Spinal manipulation is one of the treatment modalities most often associated with chiropractors, osteopaths and some physiotherapists. In this post we will highlight 3 recent research papers on this manual technique relating to low back pain (LBP).
Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: A double-blinded randomized controlled trial in comparison with diclofenac and placebo Spine 2013; 38(7): 540-8
The purpose of this study (von Heymann et al.) was to determine whether the treatment of acute low back pain (LBP) by spinal manipulation is equal to or better than NSAID medication, and whether active intervention is more useful than rescue medication only. NSAID stands for Non-steroidal anti-inflammatory drug and common examples in the UK include ibuprofen and diclofenac.
Patients were between 18-55 years old and had LBP less than 48 hours prior to presentation. Those who had underlying osteoporosis, osteoarthritis or chronic LBP were excluded. The primary outcome measure was the Roland-Morris Disability Score (RMS).
101 patients were recruited but only 93 subjects were evaluable, with 22 of them undergoing placebo treatment (sham manipulation), 36 diclofenac, and 35 spinal manipulation.
The results showed that both the manipulation and diclofenac groups were superior to the control (sham manipulation) and that manipulation was significantly superior to diclofenac. The authors suggested that, given the study’s limitations, HVLA (high velocity low amplitude) manipulation can be recommended for patients with acute nonspecific LBP.
Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With Acute Low Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study Spine 2013 Apr 1;38(7):540-8
Again from the Journal Spine , this study above compared standard medical care (SMC) to SMC with chiropractic manipulative therapy (CMT) for US military patients (18-35 years old) with acute LBP (less than 4 weeks). A greater reduction in acute lower back pain was reported when they received a combination of chiropractic and medical treatment, as opposed to just received medical attention.
After exclusions 91 subjects were randomly assigned to 1 of 2 groups:
1) Standard Medical Care (SMC) – this included “any or all of the following: a focused history and physical examination, diagnostic imaging as indicated, education about self-management including maintaining activity levels as tolerated, pharmacological management with the use of analgesics and anti-inflammatory agents, and physical therapy and modalities such as heat/ice and referral to a pain clinic.
2) SMC plus chiropractic manipulative therapy (SMC plus CMT) – up to 2 visits weekly for 4 weeks. HVLA manipulation was the primary approach for all subjects, but with ancillary treatments at the chiropractor’s discretion as described in the paper. The median number of CMT treatments given was 7 (range 2-8).
The primary outcome measures were the numerical rating scale (NRS) for pain and the Roland Morris Disability Questionnaire (RMQ) and the back-pain functional scale for function. Secondary outcome measures were global improvement and patient satisfaction.
• Pain. Both groups improved, as one would expect in this LPB population, but the SMC plus CMT group had significantly greater pain reduction at both 2 and 4 weeks, which were the 2 times for follow-up and assessment in this study.
• Function. Again, both groups improved but on both the RMQ and the back-pain functional scale the SMC plus CMT group had significantly better results. For example on the RMQ, where a minimal clinically important difference is a reduction of 2.5 points out of 24, the SMC plus CMT subjects had a clinically important advantage over the SMC subjects of 3.9 at 2 weeks and 4.0 after 4 weeks.
• Global improvement. 73% of subjects in the SMC plus CMT group rated their global improvement as pain completely gone, much better, or moderately better, compared with 17% in the SMC group.
• Satisfaction. Importantly, on a scale of 0 to 10 where 10 is completely satisfied, average satisfaction for care in the SMC plus CMT group was 8.9 at both weeks 2 and 4, whereas average satisfaction for the SMC group was 4.5 and 5.4 respectively.
• Adverse events. As in all previous controlled trials of spinal manipulation “there were no serious adverse events.”
Survey based investigation into general practitioner referral patterns for spinal manipulative therapy Chiropractic & Manual Therapies 2013, 21:16
In the UK clinical guidelines encourage general medical practitioners (GPs) to refer back pain patients for spinal manipulation. In this study, Kier et al. surveyed 182 or approximately 20% of GPs in Wales in 2007 with a response rate of 50.8% to get information in two unexplored areas – first “the proportion of GPs who either do refer, or would consider referring, patients to SMT practitioners, in compliance with the low-back pain guidelines”; and secondly GPs’ preference towards a specific provider of SMT both with respect to referrals and personal use.
a) A high proportion of the GPs responding to this questionnaire did or would refer patients for SMT, very different from former research findings. 85% had either referred patients to SMT (72% – 131) or would consider referring (13%).
b) Of the 127 GPs who expressed a preference 58% chose a physiotherapist and 42% “either osteopath, chiropractor or both.” The survey does not give reasons, but Kier et al. note from conversations and anecdotal evidence that the general availability of physiotherapy on the National Health Service (NHS) seems to be an important factor.
c) Asked to name the type of clinician that GPs had personally sought or would consider seeking SMT treatment from for their own healthcare, the results were physiotherapist 22%/,osteopath 16%, /chiropractor 13%. An additional 23% responded that they had no preference and would seek help from any of the three professions.
Fundamental messages from this survey seem to be:
1. In spine care, family physicians/GPs are increasingly aware and accepting of the SMT skills of chiropractors, osteopaths and physiotherapists. Their perspective is that these professionals are all well-trained and largely interchangeable for their needs.
2. They will use those that they can work with most easily – in terms of a common language and approach, availability, integration of services and patient preferences. A major factor in patient preference is cost – reimbursed services under public or private insurances will be the first chosen preference of most patients – and therefore their referring physicians.
In conclusion, these studies help demonstrate the efficacy of SMT for low back pain and also that in the UK GPs are increasingly referring out for this type of treatment as per NICE guidelines.
Spinal manipulative therapy can be a very useful tool in the management of low back pain, together with lifestyle advice, various soft-tissue techniques and rehabilitative exercises. Each patient may require varying emphasis with regard to their own individual combination of care.
There are certain conditions which may be contraindicated to this type of treatment so it is important to let your health care professional know your full medical history. In the UK Physiotherapy, Chiropractic and Osteopathy are all statutory regulated professions.
We would like to acknowledge “The Chiropractic Report” for the use of some of their material in this post.