According to Michael Schneider, the vast majority of patients (>85%) with an acute episode of low back pain will not have any serious spinal abnormality or disease as the cause of their symptoms.1 Of these patients who seek treatment, most will be told they have non-specific mechanical back pain.
There is a general belief among physicians that non-specific mechanical low back pain is a self-limiting disorder that will improve regardless of the type of treatment provided.2 This is generally true—about two-thirds of acute back pain cases improve rapidly within the first four to six weeks3—yet about a third of patients report persistent back pain one year after an acute episode.4 Quick recovery from an acute episode and a return to normal function are therefore important goals in the appropriate clinical management of non-specific mechanical back pain.
Current clinical practice guidelines for the management of acute low back pain suggest that physicians provide patients with advice to remain active, over-the-counter medications such as non-steroidal anti-inflammatory drugs (NSAIDs), and self-care options.5 For patients who do not improve with self-care options, physicians are advised to consider other evidence-based non-pharmacological treatment options, including spinal manipulation.
Evidence-based medicine is the judicious use of the best current evidence combined with clinician experience and patient preferences.6 Some patients have a preference for non-pharmacological treatment options. Others may have significant interference with activities of daily living and prefer not to take a “watchful waiting” approach to the management of their acute or sub-acute back pain. For these patients, it is preferable to take a more proactive approach to their back pain including the use of spinal manipulation and exercise. In these cases, spinal manipulation can be a valuable first-line treatment option.
My colleagues and I recently published a randomised trial7 that compared four weeks of management with two types of spinal manipulation or with usual medical care (as described above). The results provide evidence for the effectiveness of both management approaches. The responder analysis showed that up to 50% of the patients in the medical care group showed moderate or substantial improvement at four weeks. This suggests that current guideline-based medical management of low back pain will lead to good outcomes in about one half of patients within four weeks.
However, the spinal manipulation (manual thrust) group achieved substantially more improvement in clinical outcomes compared with the usual medical care group—50–90% of patients receiving manual manipulation showed moderate to substantial improvement at four weeks. This suggests that a greater proportion of patients will be returned to normal function at four weeks when spinal manipulation is added as a front-line treatment option, rather than waiting for patients to exhaust self-care options.
Our trial also compared the clinical effectiveness of two common types of manipulation: manual-thrust manipulation and mechanical-assisted manipulation. The reason for this research question was that many chiropractors use mechanical instruments as a substitute treatment for manual-thrust manipulation, with the belief that they are therapeutically equivalent. The results of this study question that assumption. The proportion of patients in the mechanical-assisted group who achieved moderate (>30%) or substantial (>50%) reductions in self-reported disability and pain at the end of treatment (four weeks) was about the same as the proportions of responders in the usual medical care group. The manual-thrust group had significantly more responders at four weeks than either the mechanical-assisted or usual medical care groups.
Non-specific low back pain has a generally favourable prognosis, and can usually be managed with guideline-based medical care that includes advice to stay active, self-care options, and judicious use of NSAIDs. However, the early addition of manual-thrust spinal manipulation appears to lead to significantly greater reductions in pain and improved function at four weeks. The belief in therapeutic equivalence between manual-thrust manipulation and mechanical manipulation devices is not supported by the current evidence. Spinal manipulation (manual-thrust) can be a valuable treatment option in guideline-based medical care for low back pain.
Michael Schneider is an associate professor of physical therapy at the University of Pittsburgh, Pittsburgh, USA
- van Tulder et al. Spine 1997; 22: 427–434
- Bigos et al. AHCPR Publication No. 95-0642. 1994.
- Pengel et al. BMJ 2003; 327: 323
- Von Korff M, Saunders K. Spine 1996; 21:2833–2837
- Chou et al. Ann Intern Med 2007; 147: 478–491
- Strauss et al. Evidence-Based Medicine 4th ed. 2011
- Schneider et al. Spine 2015: 40(4): 209–217