Correspondence
Physical Therapy, Chiropractic Manipulation, or an Educational Booklet for Back Pain
N Engl J Med 1999; 340:388-391February 4, 1999
- Article
To the Editor:
The American Chiropractic Association is disturbed by the conclusions being drawn about the effectiveness of chiropractic care for the treatment of patients with low back pain on the basis of the study by Cherkin et al. (Oct. 8 issue).1 The generalizability of the study is severely limited by the exclusion of many types of patients who benefit from chiropractic spinal manipulation, including those who are pregnant and those involved in workers' compensation claims. Studies show that patients treated by chiropractors return to work twice as rapidly as those treated by physicians and at half the cost.2-4 The study excluded patients who had undergone spinal surgery. Such patients regularly seek chiropractic care because of the high incidence of failed back surgery, which results in unremitting low back pain. It also excluded those who had previously received any chiropractic care or physical therapy as well as those who had sciatica in association with low back pain. Sciatica is a condition that causes patients to seek chiropractic services on a regular basis because of their difficulty in finding relief through other means.
The types of treatment chiropractors could provide in the study were limited, whereas therapists who used the McKenzie approach not only were allowed the full scope of therapy options but were also specially trained for the project. The authors did not emphasize important differences between groups that may have been clinically meaningful to the patients, such as the use of over-the-counter medications. The three methods compared in the study — chiropractic manipulation, McKenzie physical therapy, and patient education — are important components of the chiropractic treatment plan. It is unfair to compare these three regimens separately when all of them are commonly used by chiropractors for the treatment of low back pain.
Equally disturbing is the comment made by Shekelle in his accompanying editorial5 that chiropractic care for low back pain “costs more than the usual supportive medical care delivered by health maintenance organizations.” This statement contradicts the conclusions of previous studies. A 1996 report determined that first-contact chiropractic care for common low back conditions costs substantially less than medical treatment and “deserves careful consideration” by managed-care executives concerned about controlling health care costs.6
The chiropractic profession is pleased by legitimate attempts to accumulate new data. Although the article by Cherkin et al. may constitute such an effort, it would be inappropriate to draw sweeping conclusions about the benefits of chiropractic on the basis of this limited work.
6 ReferencesMichael D. Pedigo, D.C.
American Chiropractic Association, Arlington, VA 222091
Cherkin DC ,Deyo RA ,Battie M ,Street J ,Barlow W . A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998;339:1021-1029
Full Text | Web of Science | Medline2
Stano M . A comparison of health care costs for chiropractic and medical patients. J Manipulative Physiol Ther 1993;16:291-299
Web of Science | Medline3
Ebrall PS . Mechanical low-back pain: a comparison of medical and chiropractic management within the Victorian WorkCare Scheme. Chiropract J Aust 1992;22:47-534
Jarvis KB ,Phillips RB ,Morris EK . Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes. J Occup Med 1991;33:847-852
CrossRef | Medline5
Shekelle PG . What role for chiropractic in health care? N Engl J Med 1998;339:1074-1075
Full Text | Web of Science | Medline6
Stano M ,Smith M . Chiropractic and medical costs of low back care. Med Care 1996;34:191-204
CrossRef | Web of Science | Medline
To the Editor:
We believe that the study by Cherkin et al. fails to represent physical therapy accurately. The approach described in the study could be more specifically referred to as “use of the exercise portion of the McKenzie approach to physical therapy,” because therapists were not allowed to use other methods. Only the efficacy of the McKenzie approach was tested, not the efficacy of physical therapy.
Approximately 80 percent of physical therapies use approaches such as heat, electrical stimulation, ultrasonography, massage, and joint mobilization as adjuncts to exercise and have been proved to be effective.1-4 Thus, such a limited study, restricted merely to an exercise component, is not realistic and may lead to conclusions about the benefits of physical therapy that are unfounded.
Most therapists do not use just one specific treatment technique (for instance, the McKenzie approach). Therapists are schooled, just as physicians are, in numerous treatment options for patients. In a study of the benefits of medical treatment, it would be just as inaccurate to limit physicians to the use of one brand-name nonsteroidal antiinflammatory drug for low back pain.
To place in context the actual practice of physical therapy and its benefits, a study must consider the broad range of patients seen in a typical practice (i.e., patients with multiple conditions, radiculopathies, and other complications). Cherkin et al. studied only patients with low back pain. The relatively low severity of back pain may have created bias toward the group assigned to receive an educational booklet, since most patients were likely to get well without intervention. We believe that patients with more severe disabilities would have had a greater response to physical therapy.
4 ReferencesCarole B. Lewis, P.T., Ph.D.
Joseph Laukaitis, M.D.
George Washington University, School of Medicine and Health Sciences, Washington, DC 200371
Augustinsson LE ,Bohlin P ,Bundsen P , et al. Pain relief during delivery by transcutaneous electrical nerve stimulation. Pain 1977;4:59-65
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Harris PR . Iontophoresis: clinical research in musculoskeletal inflammatory conditions. J Orthop Sports Phys Ther 1982;4:109-112
Medline3
Lentell G, Hetherington T, Eagan J, Morgan M. The use of thermal agents to influence the effectiveness of a low-load prolonged stretch.J Orthop Sports Phys Ther 1992;16:200-7.
4
Nwuga VC . Ultrasound in treatment of back pain resulting from prolapsed intervertebral disc. Arch Phys Med Rehabil 1983;64:88-89
Web of Science | Medline
To the Editor:
In the study by Cherkin et al., the decision to use the McKenzie method of physical therapy is interesting. The McKenzie approach uses exercises that “centralize” pain away from the feet, legs, and buttocks toward the lower back. The study excluded subjects if they had sciatica; therefore, subjects already had “centralized” pain. Perhaps another, more suitable exercise regimen could have been chosen — for example, specific stretching exercises. The results in the physical-therapy group might have been different if Cherkin et al. had evaluated an exercise program tailored to physical findings in patients with nonradicular low back pain.
Elisabeth A. Lachmann, M.D.
New York Presbyterian HospitalRichard S. Tunkel, M.D.
Memorial Sloan-Kettering Cancer CenterWillibald Nagler, M.D.
New York Presbyterian Hospital, New York, NY 10021To the Editor:
In chiropractic school I was taught to correct spinal subluxations, not to treat low back pain (or any other condition). If Cherkin et al. had measured the reduction of the subluxation before measuring low back outcomes, I believe the results would have differed considerably.
Limiting the number of chiropractic adjustments to nine is similar to limiting antibiotic treatment to five days. With the use of this approach, some patients would get well, but many others would not, and a false conclusion would be reached concerning the effectiveness of antibiotics. Some measure must be used to determine the proper length of time for antibiotic therapy in order to compare it with other therapies. For chiropractic the criterion must be the reduction of subluxation. A reduction in subluxation could be demonstrated by means of radiography, an inclinometer, postural assessment (the presence of dyskinesia), surface electromyography (the presence of dysponesis), or paraspinal thermal asymmetry (the presence of dysautonomia), among other means. Once a reduction has been assessed, use of the protocol for assessing the outcome of low back pain would result in a valid comparison of chiropractic with other methods.
Manon Fielding, D.C.
Fielding Chiropractic Center, Hillsborough, NC 27278To the Editor:
Cherkin et al. fall into the common trap of looking at low back pain as a single entity, rather than as a symptom with several possible causes. Chiropractic manipulation and the McKenzie approach should be investigated as treatments for specific causes of low back pain (segmental dysfunction and disk-derangement syndromes, respectively), rather than as treatments for a nonspecific group of symptoms.
Ronald J. Tyszkowski, D.C.
Rhode Island Spine Center, Providence, RI 02903To the Editor:
Cherkin et al. did not obtain radiographs as part of this study. When the chiropractors obtained a radiograph before beginning treatment, it was included as a cost of treatment.
Patients 20 to 64 years of age were eligible. Vertebral compression fractures are common in older patients. A recent study reported an 8 percent prevalence of vertebral fractures (assessed by measurements of radiographs taken in a random sample of the population) in men and women between the ages of 60 and 64.1 Therefore, the chiropractors performed an appropriate diagnostic test for patients who had had back pain for more than a week, especially patients older than 50. Some of the patients in my osteoporosis clinic have been referred by chiropractors who obtained radiographs that were deemed unnecessary by physicians.
Vertebral fractures typically heal, and the pain resolves. Within the time span considered in the study by Cherkin et al., the outcome would appear to be satisfactory. In the long run, however, the failure to recognize osteoporotic fractures is a serious problem because the presence of a vertebral fracture is a strong risk factor for another fracture. In a large study of women who had radiographs taken 3.7 years apart, those with vertebral fractures on the first radiograph were four times as likely to have a new fracture as women without a base-line vertebral fracture.2 In the placebo group of a three-year clinical trial of women who had low bone density, those with previous fractures had a 19 percent incidence of new fractures, as compared with an incidence of only 2 percent in those without previous fractures.3 The rate of new fractures can be halved with medication. If no radiographs are taken, however, patients will remain untreated and fractures that could have been prevented will occur.
3 ReferencesSusan M. Ott, M.D.
University of Washington, Seattle, WA 981951
Burger H ,van Daele PL ,Grashuis K , et al. Vertebral deformities and functional impairment in men and women. J Bone Miner Res 1997;12:152-157
CrossRef | Web of Science | Medline2
Nevitt MC ,Ettinger B ,Black DM , et al. The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med 1998;128:793-800
Web of Science | Medline3
Liberman UA ,Weiss SR ,Broll J , et al. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. N Engl J Med 1995;333:1437-1443
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: In response to Lewis and Laukaitis: we chose the McKenzie method because it was the most popular form of physical therapy in Washington State.1 This approach does not consider methods such as those referred to by Lewis and Laukaitis to be useful and excludes them because they conflict with a philosophy oriented toward self-care. Furthermore, these methods are of questionable effectiveness.2 We agree that “most patients were likely to get well without intervention,” and this is exactly why well-controlled trials are so essential. At entry into the study the subjects had moderately severe dysfunction, and the severity of dysfunction decreased by about 65 percent in all three groups, including the booklet group.
In response to Lachmann et al.: therapists were able to assign McKenzie diagnoses to 95 percent of their patients, 76 percent of whom received diagnoses (e.g., asymmetric lumbar pain) indicating that centralization of pain was possible. In the McKenzie approach, patients are assigned to one of nine diagnostic categories, each of which calls for a different therapy.3
We agree with Pedigo that our results cannot be generalized to patients with conditions such as sciatica or to those who have undergone back surgery. However, only 6 percent of chiropractic patients have sciatica, and only 2 percent have had prior surgery.4 The chiropractors in our study, who did not normally recommend extension exercises, were allowed to treat the study subjects as they treated their regular patients, except for the limitation on the number of visits. In the case of 75 percent of their patients, fewer than nine visits were judged to be necessary.
Each physical therapist had completed only one week of McKenzie training before receiving several days of coaching by McKenzie Institute faculty just before the study. The results of chiropractors who used McKenzie therapy and other techniques may be more effective than the results of those who rely primarily on spinal manipulation, but only a small fraction have received McKenzie training, and our study did not find this approach to be very effective.
In response to Tyszkowski: we excluded patients with clearly definable clinical characteristics (e.g., sciatica and prior back surgery). Further restrictions were not considered because of the lack of widely accepted and reliable criteria for discriminating among patients with nonspecific back pain.2
In response to Fielding: we focused on relief of pain and restoration of function because these outcomes matter most to patients. Within chiropractic, there is no consensus on the definition of “subluxation” and there are “little hard data regarding the reliability and validity of its clinical identification and pathophysiologic impact.”5 We limited subjects to nine visits on the advice of our chiropractic consultants, who believed this number would permit an adequate trial of manipulation.
5 ReferencesDan Cherkin, Ph.D.
Janet Street, M.N., C.P.N.P.
Group Health Center for Health Studies, Seattle, WA 98101Richard Deyo, M.D., M.P.H.
University of Washington, Seattle, WA 981951
Battie MC ,Cherkin DC ,Dunn R ,Ciol MA ,Wheeler KJ . Managing low back pain: attitudes and treatment preferences of physical therapists. Phys Ther 1994;74:219-226
Web of Science | Medline2
Bigos SJ, Bowyer OR, Braen GR, et al. Acute low back pain problems in adults. Clinical practice guideline no. 14. Rockville, Md.: Department of Health and Human Services, December 1994:36-7. (AHCPR publication no. 95-0642.)
3
Donelson R . The McKenzie approach to evaluating and treating low back pain. Orthop Rev 1990;19:681-686
Medline4
Hurwitz EL ,Coulter ID ,Adams AH ,Genovese BJ ,Shekelle PG . Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88:771-776
CrossRef | Web of Science | Medline5
Cherkin DC, Mootz RD. Synopsis, research priorities, and policy issues. In: Cherkin DC, Mootz RD, eds. Chiropractic in the United States: training, practice, and research. Rockville, Md.: Department of Health and Human Services, 1997:124. (AHCPR publication no. 98-N002.)
Author/Editor Response
Pedigo asserts that my statement that chiropractic care for low back pain costs more than the usual supportive medical care delivered by health maintenance organizations contradicts the conclusions of previous studies. The one study Pedigo cites to support his view is a retrospective analysis of claims data. Such analyses are prone to bias because of differences in the severity of illness among patients who seek care from different types of providers. The best way to protect against such bias is to randomly assign patients with back pain to different treatment groups. Three randomized studies of chiropractic care for low back pain, including the study by Cherkin et al., that measured direct medical costs all reported that the patients who were randomly assigned to chiropractic care had higher costs.1-3 A prospective observational cohort study of patients with acute low back pain measured the severity of illness and found no differences between patients seeking care from chiropractors and those seeking care from medical doctors and that patients treated by chiropractors had greater costs than patients treated by primary care physicians.4
Pedigo's assertion that patients involved in workers' compensation claims who are treated by chiropractors “return to work twice as rapidly as those treated by physicians and at half the cost” is not supported by the best available systematic review of the topic.5
The published data about the benefits and costs of spinal manipulation and chiropractic care for low back pain are not all in agreement. I believe that the best studies consistently report that spinal manipulation has a small beneficial effect and that chiropractic care for low back pain costs more than medical care. As I indicated in my editorial, the challenge to chiropractic is to make the benefit of chiropractic care worth this cost.
5 ReferencesPaul G. Shekelle, M.D., Ph.D.
West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA 900731
Cherkin DC ,Deyo RA ,Battie M ,Street J ,Barlow W . A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998;339:1021-1029
Full Text | Web of Science | Medline2
Meade TW ,Dyer S ,Browne W ,Townsend J ,Frank AO . Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;306:1431-1437
CrossRef3
Skargren EI ,Oberg BE ,Carlsson PG ,Gade M . Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain: six-month follow-up. Spine 1997;22:2167-2177
CrossRef | Web of Science | Medline4
Carey TS ,Garrett J ,Jackman A , et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med 1995;333:913-917
Full Text | Web of Science | Medline5
Assendelft WJ ,Bouter LM . Does the goose really lay golden eggs? A methodological review of workmen's compensation studies. J Manipulative Physiol Ther 1993;16:161-168
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- Citing Articles (1)
Citing Articles
1
Richard A. Cooper, Heather J. McKee. (2003) Chiropractic in the United States: Trends and Issues. Milbank Quarterly 81:1, 107-138
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