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Spinal manipulation (and/ or use of diclofenac) does not speed up recovery from back pain reported five newspapers (9 November 2007). The newspaper reports of a well-conducted trial of people with acute back pain were generally accurate. The study's results appear reliable, and are applicable to people with acute lower back pain.

On 9 November 2007 five newspapers (1-5) reported that chiropractic treatment is ineffective for the treatment of back pain.
The reports were based on a randomised controlled trial (6) of 240 people with acute lower back pain who were advised to remain active and take paracetamol. Participants received either genuine or imitation diclofenac (a non-steroidal anti-inflammatory drug) and either genuine or imitation spinal manipulation. The spinal manipulation was delivered by trained physiotherapists (not chiropractors). The trial reported that there was no significant difference in the time to recovery between people receiving active diclofenac and/or active spinal manipulation compared to placebo forms.
The results of this well-conducted trial appear reliable, and applicable to people suffering from acute lower back pain, however, the results may not be applicable to people with chronic back pain. The newspapers are generally accurate in their reports of the main result of the study. One newspaper failed to mention that the study was conducted in people with acute back pain (5), and only one newspaper highlighted that the results may not be applicable to people with chronic back pain (4).

Evaluation of the evidence base for diclofenac and spinal manipulation to treat acute low back pain

Where does the evidence come from?

The study was conducted by researchers from the University of Sydney, and St Vincent's Hospital, Sydney, Australia and was led by Mr M. Hancock of the Back Pain Research Group. The study was primarily funded by Australia's National Health and Medical Research Council, with diclofenac donated by Alphapharm.

What were the authors' objectives?

To investigate whether the addition of non-steroidal anti-inflammatory drugs and/or spinal manipulation to standard treatment in people with acute lower back pain improved recovery.

What was the nature of the evidence?

This was a double blind, randomised controlled trial (RCT) involving 240 people with lower back pain of less than six weeks duration. Participants had been advised by their general practitioner to remain active and take paracetamol. Lower back pain was defined as pain between the 12th rib and buttock crease causing moderate pain and disability. Participants had to have: been pain and treatment free for one month prior to the current episode; had no known or suspected serious spinal pathology or nerve root compromise; not had spinal surgery within the prior six months, and were not currently using or had any contraindication to any of the treatments to be investigated.

The primary outcome was the number of days to recovery, measured either as the first pain-free day or the first of seven consecutive days where pain was scored as 0 or 1 out of 10. Participants kept diaries in which they recorded pain scores. Secondary outcomes included pain, function, and overall perceived effect of treatment. Follow-up was at one, two, four and 12 weeks, with fortnightly telephone interviews for people who had not yet recovered, for up to three months.

What interventions were examined in the research?

All patients received 1g paracetamol four times a day for up to four weeks. Participants were randomised to one of four additional therapies; diclofenac 50 mg twice daily plus placebo manipulative therapy; spinal manipulative therapy plus placebo drug; placebo manipulative therapy and drug; diclofenac 50 mg twice daily plus manipulative therapy. Active and placebo drugs were taken twice daily for a maximum of four weeks. Spinal manipulation was undertaken two to three times a week to a maximum of 12 treatments over four weeks; placebo manipulation was detuned pulsed ultrasound.

What were the findings?

There was no significant difference in the time to recovery, pain, function, global perceived effects or adverse events between people receiving active diclofenac and/or spinal manipulation compared to the respective placebo. The only significant difference was a 1.4 point decrease in the Roland Morris Disability Questionnaire (RMDQ) score with spinal manipulation at two weeks, however, this was not consistent and there was no significant difference in RMDQ scores between spinal manipulation and placebo at one, four or 12 weeks.

What were the authors' conclusions?

The authors concluded that patients with acute lower back pain do not recover more quickly when given diclofenac and/or spinal manipulation in addition to paracetamol and remaining active.

How reliable are the conclusions?

This was a well-conducted RCT that used appropriate methods of randomisation and allocation concealment, and had independent, blinded outcome assessors. The researchers undertook a power calculation to determine the required study size for detection of differences in the primary outcome. Overall, compliance with drug therapy was poor, but did not differ significantly between treatment groups. Appropriate clinical outcomes appear to have been measured. An intention to treat analysis was not undertaken, however, there was only a single drop-out after randomisation. The results of this RCT should be reliable, and are applicable to people suffering from acute lower back pain only.

Systematic reviews

Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic.

There were no related systematic reviews identified on the Cochrane Database of Systematic Reviews (CDSR), although there is one review which is currently being undertaken and will be available in the future (7). There were two related reviews on the Database of Abstracts of Reviews of Effects (DARE) (8,9)

References and resources

1. Chiropractors 'are a waste of time'. Daily Mail, 09 November 2007, p5.

2. Chiropractors may be no use in treating back pain, study says. The Guardian, 09 November 2007, p11.

3. 'Paracetamol and reassurance' are all it takes to cure a bad back. The Independent, 09 November 2007, p26.

4. Painkillers and a walk are best for back pain. The Times, 09 November 2007, p12.

5. Chiropractors 'are a waste of money' for a bad back. The Daily Telegraph, 09 November 2007, p14.

6. Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, O Day R, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. The Lancet 2007; 370:1638-1643

7. French SD, Grant WD, Green S, Walker B. Chiropractic interventions for low-back pain. (Protocol). The Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD005427. DOI: 10.1002/14651858.CD005427.

8. Ernst E, Canter P H. Chiropractic spinal manipulation treatment for back pain: a systematic review of randomised clinical trials. Physical Therapy Reviews 2003;8(2):85-91. [DARE Abstract]

9. Hestboek L, Leboeuf-Yde C. Are chiropractic tests for the lumbo-pelvic spine reliable and valid: a systematic critical literature review. Journal of Manipulative and Physiological Therapeutics. 2000;23(4):258-275. [DARE Abstract]