical Community Recognize Chiropractic's Effectiveness
This study, conducted by the prestigious RAND Corporation, marks the first time representatives of the U.S. medical community have gone on record stating that chiropractic is an appropriate treatment for certain low back pain conditions. A second, all-chiropractic panel's ratings show agreement with the multidisciplinary panel that spinal manipulation is appropriate for specific kinds of low back pain. A utilization study examining chiropractic patients' charts in multiple geographical locations in the United States is now underway. This will allow investigators to examine actual clinical cases and learn how prevalent each condition is in practice.

The RAND Corporation ("Research and Development") is a nonprofit private corporation in Santa Monica, California. They conduct research and development for the U.S. government and private sector, commanding international respect. Its research programs include classified defense research for the military, applied economics, education, sociology, civil justice and health sciences.

The Av-Med Study
In this study, 80 patients who previously received medical treatment were subsequently referred to the Silverman Chiropractic Center. Of the 80 patients, 21 percent had just been diagnosed with spinal disc problems, 12 percent had been diagnosed as requiring surgery and 5 percent had received emergency room treatment. Following chiropractic treatment, none of the patients were required to have surgery, 86 percent of the patients needed no further care, and the estimated health care savings in the group of 80 was estimated to be $250,000.

1.  The Av-Med Study - 1993.

The Midwest Research Institute Study
This study examined clinical trials published in the professional literature between 1930 and 1981.

The researchers concluded that:

• manual therapy was superior to placebos,
• there was greater mobility following manipulation,
• the duration of treatment was shorter for the manipulated groups,
• there was improved lateral flexion and rotation after manipulation,
• the numerous case studies throughout the literature report the satisfaction of chiropractic patients with the outcome of treatments.

The Annals of Internal Medicine Study - The Third Most Widely Read Medical Journal Finds Chiropractic A Winner In Low Back Pain
The use, complications, and efficacy of spinal manipulation for low back pain was reviewed in the Annals of Internal Medicine, the third most widely read medical journal. The article concluded that spinal manipulation clearly helps patients with uncomplicated, acute low back pain.

1.  Spinal Manipulation for Low Back Pain. Shekelle P, et al. Annals of Internal Medicine - 1992;117:590-598.