1. UK BEAM Trial Team (2004) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 329:1377

This recent MRC-funded study estimated the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to “best care” in general practice for patients consulting with back pain. All groups improved over time. Exercise improved disability more than “best care” at three months. For manipulation there was an additional improvement at three months and at 12 months. For manipulation followedby exercise there was an additional improvement at three months and at 12 months. No significant differences in outcome occurred between manipulation in NHSpremises and in private premises. No serious adverse events occurred.

2. UK BEAM Trial Team (2004) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 329:1381

Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.

3. European Commission Research Directorate General (2004) European Guidelines for the management of acute non-specific low back pain in primary care

Summary of recommendations for treatment of acute non-specific low back pain:

• Give adequate information and reassure the patient
• Do not prescribe bed rest as a treatment
• Advise patients to stay active and continue normal daily activities including work if possible
• Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals; first choice paracetamol, second choice NSAIDs
• Consider adding a short course of muscle relaxants on its own or added to NSAIDs, if paracetamol or NSAIDs have failed to reduce pain
• Consider (referral for) spinal manipulation for patients who are failing to return to normal activities
• Multidisciplinary treatment programmes in occupational settings may be an option for workers with sub-acute low back pain and sick leave for more than 4 – 8 weeks

4. European Commission Research Directorate General (2004) European Guidelines for the management of chronic non-specific low back pain in primary care (2004)

Manipulation/mobilisation – Summary of the evidence:

• There is moderate evidence that manipulation is superior to sham manipulation for improving short-term pain and function in chronic low back pain (CLBP)
• There is strong evidence that manipulation and GP care/analgesics are similarly effective in the treatment of CLBP
• There is moderate evidence that spinal manipulation in addition to GP care is more effective than GP care alone in the treatment of CLBP
• There is moderate evidence that spinal manipulation is no less and no more effective than physiotherapy/exercise therapy in the treatment of CLBP
• There is moderate evidence that spinal manipulation is no less and no more effective than back-schools in the treatment of CLBP

Recommendation: Consider a short course of spinal manipulation/mobilisation as a treatment option for CLBP.

5. Department of Health (2006) Musculoskeletal Services Framework

“Chiropractors provide evidence-based, timely and effective assessment, diagnosis and management of certain musculoskeletal disorders.”

“The Framework describes a system that enables health and social care professionals to provide more easily a high-quality service to patients. A balanced, well-planned system achieves that, and helps professionals to:

• treat patients at the appropriate point in the system (closer to home or work);
• provide patients with better information to manage their condition, reducing avoidable admissions;
• plan/manage patient flows through primary and secondary care, ensuring appropriate and timely referral to specialist care services;
• develop capacity in primary care by offering a wider range of non-surgical alternatives, eg specialist practitioners, physiotherapy, podiatry, nursing, pain management advice, chiropractic, osteopathy etc.”

6. Low back pain: early management of persistent non-specific low back pain

NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Its guideline on the acute management of patients with chronic low back pain was published in May 2009.

The evidence-based recommendations include the following:

• Provide people with advice and information to promote self-management of their low back pain.
• Consider offering a course of manual therapy including spinal manipulation of up to 9 sessions over up to 12 weeks
• Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks
• Consider offering a structured exercise programme tailored to the individual.

7. Effectiveness of Manual Therapies – The UK Evidence Report

This review, by Gert Bronfort et al, was published in the journal Chiropractic & Osteopathy in 2010. Commentaries by Professor Scott Haldeman and Professor Martin Underwood accompany the report. In summary, the report demonstrates robust randomised controlled trial (RCT) evidence that the care offered by chiropractors is effective for a wide range of conditions including neck pain, pain associated with hip and knee osteoarthritis and some types of headache.