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"EDITOR,--T W Meade and colleagues have provided further data from their study comparing chiropractic with hospital physiotherapy.1 Unfortunately, their report is far from convincing. The "headline" advantage of chiropractic over hospital management at three years (29%) sounds impressive but refers to an improvement of three points on the 100 point Oswestry scale, or one and a half responses on the questionnaire. This difference may be statistically significant but is clinically trivial.
In their original article the authors noted that chiropractic was 50% more expensive,2 and in the latest report they note that the chiropractic group had more treatments in the long term. The measured improvement does not seem to support such an expenditure.
The design of the study was criticised after the first paper was published.3 The patients initially presenting to a chiropractor were self selected on the basis that they believed that chiropractic would be effective (as they were expecting to pay for treatment).
It is interesting that only the patients referred by chiropractors showed a significant advantage for chiropractic. Those initially recruited in hospital practice showed no significant difference. The study compares private practice with NHS treatment with all the implications for environmental and personal factors that this brings.
The follow up rate (70% and 77%) is inadequate and would preclude publication in some journals.4 Analysis by intention to treat does not obviate this deficiency.
Important variables such as psychological disturbance are not addressed although these are noted to have a greater impact on results than does treatment.5
It is disappointing that in the five years between the reports these and the other criticisms that were raised were not more fully addressed. Despite the acclamation of the first report in the popular media I do not think that this study has advanced our understanding of the treatment of back pain in any useful way."
Letter to the British Medical Journal (1995)