Special thanks to star Alpine physical therapist Brace Hayden, DPT, for providing this write up on a recent article from Spine.
There is no arguing that low back pain is an illness that burdens a large percentage of Americans. Sadly, centuries of folk cures and decades of research have fallen short predict reduce the prevalence of low back pain. Modern medicine has dramatically improved the health and livelihood in many arenas, but back pain remains an age-old, expensive, debilitating and frustrating… pain.
The average person with back pain and the American health care reform analyst are equally interested in sorting the worthwhile from the worthless treatments for reducing the duration and frequency of back pain episodes. Comparative effectiveness research hopes to shed light on what services should be recommended and reimbursed by insurance carriers. For example, the Cochrane Collaboration, another meta-analysis think tank, in 2010 looked at fifty studies on chiropractic treatments on low back pain and found muddled results across years of research.
. . . there is . . no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in . . . low back pain Future research is very likely to change the estimate of (the) effect and our confidence in the results.
Double doctor, J. Michael Menke, a doctor of chiropractic and PhD academic out of the International Medical University in Kuala Lumpur, Malaysia, found very little supportive evidence in his meta-analyses on comparative effectiveness of various manual therapies in his review of the existing literature. “A comparative effectiveness meta-analysis” was performed to compare the relative effectiveness of various spinal manipulation treatments (from the ancient bonesetter to the modern back cracker), medical management (READ: drugs, injections, etc), physical therapy, and exercise for acute (less than a month) and chronic (more than 3 months) nonsurgical management of low back pain.
The good news is most pain originating from the muscles and joint in the human body is ‘self-limiting’, meaning slowing down, protecting your injury, and letting the body heal will often suffice. Research supports the notion that sixty to seventy percent of acute low back pain settles in six weeks without any medical treatment. Chronic low back pain sufferers get better in a year without treatment 40 to 70 percent of the time. Pain whether short-term or long-term is indubitably unpleasant, so why suffer any longer than you have to if effective treatment is available.
This study looked at 56 spinal manipulation studies published between 1974 and 2010 and classified them into six different treatment categories. The categories included: 95 spinal manipulation studies, 31 exercise studies, 51 physical therapy/physiotherapy modalities (for example, ultrasound, electrical stimulation, and hot packs) studies, 40 usual medical care studies, and 40 control group studies of subjects that received no treatment. The results found a 96 percent relative improvement in the first 6 weeks across acute back pain studies was unrelated to treatment. Thus the “carry on with your life” control group and the various treatment groups were nearly equal in settling their acute pain. The chronic pain comparison analyses found that 32 percent of the various treatment studies could claim improved outcomes. The balance of the percentage of claimed improvement in the chronic pain comparison analyses can be attributed to everything else (letting the injury run its course). Looking at the printed boxplots of the 6 treatment categories effect sizes attributable to the passage of time alone, the three largest effect sizes were in the exercise group, then the spinal manipulation group, then the modality group.
This study also examined which spinal manipulation treatment provider did the best job for improving chronic back pain. It was determined in the comparison that getting your spine manipulated in the first 6 weeks has little influence on the outcome of shortening the duration of your acute pain. Five types of spinal manipulation providers (osteopaths, physical therapists, chiropractors, allopathic medical physicians, and bonesetters) were compared. Spinal manipulation by a physical therapist was found to be most effective, and most variable, in treating both acute and chronic back pain.
In the 36 years and 8,400 patients subjected to comparative spinal manipulation studies research cost from $32 to $80 million. Menke’s comparative analysis makes the bold assertion that ‘equivocal outcomes are unacceptable for this investment’, and funding more research on the topic should be stopped. It stands to reason, that inadequate analytics and methodology throughout the studies could be part of the problem. The take home message was that all of the compared treatments for acute and chronic low back pain are hard to quantify when looking at their relative effectiveness versus letting the injury run its course.
J. Michael Menke, DC, PhD. Do manual therapies help low back Pain? A comparative effectiveness meta-analysis. Spine. April 1, 2014. Volume 39 , Number 7. pp. e463-e472.
Brent Dodge is the founding owner of Alpine Physical Therapy and is a board certified orthopedic specialist. He holds additional certifications in Functional Dry Needling, Manual Physical Therapy, and Strength and Conditioning.
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