This large UK trial funded by the Medical Research Council (MRC) compared chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin. Outcome: chiropractic treatment was 30% more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.

This follow up trial conducted in 1995, again funded by the MRC, confirmed the findings of the earlier report – patients with low back pain treated by chiropractors derive more benefit and long term satisfaction than those treated by hospitals.

Evidence:

• Manipulation can provide short-term improvement in pain and activity levels and higher patient satisfaction.

• The risks of manipulation are very low in skilled hands.

Recommendation:

Consider manipulative treatment for patients who need additional help with pain relief or who are failing to return to normal activities.

This recent MRC-funded study estimated the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to “best care” in general practice for patients consulting with back pain. All groups improved over time. Exercise improved disability more than “best care” at three months. For manipulation there was an additional improvement at three months and at 12 months. For manipulation followed by exercise there was an additional improvement at three months and at 12 months. No significant differences in outcome occurred between manipulation in NHS premises and in private premises. No serious adverse events occurred.

Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.

Summary of recommendations for treatment of acute non-specific low back pain:

• Give adequate information and reassure the patient

• Do not prescribe bed rest as a treatment

• Advise patients to stay active and continue normal daily activities including work if possible

• Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs

• Consider adding a short course of muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain

• Consider (referral for) spinal manipulation for patients who are failing to return to normal activities

• Multidisciplinary treatment programmes in occupational settings may be an option for workers with subacute low back pain and sick leave for more than 4 – 8 weeks

Manipulation/mobilisation – Summary of the evidence:

• There is moderate evidence that manipulation is superior to sham manipulation for improving short-term pain and function in chronic low back pain (CLBP)

• There is strong evidence that manipulation and GP care/analgesics are similarly effective in the treatment of CLBP

• There is moderate evidence that spinal manipulation in addition to GP care is more effective than GP care alone in the treatment of CLBP

• There is moderate evidence that spinal manipulation is no less and no more effective than physiotherapy/exercise therapy in the treatment of CLBP

• There is moderate evidence that spinal manipulation is no less and no more effective than back-schools in the treatment of CLBP

Recommendation:

Consider a short course of spinal manipulation/mobilisation as a treatment option for CLBP.

Chiropractic intervention and posture training can limit episodes of acute pain. Spinal rehabilitation, which may include components such as education, lifestyle change, weight loss, general fitness and specific low-back training exercises, may be required.

“Chiropractors provide evidence-based, timely and effective assessment, diagnosis and management of certain musculoskeletal disorders.” “The Framework describes a system that enables health and social care professionals to provide more easily a high-quality service to patients. A balanced, well-planned system achieves that, and helps professionals to:

• treat patients at the appropriate point in the system (closer to home or work);

• provide patients with better information to manage their condition, reducing avoidable admissions;

• plan/manage patient flows through primary and secondary care, ensuring appropriate and timely referral to specialist care services;

• develop capacity in primary care by offering a wider range of non-surgical alternatives, eg specialist practitioners, physiotherapy, podiatry, nursing, pain management advice, chiropractic, osteopathy etc.”

NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Its guideline on the acute management of patients with chronic low back pain was published in May 2009. The evidence-based recommendations include the following:

• Provide people with advice and information to promote self-management of their low back pain.

• Consider offering a course of manual therapy including spinal manipulation of up to 9 sessions over up to 12 weeks

• Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks

• Consider offering a structured exercise programme tailored to the individual.

These studies show the effectiveness of Chiropractic treatment for low back pain with leg pains NB: All chiropractors are trained to provide spinal manipulation. Chiropractors are also trained to provide suitable exercise advice and many have in-house facilities for supervised exercise. Note that chiropractic is a profession, not a treatment. Chiropractors provide a package of care, which may include spinal manipulation, based on a detailed case history and careful diagnosis.