Osteopathic Manipulation for Low Back Pain

abstract & commentary

Source: Andersson GB, et al. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med 1999;341:1426-1431.

Over a two-year period, 178 patients between the ages of 20 and 59 years with low back pain of three weeks to six months duration were enrolled in this 12-week comparison study of standard medical care vs. osteopathic spinal manipulation. Patients with clinically apparent nerve root compression, scoliosis, serious medical disease, diabetic neuropathy, drug or alcohol abuse, psychiatric illness, or with no known manipulatable lesion were excluded, as were cases involving litigation.

Patients were divided between a) standard medical care (n = 85) including muscle relaxants, analgesics, anti-inflammatory medication, physical therapy, ultrasound, diathermy, corset use, and transcutaneous electrical nerve stimulation, or b) osteopathy (n = 93), comprising the above supplemented by manipulation techniques, including thrust, muscle energy, counterstrain, articulation, and myofascial release. At four weekly, followed by four biweekly, visits, patients were evaluated by a nurse practitioner and physician; primary outcome measures included a visual-analog pain scale, the 24- item Roland-Morris adaptation of the Sickness Impact Profile which evaluates loss of function due to back pain (Roland M, Morris R. Spine 1983;8:141-144), two items from the North American Lumbar Spine Society Outcome Assessment Instrument to evaluate pain frequency and vexatiousness (Daltroy LH, et al. Spine 1996;21: 741-749), and the 10-item Oswestry pain questionnaire dealing with pain and disability (Fairbank JC, et al. Physiotherapy 1980;66:271-273). Statistical analysis included the Wilcox rank-sum test, chi-square test, and Fisher’s exact test.

Twenty-three patients dropped out and were excluded from the primary analysis (2 for elevated sedimentation rate discovered on work-up, 21 for unknown reasons/poor follow-up). Both groups were well matched demographically, socioeconomically, and with respect to work-related conditions, job satisfaction, education, income, and marital status. Overall, both groups were comparable for all primary end points with improvement noted in all measurements, but the standard group used significantly more physical therapy, nonsteroidal anti-inflammatory agents, and muscle relaxants, resulting in a significant difference in cost. More than 90% in both groups were satisfied with their care and 80% overall accepted their back problem well. Osteopathic care is comparable to standard medical care for low back pain but appears to offer the advantage of greater cost-effectiveness, as realized by the use of less medication and less physical therapy.

Commentary

Among alternative modes of therapy for nonspecific low back pain, acupuncture, one of the oldest and least understood would appear, based on a literature review of randomized controlled trials, to be of no significant benefit (van Tulder MW, et al. Spine 1999;24:1113-1123). Of 11 controlled trials, only two met a preset standard for high quality and these demonstrated no benefit for acupuncture over no treatment, nor compared to transcutaneous nerve stimulation (TENS) or trigger point injection. Evidence indicated that for chronic low back pain, placebo or sham acupuncture was not inferior to true acupuncture.

Low-intensity (1.06 microm) neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, administered thrice weekly for four weeks in a randomized, double-blind, placebo-controlled fashion to 63 low back pain patients, ages 18-70 years, demonstrated only moderate benefit which diminished by one month of follow-up (Basford JR, et al. Arch Phys Med Rehabil 1999;80:647-652). One factor of definite use in the management and prevention of low back pain is cessation of smoking (Scott SC, et al. Spine 1999;24:1090-1098). Among more than 3200 patients with and without scoliosis, a statistically significant association was found between smoking and low back pain in women with or without scoliosis and in men with scoliosis, but not without. Back pain was more prevalent with increased smoking, and pain intensity, frequency, and duration of episodes similarly increased with tobacco use. Overall, smoking appears to exacerbate back pain, particularly in individuals with pre-existing spinal pathology, but in everyone cessation of smoking is to be strongly encouraged. —mr

Osteopathic care for low back pain:

a. is not as safe as standard medical care.

b. may offer the advantage over standard medical care of requiring less medication for benefit to be realized.

c. requires more medication for benefit to be realized than standard medical care, but patients prefer the former due to its simplicity.

d. is no more beneficial than doing nothing.

e. is the gold standard for care of low back pain.