Re: Spinal manipulation in low back pain: Dr Quon responds

I would like to thank Dr Preshaw for his response to my brief article on chiropractic treatment for injured workers on behalf of WorkSafeBC.

Owing to restrictions on the size and scope of the original article, it wasn’t possible to include a lengthy reference list and detailed summary of the evidence on spinal manipulation. Nonetheless, no fewer than 10 international, independently developed, evidence-based clinical practice guidelines recommend spinal manipulative therapy (SMT) either more often, or at least as often, as other widely accepted interventions for low back pain. These include treatments such as reassurance, advice to remain active, nonsteroidal anti-inflammatories, and muscle relaxants.[1-10

The article specifically references Dagenais and colleagues because this research summarizes the quality and recommendations both for multiple guidelines and for modalities other than SMT.[11] More importantly, it summarizes this information in a transparent and scientifically rigorous manner. 

When they published their synthesis, Dagenais and colleagues were indeed employed by a for-profit organization (Palladin Health). However, this was neither as fee-for-service clinicians nor as advocates for any single profession. On the contrary, they were retained as scientific consultants (epidemiologists and spine specialists), charged with developing cost-effective treatment pathways for a large, managed care network. Their bias, if any, was toward reducing costs, rather than promoting costly and ineffective interventions. 

The terms “acute” and “chronic” were intentionally omitted from the title of the article. This reflects existing service utilization patterns—many claimants initially see other care providers and are just as often as not beyond the acute phase of their injury before finding their way to a chiropractor. 

My reference to a systematic review on the effectiveness of SMT for chronic, rather than acute, low back pain was also intentional,[12] because systematic reviews are generally more cautious in endorsing spinal manipulation for chronic low back pain, as compared with chiropractic care for acute low back pain.[4]

Finally, regarding the reference to a quote from Rubinstein and colleagues that “… SMT (spinal manipulation therapy) has a small, statistically significant but not clinically relevant, short-term effect on pain relief… and functional status… compared to other interventions,”[12] the often-overlooked corollary to this statement is that other widely accepted treatments for low back pain have a small, statistically significant, but not clinically relevant, worse short-term effect (on pain relief and functional status) when compared to SMT. 

Admittedly, the so-called “effect sizes” for all commonly administered stand-alone modalities for low back pain (acute or chronic) are only small to moderate.[13] Hence, it’s important that research continues into the development of more effective and efficient interventions for low back pain. In the meantime, the current focus in evidence-based chiropractic is to promote multimodal, patient-centred therapy. This involves a combination of patient activation, SMT, and other modalities that demonstrate an equally moderate (as opposed to only small) treatment effect within randomized controlled trials. 

Thank you for the opportunity to address these important issues.
—Jeffrey Quon, DC, MHSc, PhD (Epi), FCCS(C)
WorkSafeBC chiropractic consultant


1.    Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-491.
2.    The Norwegian Back Pain Network. Acute low back pain: Interdisciplinary clinical guidelines. Oslo, UK: The Norwegian Back Pain Network, 2002. 
3.    Negrini S, Giovannoni S, Minozzi S, et al. Diagnostic therapeutic flow-charts for low back pain patients: The Italian clinical guidelines. Eura Medicophys 2006;42:151-170.
4.    van Tulder MW, Becker A, Bekkering T, et al. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006;15(Suppl 2):S169-91. 
5.    Airaksinen O, Brox JL, Cedraschi C, et al. European guidelines for the management of chronic nonspecific low back pain in primary care. COST B13 Working Group on Guidelines for Chronic Low Back Pain, European Commission, 2005.
6.    Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. Brisbane, Australia: Australian Academic Press Pty. Ltd., 2003. 
7.    Nielens H, Van Zundert J, Mairiaux P, et al. Chronic low back pain. Good Clinical practice (GCP). Brussels, Belgium: Belgian Health Care Knowledge Centre (KCE), 2006. Report No.: 48 C (D/2006/10.273/71).
8.    Accident Compensation Corporation, New Zealand Guidelines Group. New Zealand acute low back pain guide. Wellington, New Zealand: Accident Compensation Corporation (ACC), 2004.
9.    National Institute for Health and Clinical Excellence (NICE). Low back pain: Early management of persistent non-specific low back pain. London, UK: National Institute of Health and Clinical Excellence, 2009. Report No.: NICE clinical guideline 88. 
10.    Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: An evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34:1066-1077.
11.    Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010;10:514-529.
12. Rubinstein SM, van Middelkoop M, Assendelft WJJ, et al. Spinal manipulative therapy for chronic low-back pain. Cochrane Database System Rev 2011;16:CD008112.
13. Keller A, Hayden J, Bombardier C, et al. Effect sizes of non-surgical treatments of non-specific low-back pain. Eur Spine J 2007;16:1776-1788.

Jeffrey Quon, DC, MHSc, PhD, FCCSC. Re: Spinal manipulation in low back pain: Dr Quon responds. BCMJ, Vol. 56, No. 1, January, February, 2014, Page(s) 8,10 - Letters.

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