Spinal Manipulation: Benefit in Acute Low Back Pain

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Spinal Manipulation: Benefit in Acute Low Back Pain


Spinal manipulation modestly improves pain and function in acute low back pain, a new systematic review and meta-analysis has found. Results were published online April 11 in JAMA.
“The principal conclusion of this review was that SMT [spinal manipulation therapy] treatments for acute low back pain were associated with statistically significant benefit in pain and function at up to 6 weeks, that was, on average, clinically modest,” lead author Paul G. Shekelle, MD, PhD, from the West Los Angeles Veterans Affairs Medical Center, California, and colleagues write.
Citing a Cochrane Review, the authors note that the amount of benefit was about the same as for nonsteroidal anti-inflammatory drugs (NSAIDs).
Back pain represents one of the most common reasons why patients seek care, with an estimated 50% or more of people experiencing back pain in their lifetime, the authors explain. Many treatments exist, including analgesics, muscle relaxants, exercises, physical therapy, heat, and spinal manipulation. Yet none have proven better than any other.
Although the current meta-analysis and a recent review and guidelines by the American College of Physicians did not find spinal manipulation to be less effective than conventional treatment, mainstream medicine does not widely accept this treatment modality. Several issues may explain this hesitancy, according to Dr Deyo.
First, the biological rationale for how spinal manipulation improves low back pain remains unclear. Second, the safety of spinal manipulation remains a concern. Case reports have described serious events, which are nevertheless “extremely rare,” Dr Deyo points out. In contrast, renal and gastrointestinal adverse effects of NSAIDs are common. Also, low back pain represents one of the most common reasons for prescribing opioids in the United States, with associated risks for dependency and overdose.
Another consideration: How long do the effects of spinal manipulation last? Some studies have suggested fewer benefits with longer-term follow-up.
Finally, cost of care may be an issue. Spinal manipulation entails multiple visits, which may be more expensive than NSAIDs. Conversely, caring for renal and gastrointestinal complications of NSAIDs and prescription opioid abuse may ultimately cost more than spinal manipulation.
JAMA. 2017;317:1418-1419, 1451-1460. Published online April 11, 2017.
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