• 80% of people will be disabled by low back pain during their adult lives.
• It is the third most frequent reason (after respiratory disorder and headache) that people consult a health practitioner.
• The World Health Organization describes disability from low back pain as epidemic.
• 50-60% of workers’ compensation cost is from back pain.

The British Medical Research Council Trial by Meade et al, published in the British Medical Journal in June 1990 with long term follow up results published in August 1995.

• This was an independent study and subsequently endorsed by the British Medical Association.
• It is well-designed, large, and compared chiropractic with medical/physiotherapy hospital out patient practice.
• The study showed excellent short and long-term results for chiropractic patients, for patients with both acute and chronic pain, for patients with moderate or severe pain.
• Researchers expressly argued for greater use of and government funding for chiropractic services because of superior effectiveness and cost-effectiveness.

The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-back Pain, Manga et al, a government commissioned report published in 1993 by health economists from the University of Ottawa. Manga et al looked at all the international evidence, from hard science to workers’ compensation and other economic data, and concluded: “In our view, the constellation of evidence of:

• The effectiveness and cost-effectiveness of chiropractic management of low-back pain.
• The untested, questionable or harmful nature of many current medical therapies.
• The economic efficiency of chiropractic care for low-back pain compared with medical care.
• The safety of chiropractic care.
• The higher satisfaction levels expressed by patients of chiropractors.

The U.S. and UK government sponsored multi-disciplinary Guidelines for management of Low Back Pain, December 1994.

These review the controlled trial evidence and recommend:

• Spinal manipulation and over-the-counter medication (Acetaminophen, Ibuprofen) for most patients with acute low back pain.
• Patients should be encouraged to remain active and be given appropriate education in posture and exercises.
• Not to rest or ‘wait and see’.

Neck pain is a common musculoskeletal complaint and often is the result of repetitive strain injuries (as found with assembly workers or computer operators) and motor vehicle accidents (whiplash) or trauma.

There is now a clear movement in health care towards early active treatment including spinal manipulation, mobilization, stretching, exercise and early return to work / activity and medical and chiropractic specialists warn against passive management and counsel against extended rest and dependency on drugs and stress that the primary goal is the recovery of function.

Quebec Task Force Report. Redefining Whiplash and its Management, May 1995, which is an evidence-based guideline on management from an international interdisciplinary panel. The main issues regarding the management of neck pain are:

• The same principles apply as in the management of low back pain.
• The Report supports the safety and effectiveness of cervical manipulation in treating neck pain.
• It is the Task Force consensus that the use of short term spinal manipulation and mobilization by trained persons, the use of non-steroidal anti-inflammatory (NSAIDs) and analgesics, and active exercises are the most helpful and appropriate in treating uncomplicated neck pain.
• The Task Force further recommends that prolonged use of soft collars, rest or inactivity probably prolong disability.
• The Task Force finds that scientifically unproven therapies include cervical pillows, postural alignment training, acupuncture, spray and stretch, electrical stimulation, ultrasound, laser, short wave diathermy, heat, ice, massage, epidural or intrathecal

Early Mobilization of Acute Whiplash Injuries. Mealy, et al in the British Medical Journal, 1986. This is a randomized study, which followed patients with acute soft tissue whiplash injuries:

There were two groups:

1. Given the standard treatment of rest and initial immobilization with a soft cervical collar.
2. Given “active treatment” of ice in the first 24 hours and then appropriate manipulative techniques and daily exercises. The researchers found that the patients receiving the early active treatment (#2) had a statistically significant increase in cervical spine movement but not those given the standard treatment (#1) and group #2 had a significant decrease in pain and they concluded that early active management was preferred.

The immediate Effect of Manipulation versus Mobilization on Pain and Range of Motion in the Cervical Spine: A Randomized Controlled Trial, Journal of manipulative and Physiological Therapeutics, Cassidy, Lopes, et al. Shows the spinal manipulation has better immediate effects than mobilization in terms of increased ranges of joint motion.

The Appropriateness of Manipulation and Mobilization of the Cervical Spine, (Research and Development) Corporation of California, July 1996. Rand is a non-profit private corporation, which conducts research and development for the US government and the private sector.

The RAND Report recommends:

• Cervical manipulation and mobilization for neck and headaches.
• Cervical manipulation is far safer than a number of medical treatments given for the same symptoms (mortality rate for cervical spine surgery is 6,900 per million, serious gastrointestinal events from NSAID’s are 1000 per 1 million)

• A comprehensive US study (1992) estimated that approximately 27 % of females and 14 % of males suffer from severe headaches and that over 10 million Americans (4%) suffered moderate to severe disability from various forms of headache.
• A 1993 paper in the journal Headache calculated that headaches resulted in 74.2 million days of restricted work activity per annum in the US with an estimated cost of $1.4 billion dollars in lost productivity.
• A 1992 Canadian study found that 14% of Canadians suffer from migraine headaches, and that 50% of these have significant disability – 36% suffer chronic tension headaches with an 18% disability and 14% suffer from both tension and migraine. It was calculated that over 7 million workdays per year were lost because of headaches.
• From the point of view of the patient, given the high incidence of headaches, the issue is whether medical physicians or chiropractors should treat headache sufferers. There is a clear role for both.

Medical leaders acknowledge that there is still grave confusion in the diagnosis of headaches. It was only in 1988 that the International Headache Society recognized cervicogenic headache (headache as the result of pain radiating from the facet joints of the C2 and the C3 vertebrae) as a distinct entity and thus common forms of headache include primary types (benign – the headache pose no danger to the patient other than the headache itself); migraine, tension, cluster and cerviogenic and secondary types (those caused by underlying disease and pose a serious threat to the patient’s health) of which there are hundred’s of possible causes and include tumor (space occupying lesion) temporal arthritis, meningitis, acute glaucoma and subarachnoid hemorrhage.

There is a good body of research studying the cervical spine and headaches. Some studies include:

A Controlled Trial of Cervical Manipulation for Migraine, Australian, New Zealand journal of Medicine, Parker et al, 1978. One of the first clinical trials ever conducted on spinal manipulation and migraines.

• Compared chiropractic manipulation, medical manipulation and mobilization by physical therapists. All groups of patients benefited from treatment, chiropractic patients benefited most on all measures (complete cure, frequency of attack, mean duration, mean disability, mean intensity of pain)- a follow-up study showed that the patients who improved maintained this benefit after 20 months.

The Efficacy of Cervical Adjustments (Toggle Recoil) for Chronic Headaches with Upper Cervical Subluxation, Whittingham, 1995.

• Results after treatment and at 6 months follow-up, measured subjectively (Neck Disability Index, Sickness Impact Profile, pain drawings and daily headache diaries) and objectively (cervical range of motion, pressure algometry) showed a statistically significant improvement (decrease in chronic headache) in the patients treated with spinal manipulation but not in the control group patients.

Spinal Manipulation vs. Amitriptyline for the treatment of Chronic Tension-Type Headaches. JMPT, Boline, DC, Kassam, PhD et al, 1995.

• Compared the effectiveness of spinal manipulation and medication (Amitriptyline) for the treatment of tension headaches.
• Found that the patients in the spinal manipulation group showed a reduction of 42% in headache frequency, 32% in headache intensity and a 30% decrease in usage of over the counter medication and a 16% improvement in functional health status while the medication group showed an improvement of only 6% or less in all the outcome measures.