JAMA. 2017 (Apr 11); 317 (14): 1451–1460 ~ FULL TEXT
Neil M. Paige, MD, MSHS, Isomi M. Miake-Lye, BA, Marika Suttorp Booth, MS,
Jessica M. Beroes, BS, Aram S. Mardian, MD, Paul Dougherty, DC,
Richard Branson, DC, Baron Tang, PT, DPT, Sally C. Morton, PhD,
Paul G. Shekelle, MD, PhD
West Los Angeles Veterans Affairs Medical Center,
Los Angeles, California.
Commentary from the Illinois Chiropractic Society |
JAMA Endorses Spinal Manipulation
For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain.  On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.
The authors concluded:
“Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”
This study comes on the heels of a February 2017 Clinical Practice Guideline from the
American College of Physicians recommending spinal manipulation for acute,
sub-acute, and chronic low back pain (LBP).
These high-quality studies in respected medical journals add to a growing list of scientific support for spinal manipulation therapy (SMT). So why are our offices not flooded with medical referrals? An editorial accompanying the JAMA study provides perspective as to why some medical providers may be reluctant to refer to chiropractic physicians:
“Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors. Chiropractic therapy is not widely accepted by some traditional health care practitioners. This may be, at least in part, because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.
However, chiropractic care is popular today with the US public. According to a 2012 report, among patients with back or neck pain, approximately 30% sought care from a chiropractor. In a 2013 survey by Consumer Reports magazine involving 14,000 subscribers with low back pain, chiropractic care had the largest proportion of "highly satisfied" patients. Among approximately 4000 respondents who had seen a chiropractor, 59% were highly satisfied compared with 55% who saw a physical therapist and 34% who saw a primary care physician.
“Serious complications (related to SMT) are extremely rare… if spinal manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for patients with uncomplicated low back pain”.
The emerging health care model dictates that all providers embrace proven clinically effective treatments, regardless of long-standing philosophical bias. If we expect medical providers to advance their thinking to accept validated chiropractic therapies, we must first be willing to reciprocate. By working together to provide evidence-based patient-centric care, we can advance our profession to become the undeniable first choice for both patients and providers.
Paige NM, Miake-Lye IM, Booth MS, et al.
Association of Spinal Manipulative Therapy With Clinical Benefit and Harm
for Acute Low Back Pain; Systematic Review and Meta-analysis
JAMA. 2017 (Apr 11); 317 (14): 1451–1460
Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee
of the American College of Physicians.
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Ann Intern Med. 2017 (Apr 4); 166 (7): 514–530
The Role of Spinal Manipulation in the Treatment of Low Back Pain.
JAMA. 2017; 317 (14): 1418-1419
IMPORTANCE: Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT.
OBJECTIVE: To systematically review studies of the effectiveness and harms of SMT for acute (?6 weeks) low back pain.
DATA SOURCES: Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms.
DATA EXTRACTION AND SYNTHESIS: Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.
MAIN OUTCOMES AND MEASURES: Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks.
FINDINGS: Of 26 eligible RCTs identified, 15 RCTs (1,711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1,381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.
CONCLUSIONS AND RELEVANCE: Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.
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