Editorial

Stan Innes BAppSc(Chiro), BA(Hons), Mpsych.

I came across Professor Edzard Ernst's article in the February edition of the Journal of Pain and Symptom Management “Chiropractic: A Critical Evaluation” (1). He held the chair of physical and rehabilitation medicine at the Medical Faculty of Vienna. He became the UK's first professor of complementary medicine in 2003.

An interview with Professor Ernst was published in the Guardian (2). It reported that “ Complementary and alternative medicine (CAM) practitioners were a little unsettled when the post was given to a conventional scientist who declared his intention was to put therapies and treatments from acupuncture to herbs to reflexology under rigorous scrutiny, to find out what worked and what did not….. Having won most of the mainstream critics over, but failed so regularly with the CAM lobby that after a few years of assiduously attending meetings, giving lectures and trying to convince them of the value of rigorous randomised controlled trials, he gave up: "They say you can't squeeze a holistic, individualised approach like homeopathy or spiritual healing into the straitjacket of RCTs - not that it is the only research tool, but it is a good one. The argument surfaces on a daily basis. It is as frequent as it is wrong." But he adds: "People mistakenly think I must be a promoter of complementary medicine - that I should have an allegiance to the camp. I don't. My allegiance is firstly to the patient - I feel that very strongly as an ex-clinician - and secondly to science. If in the course of that I have to hurt the feelings of homeopaths I regret that, but I can't help it."

While I am favourably drawn to this analysis of RCT’s as a good research tool, I am less so with his paper on Chiropractic. In it he attempts to critically evaluate chiropractic.

The specific topics include the history of chiropractic, the internal conf l icts wi thin the profession, the concepts of chiropractic, par ticularly those of subluxation and spinal manipulation, chiropractic practice and research, and the efficacy, safety, and cost of chiropractic. He sourced background material from selected articles from the published chiropractic literature and on previously published systematic reviews. He evaluated Chiropractic as being rooted in mystical concepts which has led to an internal conflict within the chiropractic profession, which continues today. Currently, he writes, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. He states that the core concepts of chiropractic, subluxation, and spinal manipulation, are not based on sound science. He expresses concern that while back and neck pain is the domain of chiropractic, many chiropractors treat conditions other than musculoskeletal problems. He continues stating that with the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. He summarises manipulation as being associated with frequent mild adverse effects and with serious complications of unknown incidence and its cost-effectiveness has not been demonstrated beyond reasonable doubt.

He concludes that the concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt. A harsh but challenging summary. I try to make it a practice to review alternative viewpoints in an effort to maintain a “perspective” as to perceived areas of deficiency. Such positions can “fuel the fire” for continued recognition and acceptance.

The recent paper by Luijsterburg et al (3) is a case in point. Simon French in the last COCA News (4) critiqued a recent Australian study published in the prestigious journal The Lancet which argued that there is no additional benefit from additional physiotherapy after high quality care from a general practitioner (GP) for people with acute low-back pain (LBP), Hancock 2007(5). The investigators concluded that people with acute non-specific LBP who attend a GP providing guideline recommended treatment get no additional benefit from attending a physiotherapist providing manual therapy nor from taking NSAIDs. Luijsterburg et al., conducted a randomised clinical trial in primary care with a 12-months follow-up period seeking to assess the effectiveness of physical therapy (PT) additional to general practitioners’ care compared to general practitioners’ care alone, in patients with acute sciatica. They believed there is a lack of knowledge concerning the effectiveness of PT in patients with sciatica. About 135 patients with acute sciatica (recruited from May 2003 to November 2004) were randomised in two groups: (1) the intervention group received PT added to the general practitioners’ care, and (2) the control group general practitioners’ care only.

The primary outcome was patients’ global perceived effect (GPE). Secondary outcomes were severity of leg and back pain, severity of disability, general health and absence from work. The outcomes were measured at 3, 6, 12 and 52 weeks after randomisation. At 3 months follow-up, 70% of the intervention group and 62% of the control group reported improvement. At 12 months followup, 79% of the intervention group and 56% of the control group reported improvement. No significant differences regarding leg pain, functional status, fear of movement and health status were found at short-term or long-term follow-up. At 12 months follow-up, evidence was found that PT added to general practitioners’ care is only more effective regarding GPE, and not more cost-effective in the treatment of patients with acute sciatica than general practitioners’ care alone. They concluded that there are indications that PT is especially effective regarding GPE in patients reporting severe disability at presentation. Perhaps physical therapy does have a role to play after all, despite Ernst’s position and Hancock’s study.

To stay current with the musculoskeletal research can be energy draining, time consuming, challenging to your personal views and, at times, difficult to decipher without expertise. If there are areas you would like to see addressed further via a seminar or in the COCA News then please contact me. (stan.innes@coca.com.au)

Finally I would like to make special mention of Alan Ralph who has recently left COCA; his patience and persistence while working with me on the COCA News are greatly appreciated. He has been a vital resource and I wish Alan all the best in his future endeavours.

1. Ernst. E., “Chiropractic: A Critical Evaluation”.. Journal of Pain and Symptom Management February 13, 2008
2. Boseley, S. The Alternative Professor. The Guardian, Thursday September 25 2003
3. Luijsterburg et al. Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 1 2 - m o n t h f o l l o w - u p . E u r o p e a n Sp i n e J o u r n a l Vo l ume 17, Numb e r 4 / April, 2008
4. French S. Study Questions Additional Benefit of Physical Therapy for Low-back Pain. COCA News March 2008
5. Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, Spindler MF, McAuley JH (2007). Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended firstline treatment for acute low back pain: a randomised controlled trial. Lancet 370(9599): 1638-43.