"This study confirms previous reports showing that spinal manipulation is an effective modality in chronic non-specific LBP especially for short-term effects as the disability and pain scores in our study are significantly reduced in the short-term evaluation - but not in long-term - when compared with the sham manipulation."

Oswestry Disability Score: "At the 4-month and 7-month evaluation the mean disability scores gradually elevated back toward the pretreatment level in the non-maintained SMT group. However disability score in the maintained SMT group continue improving."

Conclusions: "SMT is effective for the treatment of chronic non-specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy."

CLINICAL IMPORTANCE

This was a prospective single blinded placebo controlled study. That means this is a VERY high quality study. Subjects were randomly assigned to their groups (no bias), there was a control to remove, as much as possible, the chance that improvements were from placebo, and assessments of improvement were performed by a blinded examiner (meaning the examiner did not know which group the patient was from - ie whether the patient had or had not been treated).

"Sixty patients, with chronic, non-specific LBP lasting at least 6 months, were randomized to receive either (1) 12 treatments of sham SMT over a 1-month period, (2) 12 treatments, consisting of SMT over a 1-month period, but no treatments for the subsequent 9 months, or (3) 12 treatments over a 1-month period, along with "maintenance spinal manipulation" every 2 weeks for the following 9 months."

"To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1, 4, 7, and 10 month intervals."

The outcome measures were Oswestry, Visual Analog Scale (VAS) for pain, SF-36 to measure quality of life, Patient Self Evaluation of Improvement, and Mobility tests.

Study Results

"Patients in the second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029, respectively)."

"However, only the third group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation."

"In the non-maintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level."

"At the 4 and 7-month evaluation the mean pain score gradually elevated back toward the pretreatment level in the non-maintained spinal manipulation therapy group. However, pain score in the maintained spinal manipulation therapy
group continued improving."

Conclusions

"Spinal Manipulation Therapy is effective for the treatment of chronic low back pain. To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative therapy."

CLINICAL IMPLEMENTATION FOR PATIENT RESULTS

Spinal mobility, spinal comfort, and spine-related functional ability and quality of life all showed the exact same trend; the group that received maintenance care not only maintained but increased mobility, comfort, function, and quality of life as time under maintenance care progressed over the 10 months.

The group that did not receive maintenance care not only failed to improve, they actually lost the improvements they had made during the first month.

Dr. Chestnut’s Commentary

For the first time we have peer-reviewed evidence from a well designed study that shows a maintenance chiropractic care program consisting of care every 2 weeks for up to 10 months not only prevents relapse and a waste of initial investment, it pays dividends in continued improvements!

For as long as I can remember there has been a debate about frequency and duration of care with respect to chiropractic intervention. Much of this debate has been based on dogmatic opinion and resulted in dogmatic consensus documents. To be truthful, this is one of a very few studies that have ever validly compared different durations of care; I don't know of any that have compared frequency and duration.

The truth is that there are no valid data to determine frequency and duration of care and any claims otherwise are scientifically invalid and almost always logically absurd. There are many within the profession that claim that patients should be better in 3-5 visits and that any care beyond that represents malpractice in the form of overtreatment. There is no valid data to support such a conclusion and, in fact, the entire premise is based on the faulty assumption that back pain spontaneously and quickly (within a month) resolves in 90% of cases.