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Spinal manipulation holds its own
Chronic lower back pain reviewed
For patients suffering from chronic lower back pain, a new review of existing research finds that spinal manipulation is as helpful as other common treatments like painkillers, according to the Health Behavior News Service, part of the Center for Advancing Health.
Spinal manipulation is also safe, researchers found. Ultimately, "the decision to refer for manipulation should be based upon costs, preferences of the patient and providers, and relative safety of all treatment options," said review lead author Sidney Rubinstein, DC, a chiropractor in private practice and a postdoctoral researcher at the VU University Medical Center in Amsterdam.
Surveys suggest that half of working Americans suffer from back pain each year. An estimated 25% of American adults reported that they suffered from back pain for at least a day within the last three months, according to a 2006 Centers for Disease Control and Prevention report, and lower back pain is the fifth most common reason that people go to the doctor.
Patients frequently turn to painkillers, which can cause side effects and be addictive, or to physical therapy, which is time-consuming and expensive. The new review looks at a third option: spinal manipulation.
In North America, Rubinstein said, chiropractors perform most spinal manipulation. Practitioners move their hands around a patient's spine and joints, often producing an audible crack. "The effectiveness of this therapy has long been controversial," Rubinstein said. "Some proponents are slowly starting to view it as effective for chronic low-back pain. The results of this review will support that view."
The review authors looked for randomized controlled studies, which are researchers consider as the most reliable forms of medical research. They found 26 studies with 6,070 participants that met their criteria for inclusion in their review, but deemed only nine studies to be of high quality. The findings appear in the latest issue of The Cochrane Library. The journal is a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering the content and quality of existing medical trials on a topic.
The researchers found that spinal manipulation worked about as well as the other treatments. It appears to work well in particular for certain kinds of patients, Rubinstein said, including those with restricted movement in the back, those without psychological issues, and those without symptoms below the knee related to the sciatic nerve. Spinal manipulation "appears to be no better or worse than other existing therapies for patients with chronic low-back pain," the review says.
There is one small caveat, however. In medical research, scientists often compare a treatment to a placebo, which is difficult when you are talking about something that's difficult to fake, such as spinal manipulation. Three of the studies reviewed the kind of spinal manipulation that produces a crack sound and tried to fool some patients into not realizing they were getting a sham treatment. However, it is unclear if they succeeded, Rubinstein said. One study appeared to show that patients could distinguish whether they were getting the real thing.
So how well do the treatments spinal manipulation and the other examined in the review work overall? Rubinstein said studies have shown that they help about two-thirds of patients. Other researchers say they have a modest impact at best.
Roger Chou, MD, a physician and researcher with Oregon Health & Science University who has studied back pain, said that in general, most treatments for lower-back pain "aren't all that effective, even the ones we think that work, but some people respond better than others."
"Right now the best we can say is that clinicians and patients have a number of moderately effective treatment options to consider, including exercise, manipulation, acupuncture, yoga, massage, cognitive behavioral therapy, and some of the analgesic medications, and that it should be a decision between the clinician and patient," Chou said. "In general, I think exercise is a preferred option since it has a lot of other health benefits."
Tim Carey, MD, MPH, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, said that many patients try several treatments, of which spinal manipulation is just one approach. "We do not have a good sense of how manual therapy fits in an exercise regimen in a patient who is also taking medication, just as an example," said Carey, who studies back pain. "While manual therapy seems to be an option for chronic low back pain, the evidence at present does not support a role as a preferred option."