Advantages of Expertise-Based Trials for the Treatment of Low Back Pain

Evidence-based medicine is a major focus of research right now. Without evidence that a specific treatment is effective, methods that don't really work can be eliminated. Studying different treatments for low back pain is one way to find out what works best.

Randomized controlled trials (RCTs) are considered to be a model approach to quality research. Patients are divided randomly but equally between treatment groups. Whenever possible, the patients and/or the clinicians have limited (or no) knowledge of who is being treated and by what method.

In this systematic review, RCTs of acupuncture versus manipulation of the spine were examined and compared. Articles were included from around the world and in any language.

Each study was examined to see if it was an expertise-based RCT. This means that each participant was randomized but only clinicians with expertise in the area of intervention saw the patient.

In conventional RCTs, patients in group A (acupuncture) or B (manipulation) were treated by clinicians who may not have expert skills in the assigned area. In other words, one practitioner provided both competing therapies. In the area of acupuncture, this may have been an anesthesiologist with training in acupuncture or a chiropractor with experience in acupuncture.

Bias in results can be reduced. This is done by having all patients assigned to the acupuncture group receive acupuncture from the most expert acupuncturist available. Likewise, manipulative treatment should only be delivered by someone highly skilled in this modality.

It's possible that someone providing both types of treatment but with greater expertise in one area over another will bias the treatment toward the area of their particular expertise. Having clinicians who only provide the therapy for which they are an expert would increase the validity of RCTs and make them evidence-based.

Bradley C. Johnston, ND, et al. The Use of Expertise-Based Randomized Controlled Trials to Assess Spinal Manipulation and Acupuncture for Low Back Pain. A Systematic Review. In Spine. April 15, 2008. Vol. 33. No. 8. Pp. 914-918.

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