Randomized clinical trial.
To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care.
Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking.
A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms.
Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80–2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08–2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62–1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.
Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.
In a managed-care population comprised of mostly subacute and chronic low back pain patients, relatively small differences in clinical outcomes were observed between 4 popular low back pain management strategies during 18 months of follow-up. Larger differences were observed for patients' perceptions of improvement.
From the Departments of *Epidemiology and §Health Services, UCLA School of Public Health, Los Angeles, CA; †Southern California University of Health Sciences, Whittier, CA; and ‡Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI.
Supported by grants from the Agency for Healthcare Research and Quality (AHRQ) (R01 HS07755) and the Southern California University of Health Sciences. Dr. Hurwitz was also supported by a grant from the National Center for Complementary and Alternative Medicine (K23 AT00055).
Acknowledgment date: December 8, 2004. First revision date: February 1, 2005. Acceptance date: April 5, 2005.
The manuscript submitted does not contain information about medical device(s)/drug(s).
Federal and Institutional funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Eric L. Hurwitz, DC, PhD, Department of Public Health Sciences and Epidemiology, John A. Burns School of Medicine, University of Hawaii, Manoa, 1960 East-West Road, Biomed. D-104H, Honolulu, HI 96822. E-mail: firstname.lastname@example.org