Whenever a doctor and patient select a treatment, they do so because they anticipate the benefits of that treatment will exceed its potential harms. Thus, it is critically important that information is available which combines the best evidence on both benefits and harms.11 The wide variation in care for patients with low back pain suggests there is professional uncertainty about the optimal approach and the quality of data regarding benefits and harms.7, 12
Numerous systematic reviews have provided guidance for patients with chronic low back pain.1-5, 8-10, 13-14 Although these reviews provide data regarding the benefits of various treatments, they do not provide data about the frequency or severity of potential harms. Yet harms are easier to inflict, and can have greater and more enduring effects than benefits.
In practice, doctors and patients need to compare many treatment options. To do this, they need summary statistics for both benefits and harms. It is difficult to select the best treatment option when you do not have data for both factors.
Important New Research Comparing Benefits and Harms
Recently, an international, multidisciplinary research team conducted a systematic review and meta-analysis to compare the benefits and harms of common treatments for adults with nonspecific chronic low back pain without radiculopathy.
The study was published in The Spine Journal, the highest-rated spine science journal.6 The research team consisted of three PhDs, one spine surgeon, one doctor of pharmacy, and one doctor of chiropractic. The team members hail from prestigious research institutions, including the University of Sydney, University of Colorado, Weill Cornell Medical Center, Italian Scientific Spine Institute, Macquarie University, and the Institute of Evidence-Based Chiropractic.
The review investigated studies of common interventions, including nonpharmacological treatments (spinal manipulation, needle acupuncture), pharmacological treatments [skeletal muscle relaxants, opioid analgesics, gabapentinoids (gabapentin and pregabalin, systemic corticosteroids, NSAIDs, acetaminophen)], and invasive treatments (spinal surgery, spinal corticosteroid injections).
The search retrieved 17,362 records. Benefit studies were required to be high-quality, placebo-controlled, randomized clinical trials with at least 30 patients per group and a loss to follow-up of less than 20%.
The Benefit-Harm Scale
The Benefit-Harm Scale is a newly developed scale that summarizes benefits and harms of specified treatments in a simple format that is easy for doctors to understand. The benefit domain recognizes that reproducibility of clinical trial findings is important, so it values multiple trials over a single trial.
Because measuring serious adverse events is more important than including reports of mild pain that resolve quickly, the research team examined only serious adverse events.
The Findings for Benefits
This meta-analysis provided 22 summary data points. Overall, the research team found that acupuncture and manipulation were effective in reducing pain intensity. The benefits of the pharmacological and invasive interventions were uncertain due to the absence of trials meeting the eligibility criteria. It was surprising that there was no quality research for any of the pharmacological agents, corticosteroid injections or surgery.
The Findings for Harms
The harms warnings (serious adverse events) were lowest for acupuncture, spinal manipulation, NSAIDs, combination-ingredient opioids, and steroid injections; and higher for single-ingredient opioid analgesics (moderate risk) and surgery (very high risk).
Benefits And Harms Of Interventions For Chronic Low Back Pain
Chiropractic Answers the Call
The chiropractic profession has long been criticized for lacking quality clinical research. But over the past two decades, the profession has published numerous quality studies in prestigious medical journals. The vast majority of these studies support the effectiveness and safety of chiropractic care.
In contrast, there is an absence of quality research to support the use of pharmaceuticals and spinal surgery for patients with chronic low back pain. Do those treatments have any value? Are they more harmful than beneficial? Right now, we cannot be certain, because pharma companies and surgeons have failed to provide quality research.
Until and unless we have convincing research to support the use of drugs and surgery for low back pain, doctors, patients, insurance companies and regulators need to use the utmost care in assessing treatment options, based on the best available evidence regarding safety and effectiveness.
References
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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A central challenge in creating our identity is that chiropractic is a method of care, not a technique or procedure. This is an important concept for us to promote. Our patients are treated with lifestyle modification, exercise, nutritional supplements, diet and a whole-body approach to accelerate the natural healing process. We are not simply CMT providers.
The results of a global survey released late last year (2023) unveiled some startling findings among medical and nursing students. The “Clinician of the Future: 2023 Education Edition” surveyed 2,212 students, of which 446 were in the United States, from 91 countries.
