AMA Validates Chiropractic?

Under the heading of, "I never thought I'd see the day when..." comes a study recently published in the Journal of the American Medical Association (JAMA).¹ The goal of the study was to "systematically review studies of the effectiveness and harms of SMT (spinal manipulative therapy) for acute (6 weeks) low back pain." Paige, et al., identified 26 randomized clinical trials (RCTs) to measure improvements in pain and function, and assess any harm.

Important Findings

• Fifteen RCTs comprising a total of 1,711 patients "provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain."
• Twelve RCTs comprising 1,381 patients "produced moderate-quality evidence that SMT has a statistically significant association with improvements in function."
• "No RCT reported any serious adverse event."
• The authors concluded that SMT provides "modest improvements" in both pain and function for up to six weeks. While this might seem like faint praise, the most recent studies on drug alternatives to chiropractic care have demonstrated the following:
• "Paracetamol [acetaminophen] is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis. These results support the reconsideration of recommendations to use paracetamol for patients with low back pain and osteoarthritis of the hip or knee in clinical practice guidelines."²
• "[C]ompared with placebo, NSAIDs do not provide a clinically important effect on spinal pain, and six patients must be treated with NSAIDs for one patient to achieve a clinically important benefit in the short-term."³
• "[W]hen this result is taken together with those from recent reviews on paracetamol [acetaminophen/Tylenol] and opioids, it is now clear that the three most widely used, and guideline-recommended medicines for spinal pain do not provide clinically important effects over placebo."³

An MD in Our Corner?

Published in the same issue with the Paige, et al., study is an editorial by Richard A. Deyo, MD, MPH.⁴ Dr. Deyo has dedicated several decades to the study of spine care. The list of papers he has participated on is extensive. (His work has been referenced 92 times in Dynamic Chiropractic alone.) In his editorial, Dr. Deyo makes many important points including:

• Thirty percent of patients with back or neck pain seek chiropractic care.⁵
• Fifty-nine percent of consumers surveyed by Consumer Reports were highly satisfied with chiropractic care compared to 55 percent for PTs and 34 percent for primary MDs.⁶
• Serious complications for low-back SMT are very rare, while NSAIDs users commonly see renal and gastrointestinal adverse effects.^7-8
• Looking at the cost of drugs, surgery and their complications, chiropractic back pain patients "did not incur higher overall treatment costs compared with those who received only conventional care."⁵

Progress at Last?

All of the above reinforces our understanding that drugs (and certainly surgery) are not the answer. As established by the AHCPR in Acute Low Back Problems in Adults: Assessment and Treatment some 23 years ago, spinal manipulation (chiropractic, according to the definition used by the panel) "is safe and effective for patients in the first month of acute low back symptoms without radiculopathy."⁹

On Sept. 25 of this year, we will be celebrating the 30th anniversary of Judge Getzendanner's decision that the AMA violated the Sherman Act in its attempt to restrain trade through a conspiracy "to contain and eliminate the chiropractic profession."¹⁰ How fitting it is that the AMA's primary journal has finally published a study, with an editorial, demonstrating the value of chiropractic after all these years.

The AMA as an organization hasn't really validated chiropractic, but its flagship journal has published two articles that will speak loudly to AMA members and the world about one of the benefits of chiropractic care.

Author's Note: The Paige, et al., study completes a circle that required decades of work by many. We have seen the tide change from an open effort to destroy chiropractic to publishing a study to demonstrate our value. This is hopefully just the beginning.

References

1. 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;317(14):1451-1460.
2. Machado GC, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomized placebo controlled trials. BMJ, 2015;350:h1225.
3. Machado GC, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Disease; e-pub ahead of print, Feb. 2, 2017.
4. Deyo RA. "The Role of Spinal Manipulation in the Treatment of Low Back Pain." (Editorial) JAMA, 2017;317(14):1418-1419. (Please note that Dr. Deyo's editorial is less than two pages long without references. You can read the entire first page free by clicking on the link in the article where I discuss Dr. Deyo.)
5. Martin BI, Gerkovich MM, Deyo RA, et al. The association of complementary and alternative medicine use and health care expenditures for back and neck problems. Med Care, 2012;50(12):1029-1036.
6. "Relief for Your Aching Back: What Worked for Our Readers." Consumer Reports, 2013.
7. Whelton A, Hamilton CW. Nonsteroidal anti-inflammatory drugs: effects on kidney function. J Clin Pharmacol, 1991;31(7):588-598.
8. Vonkeman HE, van de Laar MAFJ. Nonsteroidal anti-inflammatory drugs: adverse effects and their prevention. Semin Arthritis Rheum, 2010;39(4):294-312.
9. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994.
10. "U.S. Judge Finds Medical Group Conspired Against Chiropractors." The New York Times, Aug. 29, 1987.

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