As doctors of chiropractic are well-aware, back pain is a troubling and all-too-common phenomenon. Of the millions of people with back pain who choose to see a health care provider annually, 70 percent are seen by either a chiropractor or a medical doctor for treatment.
A new observational study published in the Journal of Manipulative and Physiological Therapeutics examined the effectiveness of chiropractors versus medical doctors in managing patients with both acute and chronic low back pain (LBP) in a nonrandomized clinic setting. Specifically, the study "reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain ... and assesses the influence of doctor type and pain duration on clinical outcomes." The research team discovered that while both MDs and DCs were effective in relieving pain, chiropractors did a better job of relieving chronic pain in the short term, and provided greater relief for both acute and chronic pain patients for up to a year after treatment.
The study involved 2,780 patients of medical doctors and chiropractors at more than 60 clinics over a two-year period. All of the patients were at least 18 years old and had suffered either acute (seven weeks or fewer) or chronic (more than seven weeks) LBP of mechanical origin. Data were obtained at each patient's initial visit, using a self-administered questionnaire. Follow-up questionnaires were mailed to all patients at 2 weeks, 1 month, 3 months, 6 months and 12 months after the first visit. Patients enrolled during the first year of the survey received additional questionnaires at 24 and 36 months; those enrolled in the second year were surveyed at 36 and 48 months.
The practitioners in the study employed a variety of methods to treat back pain. "Chiropractic care" included spinal manipulation, physical therapy, exercise plans and self-care education. "Medical care" involved prescription drugs, exercise plans and self-care advice; approximately 25 percent of this group referred for physical therapy.
Patients rated the severity of their pain using a 100-point visual analog scale. Other statistical methods used in the analysis included the Revised Oswestry Disability Questionnaire (to measure functional disability), a medical outcomes study (to assess physical functioning, general health, vitality and other parameters), a depression questionnaire, and six-point Likert scales to evaluate stress levels.
Pain reduction and improvement in disability were observed in all four groups. Most of the pain relief was achieved by three-month follow-up, and remained relatively constant through 12 months. However, pain and disability levels rose substantially between 12 months and 24 months, then plateaued through to the four-year follow-up.
The researchers noted a "modest advantage" in chronic LBP patients treated by a chiropractor compared to a medical doctor in the first 12 months, with "clinical importance" noted at one month and three months after the initial visit. With acute back pain patients, only a slight advantage was seen for chiropractic care in the first 12 months.
"Our study generally supports the findings of systematic reviews of spinal manipulation for a profession whose signature therapy is manipulation. Interestingly, an advantage for DC care was notable for chronic patients, a population for which systematic reviews have been more circumspect," the research team noted.
In terms of pain levels, "clinical important differences" were seen in both acute and chronic LBP patients receiving chiropractic care compared to patients treated by a medical doctor, "at all time points within 12 months" of the initial visit. On average, VAS scores were 12.2 points lower in chronic LBP chiropractic patients at the one-month follow-up, and 10.5 points lower at the three-month follow-up, than chronic LBP patients receiving medical care.
These differences were even more dramatic when leg pain was included in the analysis. Chronic LBP patients with pain radiating below the knee who were treated by a chiropractor had pain levels an average of 18.3-21.7 points lower than the same subgroup of patients treated by a medical doctor. Disability levels were 9.0-13.9 points lower over a three-year period in the same chiropractic subgroup.
"Perhaps the greatest potential for DC care is in treatment of LBP with concomitant pain radiating below the knee," the investigators opined. "Chronic care for LBP in general should be explored."
At the three-year follow-up, patients were also asked to recall the number of days they had suffered low back pain in the previous year. Patients in the acute groups recalled having LBP less frequently than chronic patients; in each group, however, patients receiving chiropractic care reported fewer days of LBP than those treated by a medical doctor.
"In terms of relative effectiveness, chiropractic care demonstrated advantage over medical care for chronic patients in the first year, particularly for those with leg pain radiating below the knee," the researchers concluded. "Most of the relief was achieved within 3 months and sustained for 12 months; greater improvement was seen in acute patients." They add that while LBP patients appear to approve under the care of either a chiropractor or medical doctor, patient choice of provider and referrals between professions should be "prime considerations" for health care practitioners, policy-makers and third parties in identifying the appropriate services and treatments for back pain.
Reference
Haas M, Goldberg B, Aickin M, et al. A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up. Journal of Manipulative and Physiological Therapeutics March/April 2004;27 (3):160-169.
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