Posted on January 10th, 2023
Chiropractors can help ease some cases of low back pain, though their treatments may be no better than taking an over-the-counter pain reliever, a new analysis finds.
The review of 26 clinical trials found that manipulating the spine can bring "modest" relief to people with acute low back pain—pain that has lasted no more than six weeks.
Chiropractors perform spinal manipulation, as do some doctors, physical therapists and other health professionals. Most insurers, Medicare and Medicaid pay for some chiropractic services, according to the American Chiropractic Association.
But spinal manipulation is no magic bullet, the researchers behind the new study said. The benefits appear similar to those of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen.
It seems that when it comes to low back pain, no one has found a quick fix.
That didn't stop the American College of Physicians (ACP) from releasing new guidelines earlier this year on managing low back pain.
The guidelines advise non-drug options first—including tactics such as heat wraps, acupuncture, massage, exercise and spinal manipulation.
But while they are recommended, none of those options seems hugely effective. An ACP evidence review found each to have a "small" to "moderate" benefit.
Instead, time may be the best healer, the researchers said.
"Most acute back pain goes away on its own in a few days to weeks," said review author Dr. Paul Shekelle, chief of general internal medicine at the VA Greater Los Angeles Healthcare System.
"Most treatments—whether they be NSAIDs or muscle relaxants or spinal manipulation therapy—have, on average, small effects," Shekelle said.
"Some patients have much larger effects," he pointed out. "But, on average, there is no magic bullet for back pain."
One thing that does seem important, Shekelle said, is that people remain active when they have acute back pain. That seems to speed the recovery process.
Back pain is one of the most common health complaints among Americans. It affects around 80 percent of the population at some point, according to the U.S. National Institutes of Health. Usually, the lower back is the problem area.
In some cases, people suffer pain caused by compression of a nerve—from a herniated spinal disc, for instance. Sciatica, where pain radiates down the leg, is a common example.
But most often, according to Shekelle, people have what's called "nonspecific" back pain, where there's no clear cause.
His team analyzed trials that tested spinal manipulation in patients with acute back pain—not sciatica or chronic pain (longer than 12 weeks).
Out of 26 trials, the researchers found that 15 reported "moderate-quality" evidence that spinal manipulation brought patients modest pain relief over six weeks. In 12 trials, patients saw some improvements in their daily functioning, on average.
The therapy did appear to be relatively safe. Around half of patients said they developed minor side effects such as headaches or a temporary increase in pain or muscle stiffness.
The review was published April 11 in the Journal of the American Medical Association.
According to Shekelle, many studies in the review compared spinal manipulation against tactics that were not expected to be effective, such as giving patients an educational booklet.
Another issue, he said, was that spinal manipulation was often combined with another therapy, including exercise. That makes it harder to know how effective the spinal manipulation was on its own.
"And then, of course, there are all the things a patient may be doing for their back pain that aren't part of the trial," Shekelle said, "like using heat, or getting home massage, or who knows what else."
The good news is, most people with acute back pain "will almost certainly improve with time," said Dr. Richard Deyo, a professor at Oregon Health and Science University in Portland.
"It's perfectly reasonable for people to self-treat, with things like heat wraps," said Deyo, who wrote an editorial that was published with the study.
For people with more severe pain, the choice of therapy often comes down to what's practical and affordable, according to Deyo.
Why does spinal manipulation help some people with low back pain? "We don't know," Deyo said, "but there are theories."
The therapy might, for instance, ease muscle tension, reposition spinal disc material, or stimulate large nerves in a way that disrupts pain signals.
"Or maybe," Deyo said, "it's partly the hands-on nature, and ongoing relationship with the provider."