The Editorial, "Chiropractic for low back pain - we don't know whether it does more good than harm"1, seems to have been written more in a spirit of professional aversion than one of critical doubt. This impression is conditioned by previous commentaries by these authors in the popular press2 and the biomedical literature3-6.
The question is why? There is substantial scientific evidence that the manipulation that chiropractors (and indeed osteopaths and some physiotherapists) do for back pain is both effective and safe. This evidence has been reviewed by multidisciplinary panels of experts in both the UK and USA7-8 , resulting in the production of two national clinical practice guidelines for acute back pain which totally disagree with these authors. The only randomised controlled trial of overall chiropractic management for back pain9-10, in contrast to manipulation alone, is not mentioned in this Editorial, yet this trial (included erroneously by one of these authors in 199111 in a review of manipulation trials) was ranked as high quality, was positive in its evidence for chiropractic management and yet was subsequently condemned as seriously flawed by him in a separate paper6. This Editorial is equally contradictory.
No one would dispute the need to research further the evidence for the effectiveness, cost-effectiveness and safety of manipulation and associated treatment approaches. The Medical Research Council is currently supporting a large randomised trial in this area by a multidisciplinary research team led by the Department of Health Sciences and Clinical Evaluation at the University of York. Many other studies are in progress. Nevertheless, the current UK National Clinical Practice Guideline Evidence Review states: "Within the first 6 weeks of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared." and "The risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner" 7.
Both the Chiropractors and Osteopaths Acts and their General Councils will provide these assurances for the public, however, there is no certainty in science. Those who demand certain proof of things are already prejudiced against them.
Alan Breen, Research Director
Anglo-European College of Chiropractic, Bournemouth BH5 2DF
1. Ernst E, Assendelft WJJ. Chiropractic for low back pain - we don't know whether it does more good than harm. British Medical Journal 1998;317:160. (18 July)
2. Ernst E. Hidden truths behind healing hands. The Independent 1998, June 2.
3. Ernst E. Beyond reasonable doubt. New Scientist 1998 April 18:49.
4. Ernst E. Cervical manipulation - is it really safe? Internal Journal of Risk & Safety in Medicine 1994;145-49.
5. Ernst E. Bitter pills of nature: safety issues in complementary medicine. Pain 1995;60:237-38.
6. Assendelft WJJ, Bouter LM, Kessels AGJ. Effectiveness of chiropractic and physiotherapy in the treatment of low back pain: a critical discussion of the British Randomised Clinical Trial. Journal of Manipulative and Physiological Therapeutics 1991;14(5):281-86.
7. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Clinical guidelines for the management of acute low back pain: clinical guidelines and evidence review. London: Royal College of General Practitioners, 1996.
8. Agency for Health Care Policy Research. Management guidelines for acute back pain. Washington DC: US Department of Health and Human Services, 1994.
9. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1990;300(6737):1431-37. (June)
10. Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. British Medical Journal 1995;311:349-51. (November)
11. Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. British Medical Journal 1991;303:1298-1302. (November)
Rapid Response:
Re: Chiropractic for low back pain
EDITOR,
The Editorial, "Chiropractic for low back pain - we don't know whether it does more good than harm"1, seems to have been written more in a spirit of professional aversion than one of critical doubt. This impression is conditioned by previous commentaries by these authors in the popular press2 and the biomedical literature3-6.
The question is why? There is substantial scientific evidence that the manipulation that chiropractors (and indeed osteopaths and some physiotherapists) do for back pain is both effective and safe. This evidence has been reviewed by multidisciplinary panels of experts in both the UK and USA7-8 , resulting in the production of two national clinical practice guidelines for acute back pain which totally disagree with these authors. The only randomised controlled trial of overall chiropractic management for back pain9-10, in contrast to manipulation alone, is not mentioned in this Editorial, yet this trial (included erroneously by one of these authors in 199111 in a review of manipulation trials) was ranked as high quality, was positive in its evidence for chiropractic management and yet was subsequently condemned as seriously flawed by him in a separate paper6. This Editorial is equally contradictory.
No one would dispute the need to research further the evidence for the effectiveness, cost-effectiveness and safety of manipulation and associated treatment approaches. The Medical Research Council is currently supporting a large randomised trial in this area by a multidisciplinary research team led by the Department of Health Sciences and Clinical Evaluation at the University of York. Many other studies are in progress. Nevertheless, the current UK National Clinical Practice Guideline Evidence Review states: "Within the first 6 weeks of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared." and "The risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner" 7.
Both the Chiropractors and Osteopaths Acts and their General Councils will provide these assurances for the public, however, there is no certainty in science. Those who demand certain proof of things are already prejudiced against them.
Alan Breen, Research Director
Anglo-European College of Chiropractic, Bournemouth BH5 2DF
1. Ernst E, Assendelft WJJ. Chiropractic for low back pain - we don't know whether it does more good than harm. British Medical Journal 1998;317:160. (18 July)
2. Ernst E. Hidden truths behind healing hands. The Independent 1998, June 2.
3. Ernst E. Beyond reasonable doubt. New Scientist 1998 April 18:49.
4. Ernst E. Cervical manipulation - is it really safe? Internal Journal of Risk & Safety in Medicine 1994;145-49.
5. Ernst E. Bitter pills of nature: safety issues in complementary medicine. Pain 1995;60:237-38.
6. Assendelft WJJ, Bouter LM, Kessels AGJ. Effectiveness of chiropractic and physiotherapy in the treatment of low back pain: a critical discussion of the British Randomised Clinical Trial. Journal of Manipulative and Physiological Therapeutics 1991;14(5):281-86.
7. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Clinical guidelines for the management of acute low back pain: clinical guidelines and evidence review. London: Royal College of General Practitioners, 1996.
8. Agency for Health Care Policy Research. Management guidelines for acute back pain. Washington DC: US Department of Health and Human Services, 1994.
9. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1990;300(6737):1431-37. (June)
10. Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. British Medical Journal 1995;311:349-51. (November)
11. Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. British Medical Journal 1991;303:1298-1302. (November)
Competing interests: No competing interests