There is a range of evidence demonstrating that chiropractic care is safe and effective. Summaries of some of the most significant evidence, with links (in blue) to the detailed documents and articles, are provided below:
1. Meade et al (1990) Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 300; 1431-1437
This large UK trial funded by the Medical Research Council (MRC) compared chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin. Outcome: chiropractic treatment was 30% more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.
2. Meade et al (1995) Randomised comparison of chiropractic and hospital outpatient treatment for low back pain: results from extended follow up. BMJ 311; 349-351
This follow up trial conducted in 1995, again funded by the MRC, confirmed the findings of the earlier report – patients with low back pain treated by chiropractors derive more benefit and long term satisfaction than those treated by hospitals.
3. RCGP (1999) Clinical Guidelines for the Management of Acute Low Back Pain
- Manipulation can provide short-term improvement in pain and activity levels and higher patient satisfaction.
- The risks of manipulation are very low in skilled hands.
Consider manipulative treatment for patients who need additional help with pain relief or who are failing to return to normal activities.
4. UK BEAM Trial Team (2004) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 329:1377
This recent MRC-funded study estimated the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to “best care” in general practice for patients consulting with back pain. All groups improved over time. Exercise improved disability more than “best care” at three months. For manipulation there was an additional improvement at three months and at 12 months. For manipulation followed by exercise there was an additional improvement at three months and at 12 months. No significant differences in outcome occurred between manipulation in NHS premises and in private premises. No serious adverse events occurred.
5. UK BEAM Trial Team (2004) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 329:1381
Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.
6. European Commission Research Directorate General (2004) European Guidelines for the management of acute non-specific low back pain in primary care.
Summary of recommendations for treatment of acute non-specific low back pain:
- Give adequate information and reassure the patient
- Do not prescribe bed rest as a treatment
- Advise patients to stay active and continue normal daily activities including work if possible
- Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs
- Consider adding a short course of muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
- Consider (referral for) spinal manipulation for patients who are failing to return to normal activities
- Multidisciplinary treatment programmes in occupational settings may be an option for workers with subacute low back pain and sick leave for more than 4 – 8 weeks
7. European Commission Research Directorate General (2004) European Guidelines for the management of chronic non-specific low back pain in primary care (2004)
Manipulation/mobilisation – Summary of the evidence:
- There is moderate evidence that manipulation is superior to sham manipulation for improving short-term pain and function in chronic low back pain (CLBP)
- There is strong evidence that manipulation and GP care/analgesics are similarly effective in the treatment of CLBP
- There is moderate evidence that spinal manipulation in addition to GP care is more effective than GP care alone in the treatment of CLBP
- There is moderate evidence that spinal manipulation is no less and no more effective than physiotherapy/exercise therapy in the treatment of CLBP
- There is moderate evidence that spinal manipulation is no less and no more effective than back-schools in the treatment of CLBP
Consider a short course of spinal manipulation/mobilisation as a treatment option for CLBP.
8. NICE (2006) IPG 183 – Non-rigid stabilisation techniques for the treatment of low back pain – guidance
Chiropractic intervention and posture training can limit episodes of acute pain. Spinal rehabilitation, which may include components such as education, lifestyle change, weight loss, general fitness and specific low-back training exercises, may be required.
9. Department of Health (2006) Musculoskeletal Services Framework
“Chiropractors provide evidence-based, timely and effective assessment, diagnosis and management of certain musculoskeletal disorders.” “The Framework describes a system that enables health and social care professionals to provide more easily a high-quality service to patients. A balanced, well-planned system achieves that, and helps professionals to:
- treat patients at the appropriate point in the system (closer to home or work);
- provide patients with better information to manage their condition, reducing avoidable admissions;
- plan/manage patient flows through primary and secondary care, ensuring appropriate and timely referral to specialist care services;
- develop capacity in primary care by offering a wider range of non-surgical alternatives, eg specialist practitioners, physiotherapy, podiatry, nursing, pain management advice, chiropractic, osteopathy etc.”
10. Low back pain: early management of persistent non-specific low back pain
NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Its guideline on the acute management of patients with chronic low back pain was published in May 2009. The evidence-based recommendations include the following:
- Provide people with advice and information to promote self-management of their low back pain.
- Consider offering a course of manual therapy including spinal manipulation of up to 9 sessions over up to 12 weeks
- Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks
- Consider offering a structured exercise programme tailored to the individual.
11. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. [Santilli et al: Spine J. 2006 Mar-Apr;6(2):131-7. Epub 2006 Feb 3] Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. [Lawrence et al J Manipulative Physiol Ther 2008 Nov-Dec;31(9):659-74].
These studies show the effectiveness of Chiropractic treatment for low back pain with leg pains NB: All chiropractors are trained to provide spinal manipulation. Chiropractors are also trained to provide suitable exercise advice and many have in-house facilities for supervised exercise. Note that chiropractic is a profession, not a treatment. Chiropractors provide a package of care, which may include spinal manipulation, based on a detailed case history and careful diagnosis.
Comparative effectiveness of spinal manipulation for sciatica
In 2006, Santilli et al reported that, compared with sham manipulation, active spinal manipulation is more effective at six months at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion. A recent network meta-analysis of the many different treatment strategies (Lewis et al, 2015) has now concluded that spinal manipulation is one of a number of interventions that provides significant improvement for sciatica compared to inactive control or conservative therapy. The other effective interventions include acupuncture, non-opioid analgesia, epidural injections and surgery. Note that an earlier cohort study demonstrated similar clinical effectiveness and a cost benefit of employing spinal manipulation as opposed to nerve root injections for patients with symptomatic MRI-confirmed lumbar disc herniation (Peterson et al, 2013).
Lewis RA et al (2015) Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal 15, 1461–1477.
Peterson C et al (2013) Symptomatic magnetic resonance imaging-confirmed lumbar disc herniation patients: A comparative effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either high-velocity, low-amplitude spinal manipulative therapy or imaging-guided lumbar nerve root injections. Journal of Manipulative and Physiological Therapeutics219, 36(4), 218-225.
Santilli V et al (2006) Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal 6, 131–137.
The Bronfort Report was published 25th February 2010 by the General Chiropractic Council (GCC) to undertake a systematic review of the current research regarding chiropractic. The purpose of this was to ensure that Chiropractors were undertaking treatment that was evidence based and effective. The report can be accessed at: http://chiromt.com/content/18/1/3
Loghmani MT (PT, PhD, MTC); Warden SJ (PhD). Instrument-assisted cross fiber massage alters regional microvascular morphology in healing knee ligaments suggesting possible angiogenesis. APTA Combined Sections Meeting [platform presentation]. New Orleans (LA). 2011 Feb.
Looney B, Srokose T, Fernández-de-las-Peñas, Cleland J. Graston instrument soft tissue mobilization and home stretching for the management of plantar heel pain: a case series. Journal of Manipulative and Physiological Therapeutics (JMPT). 2011 Feb; 138-142.
Bayliss AJ, Klene FK, Gundeck EL, Loghmani MT. Treatment of a patient with post-natal chronic calf pain utilizing instrument-assisted soft tissue mobilization. APTA CSM [platform presentation]. 2010.
Loghmani MT. Instrument-assisted cross-fiber massage improves blood flow in healing knee ligaments suggesting enhanced angiogenesis. APTA CSM [orthopedic section platform presentation]. 2010.
Brantingham JW, Globe G, Jensen M, Cassa TK, Globe D, Price J, Mayer SN, Lee F. A feasibility study comparing two chiropractic protocols in the treatment of patellofemoral pain syndrome. JMPT. Sep 2009;32(7):536-548.
Loghmani MT, Warden SJ. Instrument-assisted cross-fiber massage accelerates knee ligament healing. Journal of Orthopaedic & Sports Physical Therapy (JOSPT). 2009 Jul;39(7):506-514.
Loghmani MT, Kiesel J, Lassiter J, Taylor L, Beaman M, Grogg J, Streeter H, Warden SJ. Long-term effects of instrument-assisted cross-fiber massage on healing medial collateral ligaments. JOSPT. 2007 Jan;37(1): A18.
Hayes D, Loghmani MT, Lubitz R, Moore E. A comparison of two instrument-assisted soft tissue mobilization techniques: effects on therapist discomfort/fatigue and treatment time. JOSPT. 2007 Jan;37(1): A17.
Burke J, Buchberger DJ, Carey-Loghmani MT, Dougherty PE, Greco DS, Dishman JD. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. Journal of Manipulative and Physiological Therapeutics (JMPT). 2007 Jan;30(1):50-61.
Hammer WI, Pfefer, MT. Treatment of a case of subacute lumbar compartment syndrome using the Graston Technique. JMPT. 2005 Mar/Apr; 28(3):199-204.
Gehlsen GM, Ganion LR, Helfst R. Fibroblast response to variation in soft tissue mobilization pressure. Medicine and Science in Sports and Exercise. 1999 Apr;31(4):531-535.1
Davidson CJ, Ganion LR, Gehlsen GM, Verhoestra B, Roepke JE, Sevier TL. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Medicine and Science in Sports and Exercise. 1997 Mar;29(3):313-319.1
Hammer W. The use of transverse friction massage in the management of chronic bursitis of the hip and shoulder. JMPT. 1993 Feb;16(2):107-111.