Friday, April 20, 2012

Opposing views on spinal manipulation for low back pain

Low back pain is a distressing, and distressingly common, problem encountered in family medicine. Although this symptom is usually self-limited in otherwise healthy patients, there are few truly effective treatments other than time. Seeking faster relief, many patients visit chiropractors or osteopathic physicians who provide spinal manipulative therapy. Three pro/con editorials in the April 15th issue of AFP debate the effectiveness of spinal maniplation relative to other commonly used treatments for low back pain.

In the first editorial, Drs. James Arnold and Shannon Ehleringer point out that "in two large systematic reviews, manipulation decreased pain and improved range of motion in patients with chronic neck pain and in patients with acute and chronic back pain. Manipulation improved symptoms more effectively than placebo and was as effective as nonsteroidal anti-inflammatory drugs, home exercises, physical therapy, and back school." Dr. Melicien Tettambel concurs in the second editorial, arguing that since "it is unrealistic to expect any single treatment modality to be universally effective across all patients," manipulation has a useful role as an adjunct therapy.

On the other hand, Drs. Peter Cronholm and David Nicklin contend in a third editorial that much of the evidence supporting spinal manipulation for low back pain consists of low-quality studies that demonstrate statistical but not clinical benefit. Since the benefits of manipulation are comparable to watchful waiting, they argue that the latter option should generally be preferred:

Patients in pain are unhappy, and they want relief. The evidence shows that taking acetaminophen or a nonsteroidal anti-inflammatory drug and resting as needed is as effective as spinal manipulation. However, patients attribute pain resolution to active treatment. Although a course of spinal manipulation, or physical therapy, may keep the patient happy (and occupied) while his or her pain spontaneously resolves, the improvement in pain and function is not based on large, quality studies. Whether improved patient satisfaction with spinal manipulation versus watchful waiting is worth the cost of the therapy depends on who pays and how the paying party values satisfaction. As controlling costs becomes more important, incentives make watchful waiting with nonsteroidal anti-inflammatory drugs or acetaminophen the preferred approach.

What do you say when patients ask if seeing a specialist in spinal manipulation will relieve their low back pain?