What is the evidence for chiropractic care in treating back pain?

Evidence for Chiropractic Care in Back Pain

Chiropractic spinal manipulation is a moderately effective treatment option for both acute and chronic low back pain, with small to moderate short-term benefits for acute cases and moderate benefits for chronic cases, comparable to other effective therapies like exercise and physical therapy. 1

Acute Low Back Pain (< 4 weeks)

For acute low back pain, spinal manipulation provides small to moderate short-term benefits and should be considered when patients do not improve with self-care options. 1

• Spinal manipulation administered by appropriately trained providers shows superiority over sham manipulation, with pain reduction of approximately 10 points on a 100-point visual analogue scale 1
• Functional improvement on the Roland-Morris Disability Questionnaire (RDQ) averages 2.8 points, though this did not reach statistical significance 1
• No clear differences exist between spinal manipulation and usual care, analgesics, physical therapy, or exercise therapy for acute cases 1
• The evidence quality is moderate, with a weak recommendation strength from the American College of Physicians and American Pain Society 1

Chronic Low Back Pain (> 3 months)

For chronic low back pain, spinal manipulation demonstrates moderate effectiveness and is one of several evidence-based nonpharmacologic treatment options. 1

• Against sham manipulation, pain reduction averages 10 points short-term and 19 points long-term on a 100-point scale 1
• Functional improvement averages 3.3 points on the RDQ in the short term 1
• A large trial (1,334 patients) found spinal manipulation slightly superior to usual care for pain and disability (approximately 5 points on 100-point scales) at 3 months, though effects diminished by 12 months 1
• Chiropractic care appears relatively cost-effective for chronic low back pain compared to medical care 2
• Patients with chronic low back pain in chiropractic settings achieved average 52.5% pain reduction and 52.9% disability reduction 3

Subacute Low Back Pain (4-8 weeks)

For subacute low back pain, spinal manipulation can be considered, though evidence is limited as most trials enrolled mixed populations of chronic and subacute patients. 1

• Results from chronic low back pain studies may reasonably be applied to subacute cases 1
• One trial found manipulation slightly superior to usual care with approximately 5-point improvement on 100-point scales at 3 months 1

Comparative Effectiveness

Spinal manipulation performs comparably to other effective treatments, with no single therapy established as superior first-line treatment. 1

• No significant differences exist between manipulation and general practitioner care, analgesics, physical therapy, exercises, or back schools 1
• One trial (681 patients) found no differences between chiropractic care and medical management for pain, functional status, or other outcomes 1
• Adding manipulation to exercise therapy provides no additional benefit over exercise alone 1
• Evidence is insufficient to determine whether benefits vary by profession of the manipulator (chiropractor vs. other trained clinician) 1

Treatment Intensity

For chronic low back pain, more frequent chiropractic visits (3-4 times per week for 3 weeks) produce greater pain and disability reduction at 4 weeks. 4

• A dose-response relationship exists, with approximately 5.7 points pain reduction per 3 additional visits 4
• Functional disability improved by approximately 5 points per 3 additional visits 4
• Patients in clinical practice typically receive an average of 12 treatments over a 4-week period 3

Safety Profile

Serious adverse events from spinal manipulation are extremely rare, with risk estimated at less than 1 per 1 million patient visits. 1

• No serious complications were reported in more than 70 controlled clinical trials 1
• Serious adverse events (such as worsening lumbar disc herniation or cauda equina syndrome) are very rare 1
• Five systematic reviews consistently confirmed the safety profile 1

Clinical Considerations

Patient expectations of benefit should be considered when choosing spinal manipulation, as expectations influence outcomes. 1

• Evidence is insufficient to conclude whether effectiveness varies with presence or absence of radiating pain 1
• Few trials have evaluated effectiveness specifically in patients with radicular pain or spinal stenosis 1
• Chiropractic patients with neck pain and concomitant headaches have higher disability scores but still achieve significant improvement 3
• Acute/subacute patients achieve greater pain and disability reduction (66.8% and 62.5%) compared to chronic patients (19.7% and 19.8%) 3

Mechanisms of Action

Spinal manipulation inhibits back pain partly through spinal segmental mechanisms and potentially through peripheral mechanisms regulating inflammatory responses. 5

• Spinal cord mechanisms of pain inhibition contribute to pain-relieving effects 5
• Evidence is weaker regarding peripheral and supraspinal mechanisms 5