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Comparing Three Therapies for Treatment of Back Pain



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Am Fam Physician. 1999 Feb 15;59(4):1030-1032.

Low back pain is a common patient complaint and continues to cause concern because of the high cost of treatment and lost productivity. Despite the availability of many nonsurgical treatment options, very few have proved effective. Cherkin and colleagues conducted a randomized study to compare the effectiveness of physical therapy, chiropractic manipulation and patient education in decreasing symptoms, improving function and decreasing long-term recurrence of low back pain.

Patients between the ages of 20 and 64 years who saw their primary physician for treatment for low back pain and still reported pain one week later were eligible for the study. Among the exclusion criteria were a history of back surgery, sciatica, osteoporosis, vertebral fractures or involvement in litigation or in a claims action for compensation related to a back injury. Patients who met all the study criteria were randomized into one of three groups. Patients in group 1 received physical therapy, patients in group 2 received chiropractic manipulation and patients in group 3 received a patient education booklet. There were only a few significant differences in baseline characteristics among the groups: patients assigned to the manipulation group were less likely to have sought chiropractic care previously; patients in the physical therapy group had the most bothersome symptoms; and patients in the group receiving only the patient-education booklet reported fewer days with restricted activities. Patients in the physical therapy group were taught exercises to “centralize” symptoms and to avoid movements that “peripheralize” them, as specified by the McKenzie approach. Adjunctive treatments, such as heat, ice, nerve stimulation or ultrasonography, were not used. Patients in the manipulation group received the most common type of chiropractic treatment, along with advice about exercise and activity. A consultant monitored the chiropractors' compliance with the treatment protocol. Patients in the education group received a booklet that described the causes of back pain, prognosis, appropriate use of imaging and the role of specialists, and a list of activities to promote recovery. Both long- and short-term outcomes were measured, including the effectiveness of the intervention on the current episode of back pain, the levels of function and disability, and the recurrence of pain.

The inclusion criteria were met by 323 patients. Mean patient age was 40 years, and the distribution between men and women was almost equal. Most patients had been treated previously for back pain and had had back pain for less than six weeks. After four weeks, patients in the two treatment groups reported a significant decrease in severity of symptoms compared with those in the education group. However, these differences did not remain statistically significant at 12 weeks. Evaluation of disability scores revealed that after one year, the differences among the three groups were minimal. The type of treatment received appeared to have no effect on patients' symptoms or function, including days of missed work. In addition, approximately 50 percent of all patients experienced a recurrence of back pain at one year and 70 percent experienced a recurrence during the second year. The only significant difference among the groups was in the assessment of care, with 75 percent of patients in chiropractic and physical therapy groups rating their care as “very good” or “excellent,” compared with only 30 percent in the education group. Of note, however, were differences in time and cost of care. The total time spent with a chiropractor or physical therapist was about 2.5 hours. The total cost of care to the HMO for treatment of low back pain over a two-year period differed by less than 2 percent in the chiropractic and physical therapy groups and was almost three times higher than the cost incurred by the group receiving the patient education booklet. Patients in the education group also spent less for other health care services to treat their low back pain.

The authors conclude that physical therapy or chiropractic manipulation for treatment of patients with low back pain offers minimal benefit, and there appears to be no advantage to the use of one treatment over the other. The primary benefit of treatment seems to be increased patient satisfaction and a decrease in the bothersomeness of symptoms at four weeks. However, whether the small benefits of treatment are worth the cost is a matter of debate. Future research is needed to identify which subsets of patients with low back pain are most likely to benefit from one or both types of treatment.

Cherkin DC, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. October 8, 1998;339:1021–9.



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