Spinal Manipulation Dose-response for Care of Chronic Low Back Pain
Dr. Lane’s thoughts: dose-response is a term to indicate that the researcher is measuring the response of similar patients with similar conditions to see how much or many of a treatment gives the best response and resolution of the condition.
The researcher is asking, is one treatment enough, or two, and so on until he finds the right number. It can also expose whether more than a certain number of treatments brings no greater response.
The Study: Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial
The Facts
a. Chronic low back pain (CLBP) is a common problem. The authors sought to see if there was a correlation between the number of spinal manipulations and the outcomes in patients with chronic low back pain.
b. The spinal manipulation group was compared to a group receiving light massage.
c. A large percentage of CLBP patients are treated by doctors of chiropractic with spinal manipulation.
d. It would be valuable to find out what the optimal number of visits would be to treat these problems.
e. In the 1900s RAND found that opinion as to the optimal length of time for treatment varied from two to twenty-four weeks with the proposed frequency of one to five visits per week.
f. In this study, the authors thought that on average, patients should typically improve in four to six weeks and three visits per week.
g. “In contrast, an all-chiropractic RAND expert panel recommended 30 visits over 14 weeks.”
h. The authors took 400 participants and each received 18 visits at a frequency of 3 per week for 6 weeks.
i. The difference between groups was that one group received 18 manipulations, another group had 0 manipulations, but 18 light massage visits, a group had 6 manipulations and 12 light massage visits, and a group had 12 manipulations and 6 light massage visits.
j. The outcome was determined by reported pain and functional disability at 12 and 24 weeks.
k. The authors concluded that 12 spinal manipulations over 6 weeks showed the most favorable outcomes of pain and disability. Differences beyond that point appeared to be negligible.
Take Home:
12 spinal manipulations appears to be a reasonable amount of care for this type of case.
I think it is good to come up with a reasonable number of visits for common conditions. Perhaps 12 visits really are the best overall number of visits for this condition. Perhaps it only appeared that way in this study.
However, I wonder if this, like so many other study findings, will be used inappropriately. Let me explain. Will some group decide that if you average more than 12 visits then you are a bad doctor. Perhaps your patients are on average older, more injured, less motivated, do harder labor, expect a greater degree of relief or some other factor. And there are so many factors.
It seems to me that while we should do studies such as this, we should only expect them to be applied for the purposes for which they were intended. I often say that we need to be careful what we write as our words will come back to bite us. I usually remember that when someone takes out of context some part of a study I have written. However, I have no fix for those who try to make patients fit into certain rigid molds and deliberately misuse research findings so as to make them into rules of practice.
It turned out to be 12 visits over a 6 week period), differences in perceived pain and functional disability seemed to be fairly negligible.
1) More adjustments aren’t necessarily going to make your patient feel any better. If you are currently scheduling your patients for extremely long programs of adjustments only, this study is just one of many which indicates you might want to modify your treatment plans.
2) As chiropractors we do a lot more to improve spinal structure and function than just adjust. This study included no active care. At Chiropractic Lane we do intense therapy beyond chiropractic (spinal) adjustments.
3) Finally, this study was only evaluating the effects of manipulative care in terms of the patient’s perceived pain and functional disability.
As long as we allow our whole profession to be defined only in terms of what we can do for pain (as opposed to other objectively definable clinical outcomes) then we will continually have to justify our cost effectiveness as compared to every other pain relieving modality within the healthcare universe from NSAIDS to neurosurgery.
| Source |
via Blogger http://bit.ly/1hMV9vS
Recent Comments