Chiropractic Spinal Manipulation for Treatment of Acute Low Back Pain
April 1998; Volume 1: 45-46
By Joshua J. Ofman MD, MSHS
So, you decided to lift that television set without bending your knees and now you are in bed with an aching back and can't move! What should you do? See your doctor, who will likely prescribe some anti-inflammatory drugs and muscle relaxants? See a physical therapist for some stretching exercises and ultrasound? Or, see a chiropractor or other practitioner for spinal manipulation?
Low back pain is the second most common complaint to primary care practitioners and the most frequently reported ailment for which complementary therapies are sought.1 Approximately 80% of people in Western societies will develop one or more episodes of low back pain in their lifetime, and it is the second most common cause of missed work in the United States. Most clinicians recognize that patients with acute low back pain will recover within eight weeks regardless of the therapy administered. Unfortunately, allopathic interventions have not been effective in "speeding up" recovery from this condition, which disables 4.5 million Americans annually. In addition, surveys reveal that allopathic practitioners remain skeptical of spinal manipulation and often do not recommend it to their patients with acute low back pain.2
Discipline
Chiropractors represent the second largest group of primary care providers in the United States. Approximately 10% of the adult population seeks care from a chiropractic provider.1 Chiropractors treat between 40-60% of patients with low back pain and use spinal manipulation as their main therapeutic modality. Chiropractors are licensed in at least 45 states. Insurers are required to pay for their services in all 50 states, and many managed care organizations include them on their provider panels.
History/Philosophy
Spinal manipulation, in some form, has been an integral part of many traditional cultures, from the ancient Greeks to native Americans. In the 1890s, David Palmer developed a manipulative technique using the spinal projections as levers for manual contact. Soon after, he developed the first chiropractic school, and the field was born.
The philosophy of chiropractic manipulation understands it as a means of connecting the spiritual and physical human aspects and eliminating interference. In chiropractic care, it is believed that subluxations (less than full dislocation) or malalignments of the vertebrae cause interference in the nervous system which alters the normal functioning of the individual.
Technique
Spinal manipulation refers to a high-velocity thrust to a joint that pushes it beyond its restricted range of movement. Mobilization, on the other hand, refers to low-velocity, passive movements within or at the limit of joint range. Spinal "adjustments" refer to low-amplitude thrusts lasting about one-tenth of a second applied to the vertebrae to correct subluxation. Nonspecific "long-lever" manipulations involve placing the body in a position to manipulate the entire spine as a unit, whereas "short-lever"adjustments use hands-on pressure on or near a specific vertebra. Performed competently, adjustments should be painless and harmless, and an audible snapping sound may be heard.
Safety
Because cases have been underreported, and because there has been limited prospective assessment, the true incidence of complications due to spinal manipulation is unknown and can only be approximated. Nonetheless, chiropractic spinal manipulation is believed to be extremely safe, and the estimated rate of developing severe neurologic complications such as cauda equina syndrome is 1 per 100 million spinal manipulations.3
Scientific Support/Clinical Studies
In 1992, a meta-analysis of 25 controlled trials of spinal manipulation was performed.3 Nine studies of acute/subacute, uncomplicated (without radiculopathy) low back pain were included, and the two studies of the highest quality (best methods) found that spinal manipulation resulted in improved functional status. The remaining seven studies assessed recovery from back pain as the outcome measure; at three weeks, there was a 17% higher chance of recovery in patients receiving spinal manipulation compared to other interventions such as physical therapy, analgesia, and bed rest (67% vs 50%).
In 1996, the evidence was revisited by Koes, who performed a systematic review of the available data. Twelve trials (8 of the trials in the 1992 meta-analysis, plus 3 additional trials) compared spinal manipulation to short-wave diathermy, massage, exercise, or analgesics in acute low back pain. Of the 12 trials, only five trials showed a positive effect of spinal manipulation, and the highest quality studies did not show manipulation to be any better than standard therapy.4
In the treatment of acute low back pain, the time to recovery, return to work, and the number of patients achieving a complete recovery are similar regardless of provider type-orthopedist, primary care physician, or chiropractor.5 However, it appears that patients are more satisfied with care provided by chiropractors.5,6
What about the costs of care? For a single "episode of care" (from symptom onset to resolution) for low back pain, chiropractors average 10-15 visits per episode. The same "episode" treated by primary care physicians averages 3-5 visits.5,7 Thus, depending on the nature of the reimbursement (capitated, reduced fee-for-service, or out-of-pocket), chiropractic care may result in higher direct costs to patients than allopathic care. In one study, primary care physicians provided the least expensive care, and orthopedist and chiropractor costs were about the same.5
Current Professional Group Recommendations
Based on available scientific evidence, the U.S. Agency for Health Care Policy and Research, the Evidence-Based Quebec Task Force, the Clinical Standards Advisory Group (England), and the British Association of Chartered Physiotherapists in Manipulation all advocate the use of spinal manipulation in acute low back pain without radiculopathy.
Conclusions
Evidence suggests that spinal manipulation is a safe and effective intervention that may improve the satisfaction with care and lead to a faster recovery. Because chiropractors tend to require multiple return visits, continuing chiropractic care may be more costly than management by a primary care physician. Nonetheless, if you or your patients suffer from acute low back pain of benign etiology, spinal manipulation is a safe and effective alternative to medical therapy, keeping in mind that no matter what you do, recovery will likely occur within eight weeks.
References
1. Eisenberg DM, Kesser RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328:246-252.
2. Cherkin DC, Deyo RA, Wheeler K, et al. Physician views about treating low back pain. The results of a national survey. Spine 1995;20:1-9.
3. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low-back pain. Ann Intern Med 1992;117:590-598.
4. Koes BW, Assendelft WJ, van der Heijden GJ, et al. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine 1996;21:2860-2871.
5. Carey TS, Garrett J, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. N Engl J Med. 1995;333: 913-917.
6. Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989;150:351-355.
7. Shekelle PG, Markovich M, Louie R. Comparing the costs between provider types of episodes of back pain care. Spine 1995;20:221-216.
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