British Medical Journal
June 2, 1990

T W Meade, Sandra Dyer, Wendy Browne, Joy Townsend, A 0 Frank

FROM ABSTRACT

Objective
To compare chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin.

Design
Randomised controlled trial. Allocation to chiropractic or hospital management by minimization to establish groups for analysis of results according to initial referral clinic, length of current episode, history, and severity of back pain.

Patients were followed up for up to two years.

Setting
Chiropractic and hospital outpatient clinics in 11 centers.

Patients
741 Patients aged 18-65 who had no contraindications to manipulation and who had not been treated within the past month.

Interventions
Treatment at the discretion of the chiropractors, who used chiropractic manipulation in most patients, or of the hospital staff, who most commonly used Maitland mobilisation or manipulation, or both.

Main outcome measures
Changes in the score on the Oswestry pain disability questionnaire and in the results of tests of straight leg raising and lumbar flexion.

Results
Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.

A benefit of about 7% points on the Oswestry scale was seen at two years.

The benefit of chiropractic treatment became more evident throughout the follow up period.

Secondary outcome measures also showed that chiropractic was more beneficial.

Conclusions
For patients with low back pain in whom manipulation is not contraindicated chiropractic almost certainly confers worthwhile, long term benefit in comparison with hospital outpatient management.

The benefit is seen mainly in those with chronic or severe pain.

Introducing chiropractic into NHS [National Health Service] practice should be considered.

THESE AUTHORS ALSO NOTE:

“The high incidence of back pain, its chronic and recurrent nature in many patients, and its contribution as a main cause of absence from work are well known.”

Patients were excluded if there was evidence that a nerve root was affected; if major structural abnormalities were visible on radiography; or if osteopenia or an infection was suspected.

All patients underwent x-rays of the lumbar spine.

The patients’ progress was measured with the Oswestry back pain questionnaire, which gives scores for 10 sections including intensity of pain, difficulty with lifting, walking, and traveling. The result is expressed on a scale ranging from 0% (no pain or difficulties) to 100% (highest score for pain or difficulty on all items).

Each patient was re-evaluated at weekly intervals for six weeks, at six months, and at one and two years after entry.

Additional measures of outcome included assessing straight leg raising with a goniometer and lumbar flexion.

Each patient’s treatment was at the discretion of the chiropractor or hospital team. The chiropractors were allowed to give a maximum of 10 treatments, which were intended to be concentrated within the first three months.

RESULTS

“Virtually all the patients treated by chiropractors received chiropractic manipulation with high velocity, low amplitude manipulation at some stage.”

“Patients treated by chiropractors received about 44% more treatments than those treated in hospital.”

“At six weeks 79% of hospital patients had completed treatment compared with 29% of patients treated by chiropractic.”

Almost all hospital patients had completed treatment by 12 weeks, and 97% of chiropractic patients had completed treatment by 30 weeks.

Oswestry scores between the two treatment groups “shows that the change for those treated by chiropractic was consistently greater than that for those treated in the hospital.”

“At two years the patients treated by chiropractic had improved by 7% more than those treated in the hospital.”

“For patients who originally attended a chiropractor the chiropractic treatment was more effective throughout the follow up period.”

“The results were also analyzed according to length of the current episode of pain. In both groups those treated by chiropractors improved more than those treated in hospital.”

“The change in straight leg raising and lumbar flexion was greater in those treated by chiropractic than those treated in hospital and that for nearly all other subsidiary measures patients treated by chiropractors did better than those treated in hospital.”

Fewer patients treated in the hospital were satisfied with their treatment or relieved with their symptoms than by those treated chiropractically.

“Of those with jobs, 21% of patients given chiropractic had time off work because of back pain compared with 35% of hospital patients.”

If all back pain patients without manipulation contraindications were referred for chiropractic instead of hospital treatment, there would be significant annual treatment cost reductions, a significant reduction in sickness days during two years, and a significant savings in social security payments. [Important]

“There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic.”

DISCUSSION

“The results leave little doubt that chiropractic is more effective than conventional hospital outpatient treatment.”

“The confidence intervals for the differences in Oswestry scores were wide, but the degree of improvement recorded for many of the secondary outcome measures suggests that chiropractic has appreciable benefit.”

“The effects of chiropractic seem to be long term, as there was no consistent evidence of a return to pretreatment Oswestry scores during the two years of follow up, whereas those treated in hospital may have begun to deteriorate after six months or a year.” [Important]

“Chiropractic was particularly effective in those with fairly intractable pain-that is, those with a history of severe pain. Although we have discussed the results in terms of differences at the various follow up intervals, the full effects of treatment are better thought of as an integrated benefit throughout the two year follow up period, represented by the area between the curves for the two treatments.” [Important]

“The results from the secondary outcome measures suggest that the advantage of chiropractic starts soon after treatment begins. The reason for the much larger advantage later on is not obvious. Part of the explanation could be that hospital treatment is effective in the short term but not the longer term, perhaps because it is not given for as long as chiropractic.”

“It is unlikely that the benefits of chiropractic are the result of biased outcome assessments or of a placebo effect.”

Specific components of chiropractic are responsible for its effectiveness.

“An obvious possibility is the use of high velocity, low amplitude manipulation in virtually all the patients treated by chiropractic. Another is that chiropractic was given for a longer period than hospital treatment. Whatever the explanation for the difference between the two approaches, however, this pragmatic comparison of two types of treatment used in day to day practice shows that patients treated by chiropractors were not only no worse off than those treated in hospital but almost certainly fared considerably better and that they maintained their improvement for at least two years.” [Key Point]

“Consideration should be given to recognizing appropriately trained and experienced chiropractors and to providing chiropractic within the NHS, either in hospitals or by purchasing chiropractic treatment in existing clinics.”

ADDENDUM

In view of the long-term benefit apparently due to chiropractic we initiated a three-year follow-up in 113 patients.

“At three years the mean fall [improvement] in Oswestry scores for those treated by chiropractic was 9.6 percentage points more than for those treated in hospital.”

The improvement was greater (13.8%) among those presenting with current episodes of more than a month’s duration.

“Among those with a previous history of back pain, the improvement in Oswestry score at three years was 9.7% points greater in patients treated by chiropractic than those treated in hospital.”