Chiropractic v. Physical Therapy For Back Pain


There are 18 chiropractic colleges in the United States:


Cleveland Chiropractic College – Kansas City, KS

D’Youville College – Buffalo, NY

Life Chiropractic College West – Hayward, CA

Life University – Marietta, GA

Logan University – Chesterfield, MO

National University of Health Sciences – Lombard, IL

New York Chiropractic College – Seneca Falls, NY

Northwestern Health Sciences University – Bloomington, MN

Palmer College of Chiropractic – Davenport, IA

Palmer Chiropractic College, Florida – Port Orange, FL

Palmer Chiropractic College West – San Jose, CA

Parker University – Dallas, TX

Sherman College – of Chiropractic Spartanburg, SC

Southern California University of Health Science – Whittier, CA

St. Petersburg College – St. Petersburg, FL

Texas Chiropractic College – Pasadena, TX

University of Bridgeport – Bridgeport, CT

University of Western States – Portland, OR


In contrast, there are 227 Physical Therapy Schools in the United States.


Some of the chiropractic colleges are Universities that grant academic degrees in addition to the Doctor of Chiropractic degree (DC). Others only grant Doctor of Chiropractic degrees.


Since the 1970s, the federal government has controlled chiropractic education in the United States. The United States Department of Education oversees chiropractic education by recognizing the Council for Chiropractic Education (CCE) (1):


“CCE maintains recognition by the United States Department of Education as the national accrediting body for Doctor of Chiropractic Programs and chiropractic solitary purpose institutions of higher education.”


All of the 18 chiropractic colleges in the United States are accredited by the CCE.


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Both chiropractors and physical therapists treat acute pain and chronic pain problems, including those of the spine. Both chiropractors and physical therapists are educated in the clinical application of physical therapy modalities. Some physical therapists are also trained in spinal manipulation. Physical therapist Jan Lucas Hoving, PT, PhD, and colleagues, note (2):


“Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.”


The article by Hoving and colleagues was published in the Annals of Internal Medicine, and titled (2):


Manual Therapy, Physical Therapy, or Continued Care by a

General Practitioner for Patients with Neck Pain:

A Randomized Controlled Trial


In this study, the authors compared the effectiveness of manual therapy, physical therapy, and care by a general practitioner in the treatment of spinal pain, using a randomized controlled trial design. The study involved 183 patients. These authors concluded:


“Manual therapy scored consistently better than the other two interventions on most outcome measures.”


“In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”


“The success rates for manual therapy were statistically significantly higher than those for physical therapy.”


“Manual therapy scored better than physical therapy on all outcome measures…”


“Range of motion improved more markedly for those who received manual therapy or physical therapy than for those who received continued care.”


“The postulated objective of manual therapy is the restoration of normal joint motion, was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”


“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care.”


“Manual therapy seems to be a favorable treatment option for patients with neck pain.”


“Primary care physicians should consider manual therapy when treating patients with neck pain.”


Interestingly, in this study whose primary authors are physical therapists, they found that manual manipulative therapy was superior to physical therapy in the management of neck pain.


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The core of chiropractic clinical practice is spinal manipulation. Spinal manipulation is the use of the vertebrae (usually the transverse and/or spinous process) as a lever to influence tissue integrity and improve the movement parameters of spinal articulations. When this goal is accomplished, a neurological sequence of events is established that closes the “pain gate,” resulting in reduced pain and improved function (3).


Pain is a huge problem in the United States. Acute pain comes and goes, depending on circumstances and activities. In contrast, chronic pain is an ongoing, frustrating and debilitating problem. Of the 238 million adults in the United States, approximately 116 million live with chronic pain (4, 5).


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The recent, comprehensive, and authoritative Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain were published in the October 2007 issue of the journal Annals of Internal Medicine. An extensive panel of qualified experts constructed these clinical practice guidelines after a review of the literature on the topic and then graded the validity of each study. The literature search for this guideline included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. The results were presented in two publications (6, 7):


Diagnosis and Treatment of Low Back Pain:

A Joint Clinical Practice Guideline from the

American College of Physicians and the American Pain Society


Annals of Internal Medicine

October 2007, Volume 147, Number 7, pp. 478-491


AND


Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:

A Review of the Evidence for an American Pain Society

And American College of Physicians Clinical Practice Guideline


Annals of Internal Medicine

October 2007, Volume 147, Number 7, pp. 492-504


The following chart summarizes these guideline’s conclusions. It is noteworthy that the only therapeutic intervention they found acceptable for acute, sub-acute, and chronic low back pain was spinal manipulation (7):


The Following Chart Summarizes The Treatment Benefit

For Low Back Pain




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In 1985, Dr. Kirkaldy-Willis, a Professor Emeritus of Orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada, published an article in the journal Canadian Family Physician (8). In this study, the authors present the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, presumably including physical therapy, and they were all totally disabled. These patients were given a “two or three week regimen of daily spinal manipulations by an experienced chiropractor.”


These authors considered a good result from manipulation to be:


“Symptom-free with no restrictions for work or other activities.”


OR


“Mild intermittent pain with no restrictions for work or other activities.”


81% of the patients with referred pain syndromes subsequent to joint dysfunctions achieved the “good” result.


48% of the patients with nerve compression syndromes, primarily subsequent to disc herniation and/or central canal spinal stenosis, achieved the “good” result.


Dr. Kirkaldy-Willis attributed this clinical outcome to Melzack and Wall’s 1965 “Gate Theory of Pain.” He noted that the manipulation improved motion, which improved proprioceptive neurological input into the central nervous system, which in turn blocked pain. Dr. Kirkaldy-Willis concluded:


“The physician who makes use of this [manipulation] resource will provide relief for many back pain patients.”


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In 1990, Dr. TW Meade and colleagues published the results of a randomized comparison of chiropractic and hospital outpatient treatment in the management of low back pain. This trial involved 741 patients and was published in the prestigious British Medical Journal (9). It was titled:


Low Back Pain of Mechanical Origin:

Randomized Comparison of Chiropractic and

Hospital Outpatient Treatment


The patients in this study were followed for a period between 1–3 years. Nearly all of the chiropractic management involved traditional joint manipulation. Key points from the authors include:


“Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.”


“There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic.”


“Chiropractic was particularly effective in those with fairly intractable pain-that is, those with a history of severe pain.”


“Patients treated by chiropractors were not only no worse off than those treated in hospital but almost certainly fared considerably better and that they maintained their improvement for at least two years.”


“The results leave little doubt that chiropractic is more effective than conventional hospital outpatient treatment.”


Important for this discussion, 84% of the hospital patients were treated with physical therapy and physical therapy manipulation. This observation led to an editorial follow-up in a different journal, Lancet, the following month, which stated (10):