Spinal manipulative therapy “works” for low back pain, yes — but how well does it work?

Chiropractors are leaning more and more heavily on evidence that their treatments help neck and back pain. They are leaning on that evidence because there is no evidence (according to the journal Chiropractic & Osteopathy) that adjusting the spine can do anything else that nearly all chiropractors used to believe it could do, such as prevention and cure of disease. Many still do believe that, but others are clinging to spinal manipulative therapy (SMT) as a treatment for spinal pain like it’s a life preserver: if SMT doesn’t work for back and neck pain, and work pretty well, then what reason would remain for being a chiropractor?

The evidence supporting SMT does indeed exist. Unlike much else in alternative health care, spinal manipulative therapy for spinal pain has passed some fair scientific tests. Thus, perhaps it should not be considered “alternative” medicine, but simply medicine. But how strong is that evidence? Why is there still so much arguing about it?

The effectiveness of a therapy should be quite clear and significant, after decades of study. And if it’s not, how good can it possibly be? That’s an awkward question for a lot of alternative therapies.

Case in point: this fall, the Annals of the Rheumatic Diseases published a pretty good test of SMT. The researchers took a hundred patients with nasty, fresh cases of low back pain, and delivered half of them into the care of chiropractors, and the other half into “standard care” — advice and ordinary pain medications, namely. Note that it has often been argued that SMT is best for acute low back pain, not chronic. So this is right in chiropractic’s strike zone. If there is anything special, anything even remotely impressive about SMT, it should have done rather well in this contest. It should actually pretty much pull out a can of whupass on “advice and meds.” One would hope.

It didn’t.

There was basically no difference between the groups. They did equally well — or equally poorly, if you prefer. All the patients had the same experience that pretty much everyone with chronic back pain has: they got better slowly but surely over the course of a few weeks, roughly exactly as they would have without any therapy at all. The researchers found that “SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain.”

Now you might say, “Well, good: chiropractic was as good as drugs, so it could replace drugs. That’s good!” But those drugs, taken in the quantities the subjects took them, are cheap and safe as houses. And their low cost was roughly appropriate for their took-the-edge-off effectiveness. Chiropractic therapy, by contrast, would have cost an order of magnitude more. And required appointments with chiropractors.

So, yes, SMT “works” — but how well? How impressed are you by SMT’s performance in this test? On a scale of ten?