By Michael Schneider, DC, PhD
The topic of clinical effectiveness for spinal manipulation and exercise is extremely timely and relevant to today’s healthcare provider. However, there is one aspect of this topic that continues to confuse both clinicians and patients: namely, how to interpret the mixed messages about the clinical effectiveness of manual therapy and exercise for management of low back and neck pain.
There have been multiple systematic reviews of the spinal manipulation literature with conflicting conclusions and recommendations. The same is true of the literature regarding therapeutic exercise. In addition, the conclusions of these reviews and guidelines indicate that spinal manipulation and exercise only provide modest clinical effectiveness when compared to other treatments or no treatment.
How then does one justify the use of these treatments?
For example, a current systematic review of spinal manipulative therapy (SMT) for acute low back pain (LBP) found that the average amount of improvement in pain was only about 1 point on a 0-10 scale, which was statistically, but not clinically, significant. However, this same review found greater improvements in function that were considered statistically and clinically significant. How do we explain these apparent discrepancies and justify the use of SMT?
It is well known that many primary care physicians, nurse practitioners and physician assistants consider acute low back and neck pain to be chiefly self-limiting conditions, and therefore do not recommend any type of treatment. However, it is also well known that a certain subset of acute back pain patients will transition into chronic pain sufferers. This is where the 80/20 rule applies, because about 20 percent of back pain patients account for about 80 percent of total costs. Do we have evidence or guidelines to tell us which characteristics are associated with that 20 percent of acute LBP patients who will transition into chronic LBP sufferers?
This brings up many questions:
- What are the consequences of NOT utilizing spinal manipulation and exercise interventions with acute LBP patients?
- Is there a subset of acute LBP patients who truly do not need any type of intervention?
- Why are primary care providers (MD, DO, NP, PA) NOT recommending these interventions when the most current guidelines ARE recommending them?
A healthy discussion and debate of these topics can help inform our clinical practice, as well as better equip us to confront some of the apprehensions among our medical colleagues about the use of manual therapy as a therapeutic options.
Learn more about this topic during a panel discussion featuring Dr. Schneider, Dr. Julie Fritz and Dr. Brian Degenhart at the Interprofessional Collaborative Spine Conference (ICSC), Nov. 8-9, in Pittsburgh, Pa. The event will bring together members of the chiropractic, physical therapy and osteopathic professions for a unique discussion regarding improving outcomes for patients with back pain through the use of manual therapy and other non-pharmacological approaches. For a schedule of ICSC presentations, hotel and registration information, click here.