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Three Part Question

[In patients with chronic back pain] is [spinal manipulation better than standard care] at [reducing symptoms and allowing a return to work]

Clinical Scenario

A 43 year old man attends his general practitioner with a 6 month history of simple low back pain. He is tolerating simple analgesics and manageing to stay at work but he is struggling and has had to take days off sick due to his symptoms. There is nothing to suggest a sinister underlying cause and clinical examination does not suggest a radiculopathy. He is keen to try physio or chiropractic. You wonder if with er have been shown to make a difference.

Search Strategy

Medline 1966- July 2005 via OVID on www.
AMED 1985- July 2005
CinAHL 1982 - July 2005
Cochrane Edition 3 2005
Medline: [exp Manipulation, chiropractic or exp chiropractic ormanipulation, spinal] and [limit to reviews (specificity) and English language]
AMED and CinAHL: exp Manipulation, chiropractic or exp chiropractic ormanipulation, spinal] and limit to "review"

Search Outcome

Medline: 91 papers of which 2 were directly relevant
AMED: 51 papers of which 1 additional citation found.
CinAHL: 182 papers, no new papers found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bronfort G et al 2004 USA	RCTs of more than 10 subjects receiving manipulation or mobilisation for low back pain. Only studies with patient related outcomes were included.	Systematic review.	Number of studies identified	69 studies were identified. 11 trials only considered acute back pain. 11 trials assessed chronic and acute and 14 solely chronic back pain.	Heterogenecity of studies precluded statistical pooling. Descriptive review only making implications for therapy difficult to assess. Only broad conclusions can be drawn. Some of the comparator therapies in the trials (e.g. TENS) are thought to be ineffective in their own right.
			Quality of papers	15 trials were excluded as a result of methodological weaknesses
			Chronic back pain:	The authors provide a narrative and descriptive review of manipulation/mobilisation against a variety of other therapies. There is consistency to demonstrate an efficacy equal or better to; NSAIDS and exercise; physio and home back exercise; standard GP care; TENS; information booklets; standard medical care; outpatient care; McKenzie therapy
			Authors assessment of evidence	The consistency of equivalence or superiority of manipulation/mobilisation over other therapies leads the authors to cautiously recommend the treatments.
Coulter ID 1998 USA	Summary of a RAND group consensus model examining chiropractic in low back pain	Descriptive	Number of trials included in review	29 trials found. 4 excluded due to methodological weakness.	The author found only low quality evidence trials in studies of patients with chronic low back pain. Methodology is not explicit in this paper, it is therefore difficult to see how the author went from original data to their conclusions.
			Quality of trials	Quality scores ranged from 22 to 62 on a 100 point scale.
			Trials of simple low back pain	9 trials. 5 looked at chronic low back pain.
			Results in chronic back pain	Insufficient evidence to draw conclusions in chronic pain
			Risks of manipulation	Case reports/series only found. Risks thought to be very low (estimated to be in region of 1 in 10 to 100 million)
Assendelft WJ et al 2004 Netherlands	RCT studies of spinal manipulation in low back pain. Trials had to have valid clinical end points and follow up for more than one day.	Systematic review.	Number of papers found	39 studies identified.	This is an interesting review written by an experienced researcher in the field. It is a little unclear why they appear to downplay the results of the apparent benefits to manipulation/mobilisation. In fact their discussion states that there is no benefit over other forms of mobilisation, exercise etc. It remains that it is better than nothing.
			Quality of papers found	Poor.
			Comparators against which spinal manipulation tested	Sham therapy, conventional GP therapy, analgesics, physical therapy, exercises, back school, or a collection of therapies known to be of dubious effectiveness (e.g. TENS)
			Key findings	Small improvements when compared against:sham manipulation (improvement in short-term pain, 10 mm [95% CI, 3 to 17 mm]; improvement in long-term pain, 19 mm [95% CI, 3 to 35 mm]; improvement in short-term function, 3.3 points on the RMDQ [95% CI, 0.6 to 6.0]) or the group of therapies judged to be ineffective or perhaps harmful (improvement in short-term pain, 4 mm [95% CI, 0 to 8]; improvement in short-term function, 2.6 points on the RMDQ [95% CI, 0.5 to 4.8]).
			Authors conclusions	No evidence to support the use of manipulative therapy.

Comment(s)

Any discussion regarding the effectiveness of osteopathy/chiropractic/physical therapy etc. for simple low back pain is likely to result in controversy as there are firmly held beliefs in all specialities as well as in related medical specialities such as orthopaedics. This is reflected in the three different studies outlined above. They come to different conclusions as a result of handling and interpreting the data differently. An impression of the data by this group would seem to suggest that manipulative therapy is at least as equivalent to other therapies for low back pain.

Clinical Bottom Line

Spinal Manipulation is as effective or superior to other conservative therapies in chronic low back pain.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis The Spine Journal 2004;4:335-356
2. Coulter ID Efficacy and risks of chiropractic manipulation: What does the evidence suggest Int Med 1998;1:61-66
3. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal Manipulative therapy for low back pain. Cochrane database of systematic reviews (1):CD000447,2004