What does the latest clinical guideline say about chiropractic for back pain?

It is unfortunate that chiropractic in Singapore has become synonymous with spinal manipulation. When most people think of seeing a chiropractor in Singapore, they think of getting cracked. However, this shouldn’t be the case.

Chiropractors are trained allied health providers, and should provide evidence-based care based on what actually works. If spinal adjustments work, then being cracked should be the proposed pain solution. However, if there are better options available, then chiropractors should offer whatever is better.

To a large extent, this is our fiduciary duty to our clients.

What is evidence-based care?

It is human nature to approach issues with generic broad strokes. For example, we may think insurance agents or financial advisors as unethical hard sellers. But the truth is that honest and ethical agents who provide great services do exist!

Within every industry, there are good professionals and not-so-good professionals. Chiropractic is no different. When it comes to providing top quality care, there are both evidence-based chiropractors and tradition-based chiropractors.

We like an evidence-based approach because it’s based on science and hard data. This means instead of looking at our own experiences or what people feel or think, we look at clinical outcomes in a systematic way.

If 100 back pain patients go for adjustments, how many actually respond better after?

If 100 back pain patients go for surgery, how many actually feel better after?

Science is amazing because it tells us what is more likely to work. In that sense, science helps you save time and money.

Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

back pain exercise, back pain guidelines
While The Lancet’s Low Back Pain Series was published in 2018, it still remains the most authoritative clinical guideline to date.

There are lots of clinical guidelines floating around. Most of them point to the same recommendations: Exercise is the best treatment for chronic musculoskeletal pain.

For low back pain specifically, the Lancet series (published 2018) is still the most authoritative work to date.

Just a couple of months ago though,  The Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association just published am update to their guideline. We will discuss their recommendations below.

Exercise for chronic low back pain

Clinically speaking, anything more than 12 weeks can be considered chronic or persistent. Most of your back pain would fall under this category.

Virtually all clinical guidelines, including this one, agree that exercise is the best approach to long-term back aches.

Depending on what is suitable for your case, exercise can include anything from muscle strengthening, endurance, general conditioning, or even muscle activation.

If necessary, motor control or movement-focused exercises can be prescribed to help as well.

What if I have leg pain also?

80 year old man, sciatica singapore, exercise treatment
Age is just a number. You can be 80, and be fit and pain-free. Jack Noonan was a sciatica patient who refused surgery. Through exercise, he’s able to find true freedom from pain.

Some of you may have heard of sciatica, which often includes having pain in your lower limb. According to the clinical guidelines, exercise also helps with it.

It is true that the extent of which exercise helps for sciatica-related cases is poorer. So, the clinical guideline has given exercise a “B” rating for such cases.

There are no interventions that are rated A.

What about passive treatments such as manipulation, mobilisation, or massage?

jesse cai, chiropractor singapore, lifestyle change
The shiokness that accompanies a chiropractic adjustment is very compelling. No one is denying that. The big question to ask yourself is, do the results last?

Here is where the controversy begins.

The guideline (predominantly developed by physiotherapists) gave manual therapy a grade A rating both acute and chronic lower back pain. However, there is virtually no reasonable quality research to suggests that these modalities work better than placebo!

If we were to read the fine print, the guideline specifically clarified that manual therapy should only be used as an adjunct to other treatments.

It doesn’t make sense. If a treatment is meant to be used as an adjunct ONLY with active treatments, why is it given a A-grade recommendation?

The whole point of adjunct means it is optional. In short, it doesn’t make a difference even if you don’t offer it!

This is congruent with the latest research that consistent show passive treatments DO NOT work better than placebo. Aka, they don’t really help you.

Data is beautiful. Humans? Maybe less so.

I think it’s really, really sad that a clinical guideline that is supposed to guide clinical practice has such poor taste in their recommendation.

Like spinal adjustments are synonymous to chiropractic, manual therapy such as massage and mobilisation are synonymous to physiotherapy. While I cannot be certain, the guideline seems to have framed manual therapy in a favourable light to appease their follow colleagues.

What do I do now?

chiropractor singapore, pain solution
We consider passive treatments disempowering because you have to always go back to your chiropractor and physiotherapist to feel better. Education and education are supported by research to deliver true long-term outcomes.

If you want to maximise your chance at getting results, our suggestion is to work within an evidence-based practice such as what we offer at Square One Active Recovery.

We do agree that a lot of what we offer is not intuitive, and can even challenge our biases. However, they are all based on the latest research and we can easily provide citations to support your treatment plan.

To book in for an appointment with us, reach out via the contact below for more information on how we can help you find true freedom from pain.


Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.