Initial use of spinal manipulative therapy reduces adverse drug event risk in older patients with chronic low back pain

James Whedon

The use of spinal manipulative therapy (SMT) as initial treatment of chronic low back pain (cLBP) in older patients is associated with a substantial reduction in the long-term risk of adverse drug events (ADEs) when compared to those who initially underwent opioid analgesic therapy (OAT). This is according to a recent retrospective observational study, the findings of which were published in the journal Spine by James Whedon (Southern California University of Health Sciences, Whittier, USA) et al.

Speaking to Spinal News International, Whedon said: “We performed a ‘number needed to treat’ calculation, and found that, on average, 5.7 patients would have to receive spinal manipulation instead of opioid treatment to avoid the occurrence of one adverse drug event. Thus, even a small shift toward more patients using spinal manipulation could be expected to reduce the risk of adverse events among Medicare beneficiaries with chronic low back pain.”

The aim of the study was to compare OAT and SMT—two therapies which the researchers note currently have a scarcity of evidence in relation to long-term safety—with regard to risk of ADEs among older adults with cLBP.

The researchers examined Medicare claims data spanning a five-year period on fee-for-service beneficiaries aged 65 to 84 years, continuously enrolled under Medicare Parts A, B, and D for a 60-month study period, and with an episode of cLBP in 2013. Patients with a diagnosis of cancer or use of hospice care were excluded.

All of the patients who were included in the study received long-term management of cLBP with either SMT or OAT. Cohorts of patients who received SMT or OAT only, or who switched from either SMT to OAT or OAT to SMT were examined. Poisson regression was used to estimate the adjusted incidence rate ratio for outpatient ADE among patients who initially chose OAT as compared with SMT.

The findings showed that—with controlling for patient characteristics, health status, and propensity score—the adjusted rate of ADE was more than 42 times higher for initial choice of OAT versus initial choice of SMT (rate ratio 42.85, 95% confidence interval 34.16–53.76, p<0.0001).


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