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Study: Spinal Manipulation No Help for Acute Low Back Pain
Daniel J. DeNoon
WebMD Health News
Reviewed By Louise Chang, MD
Nov. 8, 2007 -- If you've come down with low back pain but stay active and take a mild painkiller, you won't get any extra relief from spinal manipulative therapy, a new study suggests.
That's not what physiotherapist Mark J. Hancock, MAappSc, and colleagues at the University of Sydney, Australia, hoped to find. They'd hoped to expand on earlier, inconclusive evidence that spinal manipulation reduces acute low back pain.
"What we found was that in patients who had already received [acetaminophen] and advice to remain active, there was no additional benefit of spinal manipulative therapy," Hancock tells WebMD.
The study was designed to test whether spinal manipulation -- with or without an added painkiller -- could further reduce acute low back pain in patients already treated with acetaminophen (Tylenol is a major brand name).
The researchers studied 240 patients with recent-onset low back pain. The patients had already seen their doctors, who told them to stay active and to take acetaminophen four times a day.
They were randomly placed into one of four treatment groups:
- One group got spinal manipulative therapy from licensed physiotherapists plus diclofenac, an older member of the NSAID drug family that includes ibuprofen and naproxen.
- One group got spinal manipulative therapy plus an inactive placebo pill.
- One group got sham spinal manipulative therapy plus diclofenac.
- One group got sham spinal manipulative therapy plus an inactive placebo pill.
Those who got sham treatment and a fake pill did no worse than those who got either treatment, alone or in combination.
"Our findings suggest that simple treatment, including regular [acetaminophen] and advice to remain active, may be adequate for many patients with acute low back pain," Hancock says. "Patients who are not recovering quickly with this simple treatment may benefit from further treatment. There are many secondary treatment options and no single additional treatment has been shown to be clearly superior to others."
Spinal Manipulative Therapy for Low Back Pain
The study looked only at patients with acute low back pain -- that is, their backs only recently began hurting.
If they stay as active as possible, such patients usually get over their low back within 30 days, says Roger Chou, MD, associate professor of medicine at Oregon Health & Science University in Portland. Chou is director of the American Pain Society's clinical guidelines development program.
"I don't think the results of this study are all that surprising," Chou tells WebMD. "Most people are going to get better on their own after 30 days. People always wonder how well it works to add one treatment on top of another. But that hasn't been shown to work for nearly anything used to treat acute lower back pain."
Chou and colleagues recently updated treatment guidelines for low back pain. After reviewing all the evidence, they made a "weak" recommendation that spinal manipulation may be considered for the treatment of acute low back pain.
"The evidence was not real strong. We give it a weak recommendation because the benefit is not great -- only 10 points on a 100-point pain scale," Chou says.
Spinal Manipulation: Different Practitioners, Different Techniques
Exactly what is spinal manipulative therapy? The techniques used in the study call for therapists to move a patient's joints beyond the normal range of motion. This can be done with slow movements -- what physiotherapists call spinal mobilization -- or with more rapid movements, called spinal manipulation. Most chiropractors use this latter form of spinal manipulative therapy.
In the Hancock study, physiotherapists chose the form of spinal manipulative therapy they thought best for individual patients. Most of the patients in the study got the slower "spinal mobilization" form of treatment.
"The problem is, we don't have good evidence on what is the best technique," Chou says. "A lot of this depends on the provider, and the training is a lot different from country to country and from discipline to discipline. Few studies have compared one technique to another. And if you look at how effective they are against sham treatment or no treatment, they all look about the same."
This doesn't mean that spinal manipulation -- or massage, which uses different techniques -- doesn't help some patients.
"Our advice is if someone is appropriately trained to give it, it should be fine," Chou says. "Manipulation of the lower back is relatively safe. The cervical spine [in the neck region] is more complicated, and that is where there have been problems."
Hancock and colleagues report their findings in the Nov. 10 issue of The Lancet.
SOURCES: Hancock, M.J. The Lancet, Nov. 10, 2007; vol 370: pp 1638-1643. Koes, B.W. The Lancet, Nov. 10, 2007; vol 370: pp 1595-1596. Mark Hancock, MAppSc, Back Pain Research Group, University of Sydney, Australia; email interview. Roger Chou, MD, associate professor of medicine, Oregon Health & Science University, Portland; director, clinical guidelines development program, American Pain Society.
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