Chiropractic - Effectiveness

Effectiveness

Opinions differ as to the effectiveness of chiropractic treatments. Many controlled clinical studies of spinal manipulation have been conducted, but their results often disagree and they are typically of low methodological quality. A 2010 report found that manual therapies commonly used by chiropractors are effective for the treatment of low back pain, neck pain, some kinds of headaches and a number of extremity joint conditions.

A 2008 critical review found that with the possible exception of back pain, chiropractic manipulation has not been shown to be effective for any medical condition. Health claims made by chiropractors regarding use of manipulation for pediatric health conditions are supported by only low levels of scientific evidence that does not demonstrate clinically relevant benefits.

Most research has focused on spinal manipulation in general, rather than solely on chiropractic manipulation. A 2002 review of randomized clinical trials of spinal manipulation was criticized for not making this distinction; however, the review's authors stated that they did not consider this difference to be a significant point as research on spinal manipulation is equally useful regardless of which practitioner provides it.

There is a wide range of ways to measure treatment outcomes. Chiropractic care, like all medical treatment, benefits from the placebo response. It is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT), as experts often disagree about whether a proposed placebo actually has no effect. The efficacy of maintenance care in chiropractic is unknown.

Available evidence covers the following conditions:

• Low back pain. Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain remain inconsistent between countries. A 2011 Cochrane review found strong evidence that there is no clinically meaningful difference between spinal manipulation and other treatments for reducing pain and improving function for chronic low back pain. A 2010 Cochrane review found no current evidence to support or refute a clinically significant difference between the effects of combined chiropractic interventions and other interventions for chronic or mixed duration low back pain. A 2010 systematic review found that most studies suggest spinal manipulation achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise. A 2008 literature synthesis found good evidence supporting SM for low back pain regardless of duration. A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks. In 2007 the American College of Physicians and the American Pain Society recommended that clinicians consider the addition of spinal manipulation for patients who do not improve with self care options. Methods for formulating treatment guidelines for low back pain differ significantly between countries, casting some doubt on their reliability.

• Radiculopathy. There is no overall consensus on the effectiveness of manual therapies for radiculopathies. There is moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar radiculopathy and acute lumbar disc herniation with associated radiculopathy. The evidence for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration is low or very low and no evidence exists for the treatment of thoracic radiculopathy.

• Whiplash and other neck pain. There is no overall consensus on the effectiveness of manual therapies for neck pain. A 2011 systematic review concluded that thoracic spine manipulation may provide short-term improvement in patients with acute or subacute mechanical neck pain; although the body of literature is still weak. A 2010 Cochrane review found low evidence that manipulation was more effective than a control for neck pain, and moderate evidence that cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction. A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash. A 2009 systematic review of controlled clinical trials found no evidence that chiropractic spinal manipulation is effective for whiplash injury. A 2008 review found evidence that suggests that manual therapy and exercise are more effective than alternative strategies for patients with neck pain. A 2007 review found that spinal manipulation and mobilization are effective for neck pain. A 2005 review found evidence supporting spinal mobilization, and limited evidence supporting spinal manipulation for whiplash.

• Headache. There is no overall consensus on the effectiveness of manual therapies for headaches. Of two systematic reviews published in 2011, one found evidence that spinal manipulation might be as effective as propranolol or topiramate in the prevention of migraine headaches, the other concluded that evidence does not support the use of spinal manipulation for the treatment of migraine headaches. A 2004 Cochrane review found evidence that suggests spinal manipulation may be effective for migraine, tension headache and cervicogenic headache. A 2006 review found inconclusive evidence supporting manual therapies for tension headache. A 2005 review found that spinal manipulation showed a trend toward benefit in the treatment of tension headache, but the evidence was weak.

• Extremity conditions. A 2011 systematic review and meta-analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief then a supervised exercise program alone and suggested that manual therapists consider adding manual mobilisation to optimise supervised active exercise programs. There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis, however this evidence could be considered to be inconclusive. A 2008 systematic review found that the addition of cervical spine mobilization to a treatment regimen for lateral epicondylosis (tennis elbow) resulted in significantly better pain relief and functional improvements in both the short and long-term. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, limited to low level evidence supporting chiropractic management of shoulder pain and limited or fair evidence supporting chiropractic management of leg conditions.

• Other. A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension. A systematic review in 2011 found moderate evidence to support the use of manual therapy for cervicogenic dizziness. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SM) provides benefit to patients with cervicogenic dizziness, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizziness, high blood pressure, and vision conditions. Other reviews have found no evidence of significant benefit for asthma, baby colic, bedwetting, carpal tunnel syndrome, fibromyalgia, gastrointestinal disorders, kinetic imbalance due to suboccipital strain (KISS) in infants, menstrual cramps, or pelvic and back pain during pregnancy.