Is there evidence for the benefit of chiropractic manipulation for back or neck pain?

Evidence for Benefit of Chiropractic Manipulation for Back or Neck Pain

Chiropractic manipulation is not recommended for patients with rheumatoid arthritis due to potential cervical spine complications, but may provide short-term benefits for acute low back pain in otherwise healthy individuals. 1

Evidence Summary by Condition

Rheumatoid Arthritis

• The American College of Rheumatology (ACR) conditionally recommends against the use of chiropractic therapy for rheumatoid arthritis management 1
• This recommendation is based on:
  • Potential cervical spine complications
  • Perceived lack of benefit specific to RA
  • Burden and costs associated with the treatment

Ankylosing Spondylitis

• The ACR strongly recommends against spinal manipulation in patients with ankylosing spondylitis who have:
  • Spinal fusion
  • Advanced spinal osteoporosis 1
• This recommendation is based on case reports of serious adverse events including:
  • Spine fractures
  • Spinal cord injury
  • Paraplegia following chiropractic manipulation, particularly of the cervical spine 1

Low Back Pain

• For acute low back pain (duration <4 weeks):

  • Spinal manipulation administered by properly trained providers is associated with small to moderate short-term benefits 1
  • The American College of Physicians and American Pain Society conditionally recommend spinal manipulation as a non-pharmacologic option for patients who do not improve with self-care 1

• For chronic low back pain:

  • Spinal manipulation is considered "moderately effective" 1
  • Evidence does not indicate that benefits vary according to the profession of the manipulator (chiropractor vs. other trained clinician) 1
  • No significant differences were found between manipulation and general practitioner care, analgesics, physical therapy, exercises, or back school 1

Safety Considerations

• Serious adverse events after spinal manipulation (such as worsening lumbar disc herniation or cauda equina syndrome) are very rare 1
• Risk for serious adverse events is estimated as less than 1 per 1 million patient visits 1
• Patients with specific conditions should avoid manipulation:
  • Spinal fusion
  • Advanced spinal osteoporosis
  • Rheumatoid arthritis with cervical involvement

Clinical Application

For patients with acute low back pain without contraindications:

1. Consider spinal manipulation as part of a treatment plan if self-care options have failed
2. Limit to short-term use (benefits primarily seen in short term)
3. Monitor for improvement in pain and function
4. Avoid in patients with specific contraindications (spinal fusion, advanced osteoporosis, inflammatory arthritis with cervical involvement)

For patients with chronic low back pain:

1. Consider as one of several moderately effective non-pharmacologic options
2. Other equally effective options include exercise therapy, massage therapy, yoga, cognitive-behavioral therapy, and progressive relaxation 1

Limitations of Evidence

• There is insufficient evidence to recommend chiropractic maintenance therapy for prevention of symptoms or diseases 2
• The core concepts of chiropractic subluxation are not based on sound science 3
• Cost-effectiveness has not been demonstrated beyond reasonable doubt 3

In conclusion, while chiropractic manipulation may offer short-term benefits for acute low back pain in selected patients, it is contraindicated in patients with specific conditions like rheumatoid arthritis, spinal fusion, or advanced spinal osteoporosis due to potential serious complications.