002- Chiropractic Outperforms NSAID's for Low Back Pain

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Hello and welcome back to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Today we're going to look at a Spine Journal article released in April 2013. It's titled Spinal High Velocity Low Amplitude Manipulation in Acute Non Specific Low Back Pain. Specifically, this study pits chiropractic adjustments and or manipulation against commonly prescribed N sets. But before we dive into the research, I'd like to say a few words about Rocktape. Rocktape is proud to be a sponsor of the Evidence Based Chiropractor. Rock Tape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and functional fitness accessories. New from Rocktape is the Rocksauce Chill, a powerfully cool pain relief topical in a convenient roll on with 6% menthol. It's stronger than the quote unquote freeze competition. Most importantly, Rock Tape is more than just a tape company. They're a movement company. Learn more and get access to your medical discount by visiting rocktape.com now let's dive into the research. This piece from Spine Journal released in April 2013 again pitted diclofenac against chiropractic adjustments. Diclofenac, as we know, is a very commonly prescribed pain reliever. NSAID and most primary care physicians are going to do one of three things when they see a patient come into their practices with spine complaints. They're either going to treat in house, which very often means the prescription of NSAIDs. They're going to refer directly to their orthopedic friends or other MDs in the area, perhaps a neurologist or an interventional spine doc, or their third most likely referral is to a physical therapist. So chiropractic is certainly coming on strong. And with the Evidence based chiropractor we are always trying to bolster the relationships between MDs, PCPs, internal medicine docs and chiropractors. But the stark reality as we know is often patients first line of defense are NSAIDs such as diclofenac. Well this piece of research from Spine is a randomized double blinded placebo controlled parallel trial with three arms that is absolutely top tier research in what is sure to be considered a landmark in spinal manipulative research or chiropractic research. The researchers tested commonly prescribed NSAID declofenac against spinal manipulation and or adjustments and placebo. Of note is that the manipulations or chiropractic adjustments were performed with actually an antiquated technique by physicians without specific training, that is they were not chiropractors. This is a significant design flaw, but it even more emphasizes the results by which they received. It's logical to assume that chiropractors who have the greatest amount of technique training with manipulation or adjustment would receive better result. But let's talk about these results the researchers found. Well, first of all, they like to state that this is the first time that spinal manipulation was investigated in a double blinded randomized controlled design showing clear superiority compared with placebo and nsaid. Additionally, they found high velocity low amplitude manipulation can be recommended for the therapy for acute non specific low back pain. And finally, final evaluation showed manipulation being significantly better than ED said and clinically superior to placebo. Let's touch on a few things that those researchers found in those last statements. First of all, this was the first time a double blinded randomized control design showed showed clear superiority for a chiropractic adjustment or a manipulation performed by a non chiropractor. That's very important because double blind randomized controlled trials are class A research. Additionally, when they find that there's significant improvement with those receiving a manipulation and it's clinically superior to placebo, those take some X factors out of the equation. For instance, because chiropractors have such good relationships with their patients and because it's a hands on profession, certainly I think we all have heard at times that perhaps there's a placebo effect with the chiropractic adjustment or with the manipulation, on the whole, this research proves an end and puts an end to those thoughts. While a hands on component is extremely important in the deliverance of a force and also in, in my opinion, the core of what we deliver as chiropractors, it shows that there is more to it than simply the hands on application of a manipulation or adjustment. If we look deeper into the statistics gleaned from this report, we can find that 19 out of the 35 patients or people receiving the manipulation had complete relief, 10 showed improvement, 6 had no change and 0 deteriorated while undergoing manipulative care. If we look at the diclofenac or the NSAIDS, we'll find that eight patients had complete relief, 13 improved, nine had no change and seven deteriorated. So when we look at that, first of all, 19 patients who underwent manipulation versus diclofenac at eight so nearly or over double the Amount of patients within the manipulation group showed complete relief of symptomatology through this trial. Also, zero patients in the manipulation group deteriorated through this trial. Seven taking NSAIDs listed their improvement, quote unquote, as deterioration. Not only is this important showing the efficacy of a manipulation, but it also takes time and there's duration. In these trials and most practitioners, it's well known that the longer a patient is in pain, the worse the outcome becomes. So as acute pain becomes subacute pain and verges on chronic pain, it becomes more and more difficult to come back from. So patients that are deteriorating throughout a course of care, it really sets things up for challenges down the road in terms of getting those patients back to maximum functional status. A criticism of this research, and perhaps rightfully so, is that the manipulations were not performed by chiropractic physicians, by doctors of chiropractic, by DCs. I think that's a very valid point. However, in my opinion, it also heavily emphasizes the fact that even with practitioners not with the specific training and background as chiropractors performing manipulations, patients are still getting good results. So I think it really sets the first foundation in terms of imagine if these patients were receiving their manipulation or adjustment from a chiropractic physician. I think now, once we looked at the numbers, it's very safe to assume that, that these patients may have received even better result than found in the current research model. While as chiropractors we're not going to make recommendations regarding prescriptions or any sort of intake of medications that a patient may be taking, I think from a patient centric model, this piece of research is imperative to be able to promote internally in your practice because many patients are already going to be coming in taking an NSAID or taking ledicofenac, and they're going to feel as though that might be doing the real legwork, so to speak, in terms of their recovery. Research like this shows that actually a chiropractic adjustment and or manipulation might be providing just as much, if not certainly more of that functional improvement than any medication would. Certainly, from a physician to physician relationship point of view, I think this piece of research is very important as well, because many primary care physicians, internal medicine doctors, are going to be prescribing NSAIDs for patients that come in with acute or subacute spine pain. And in terms of that, I don't think that this piece of research on its own certainly is going to change their ideas of their prescriptive habits. However, I think it's an important first step and a foundational component to building that relationship, showing the value, showing the efficacy of what we can do as chiropractors. Certainly taking even one step further, if this research combined the effects of diclofenac and chiropractic adjustment, I would venture to say that there would be a strong potential for even farther improvement in terms of patient's functional status over time. And that's not to say that I'm certainly any fan of NSAIDs in an acute or subacute patient, or even a chronic patient as far as that goes. However, the reality is a majority of patients that do come into our practices are already taking NSAIDs, whether it's prescribed or whether they're taking something a little bit less intensive over the counter. So to come full circle, the Spine journal article in April 2013 titled Spinal High Velocity Low Amplitude Manipulation in Acute Non Specific Low Back Pain is really the first double blinded randomized control design which shows absolutely clear superiority of a chiropractic adjustment, or in this case a manipulation performed by a non chiropractor compared with placebo and nsaid. An absolutely foundational piece of research which every chiropractor should know about and every chiropractor should be using to their advantage in their own practice and to the physicians with whom they are building relationships. Thank you for spending the time this week. Next week we'll be back with another piece of research and we will take it from there. Have a great week in practice and we'll talk to you soon.

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