Chiropractic vs. Oral Steroids vs. Muscle Relaxants: Outcomes for Low Back Pain and Sciatica
A report on the scientific literature
By Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Reference: Studin M. (2015) Chiropractic vs. Oral Steroids vs. Muscle Relaxants: Outcomes for Low Back Pain and Sciatica,The American Chiropractor, 37(7) 42-47
Choices. Every health care practitioner is caring for his/her patients having multiple treatment options and often those choices are influenced by pieces of information. That information can be what was learned in formal training, colleagues sharing anecdotal experience, patients giving direct feedback or well-scripted “representatives” of the pharmaceutical industry who only have one agenda…sales.As a result of doctors managing their patients’ conditions, there are two major parameters that are utilized, best medical practice, also known as “experience,” and evidence-based practice or that which has only been concluded in the medical literature. Both have a strong place in a healthcare delivery system with the best possible outcomes as the ultimate goals.
“A best practiceis a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a "best" practice can evolve to become better as improvements are discovered. (“Best Practice,” http://en.wikipedia.org/ wiki/Best practice).”
“Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992. It started inmedicineasevidence-based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology, education, library and information science…” (“Evidence-Based Practice,” http://en.wikipedia.org/wiki/Evidence-based_practice) and other fields. Its basic principles are that all practical decisions made should 1) be based on research studies and 2) that these research studies are selected and interpreted according to some specific norms characteristic for EBP. Typically such norms disregardtheoretical studiesandqualitative studiesand considerquantitative studiesaccording to a narrow set of criteria of what counts asevidence.
“’Evidence-based behavioral practice’(EBBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses" (“Evidence-Based Practice, http://en.wikipedia.org/wiki/Evidence-based_practice).
This highly-debated topic of best practice vs. evidence-based practice has valid issues on each side, but putting together the two concepts as a hybrid would allow them to thrive in any healthcare delivery system as all options would be considered. This would allow advances in healthcare to save more lives, increased quality of life and at the same time, enough safeguards to prevent abuse of those with one-sided agendas to profit. It would also take the blinders off those who have dogmatic prejudice against that which has been verified to be successful in both the best practice and evidenced-based models (experience and literature).
For years, too many non-chiropractic practitioners have ignored the “best practice” model or the results reported by both the patients and the practicing chiropractors with treatments regarding low back and leg pain (often associated with herniated discs). These non-chiropractic practitioners refuse to consider chiropractic as a first referral option. The main reason cited over the past few decades as this author’s personal experience has been that there is no literature that proves these claims in spite of patients corroborating their positive experiences with the chiropractors’ claims. As a result of ignorance, blinders and possibly a deep rooted prejudice, too many patients have been and are currently being treated with poor alternatives based upon outcomes that are now being clearly reported. Treatment with both oral steroids and muscle relaxers are two often used, but inferior choices and now the literature verifies why chiropractic is the best possible first-line of referral for diagnosis that are the subject for this paper.
Goldberg et al. (2015) reported: Despite conflicting evidence, [epidural steroid injections] are frequently offered under the assumption that radicular symptoms are caused by inflammation of the affected lumbar nerve root.Epidural steroid injections are invasive, generally require a pre-procedure magnetic resonance imaging (MRI) study, and expose patients to fluoroscopic radiation. In addition, the US Food and Drug Administration recently warned of rare but serious neurologic sequella from [epidural steroid injections].Oral administration of steroid medication may provide similar anti-inflammatory activity, does not require an MRI or radiation exposure, can be delivered quickly by primary care physicians, carries less risk, and would be much less expensive than an [epidural steroid injection]. Oral steroids are used by many community physicians, have been included in some clinical guidelines,and are noted as a treatment option by some authors.However, no appropriately powered clinical trials of oral steroids for radiculopathy have been conducted to date. To address this issue, we performed a parallel-group, double-blind randomized clinical trial of a 15-day tapering course of oral prednisone vs placebo for patients with an acute lumbar radiculopathy associated with a herniated lumbar disk... (p. 1916).
Results showed that “participants in both blinded treatment groups showed an improvement in symptoms over the initial 6 weeks, with more gradual reductions until the 24-week visit, after which changes were more variable. Baseline ODI [Oswestry Disability Index] scores were 51.2 and 51.1 in the prednisone and placebo groups, respectively; corresponding ODI scores at 3 weeks were 32.2 and 37.5” (Goldberg, 2015, p. 1919-1920). This indicates that both at 3 and 6 weeks there was no difference in the placebo vs. oral steroid groups. “Among patients with acute radiculopathy due to a herniated lumbar disk, a short course of oral steroids, compared with placebo, resulted in modest improvement in function and no significant improvement in pain” (Goldberg, 2015, p.1922).
Hoiriis et al. (2004) reported, “Reviews of low back pain studies often fail to distinguish between manipulative interventions. Manipulation and spinal manipulative therapy (SMT) are vague terms describing procedures used by chiropractors, physiotherapists, massage therapists, and osteopaths. These maneuvers may decrease ligamentous adhesions and myospastn, increase disk nutrition, or alter the function of the nervous system. The manipulative procedures used in this study, referred to as chiropractic adjustments, involve specific application of force thought to restore mechanical and neurological function to the spine…This study was a randomized clinical trial (RCT) in which subjects and assessors were blinded to the interventions, chiropractic providers were blinded to medical/sham assignment and an independent consultant provided the statistical analysis. Visit lengths and provider-subject interactions were monitored to preserve patient blinding” (p. 389).
At the 2 week period, the study revealed that the chiropractic group had statistically slightly better outcomes, but statistically insignificant, than the muscle relaxants and at the 4 week period had a significantly reduced visual analog pain scale of 24% from the muscle relaxant group and 23% from the placebo group. Although the authors reported this as statistically insignificant, I don’t, and one cannot lose sight of the fact that chiropractic outperformed muscle relaxant therapy with the absence of any possibility of side effects from medications, making the utilization of the drugs clinically unnecessary based upon the outcomes of a safer and statistically better alternative.
It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 2010 that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.
The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.
Although the previous report concluded that a chiropractic spinal adjustment is an effective treatment modality for a herniated disc, a more recent study by Leemann et al. (2014), further clarifies the improvement with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients.
In this study, the acute onset patient (the pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.
Chiropractic Care and Herniated Discs with Leg Pain
2 Week Improvement
1 Month Improvement
3 Month Improvement
The caveat is that there are patients who could need drugs or surgery and an accurate diagnosis is paramount. It is incumbent upon the doctor of chiropractic to be fully trained in both the diagnostic and treatment facets of care. It is also important that the chiropractor be well-versed in MRI protocols and interpretation as well as disc pathology in order to be able to triage the patient accordingly based upon the clinical presentation inclusive of the MRI results.
Chiropractic is one of the safest treatments currently available in healthcare and when there is a treatment where the potential for benefits far outweighs any risk, it deserves serious consideration. Whedon, Mackenzie, Phillips, and Lurie (2015) based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study and accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified (Whedon et al., 2015, p. 5)
Contemporary research is clearly defining the most effective and safest treatment options for low back pain sufferers with associated leg pain (sciatica). In too many offices today, chiropractic treatment is not being considered the first option for care and the responsibility to change that habit falls to the chiropractic profession. Our profession is no different than the pharmaceutical companies who have an “army” of drug representatives. Pharmaceutical sales representative (formerly detailmen) are sales people employed bypharmaceutical companiesto persuade doctors to prescribe their drugs to patients. Drug companies in theUnited Statesspend ~$5 billion annually sending representatives to doctors,to provide product information, answer questions on product use, and deliver product samples. Companies maintain this provides an educational service by keeping doctors updated on the latest changes in medical science. Critics point to a systematic use of gifts and personal information to befriend doctors to influence their drug prescriptions.” (http://en.wikipedia.org/ wiki/Pharmaceutical_sales_representative)
What makes the chiropractic profession different from the “real world” of business? The answer is absolutely nothing and it is incumbent upon every entity of the profession from individual practitioners to organizations to start educating the public and every referral source because we now have the evidence. Oral steroids offer no relief and modest return to function. Muscle relaxants offer some help, but render worse results than chiropractic care with clearly defined side effects that can be avoided. It has been clearly concluded that chiropractic care is an extremely safe environment regarding side effects. That is verifiable with close to 7 million subjects studied. By considering chiropractic as the first-line for referral, the scientific evidence verifies solutions to low back pain and leg pain inclusive of herniated discs. The results indicate that at 2 weeks, 80.6% and at 3 months 94.5% of those with herniated dics show significant improvement with chiropractic care.
1. Best Practice. (2015). Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Best_practice
2. Evidence-Based Practice. (2015). Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Evidence-based_practice
3. Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L., Hamilton, L.,…Avins, A. L. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: A randomized clinical trial. Journal of the American Medical Association (JAMA), 313(19), 1915-1923.
4. Hoiriis, K. T., Pfleger, B., McDuffie, F. C., Cotsonis, G., Elsangak, O., Hinson, R., & Verzosa, G. T. (2004). A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for sub-acute low back pain. Journal of Manipulative and Physiological Therapeutics, 27(6), 388-398.
5. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. .Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.
6. Leeman S., Peterson C., Schmid C., Anklin B., Humphrys K. (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging Confirmed Symptomatic Lumbar Disc Herniations Receiving High Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One Year Follow Up, .Journal of Manipulative and Physiological Therapeutics, 37(3), 155-163.
7. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.
8. Pharmaceutical Sales Representative. (2015). Wikipedia. Retrieved from http://en.wikipedia.org/wiki/ Pharmaceutical_sales_representative