Am Fam Physician. 2000 Mar 1;61(5):1502-1504.
The treatment of patients with low back pain remains an unresolved issue. Because most patients with acute back pain improve in four to six weeks, it has been difficult to prove that any one therapeutic modality is superior. Spinal manipulation has been used for centuries, but only over the past 150 years have specific approaches been formalized. In the United States, most spinal manipulations are performed by chiropractors whose primary focus is the nervous system. Some osteopathic physicians also perform manipulation, but they generally employ conventional methods of diagnosing and treating back problems. A focus of the osteopathic philosophy has been the restoration of blood circulation to enhance recovery and maintain or restore health. Andersson and colleagues evaluated the use of osteopathic manipulative therapy compared with “standard” allopathic treatment in persons with low back pain.
The study enrolled patients through two medical offices of a large health maintenance organization. Adults between 20 and 59 years of age with low back pain of at least three weeks' but not more than six months' duration were eligible. Patients with symptoms of nerve root compression, scoliosis, a systemic inflammatory disorder, any serious medical condition, a history of a psychiatric or psychologic illness or pregnancy, and those who were in active litigation or receiving workers compensation were excluded.
After patients were assessed for eligibility, they were randomized to receive osteopathic manipulation or standard allopathic treatment. The standard therapy included analgesics, anti-inflammatory medications, muscle relaxants and active physical therapy, including ultrasonography, diathermy, hot or cold packs, and transcutaneous electric nerve stimulation. The manipulative therapy patients were treated with several techniques by one of three osteopathic physicians. These modalities included muscle energy, thrust, counterstrain, articulation and myofascial release. The specific therapies were individualized for each patient. All patients from both groups viewed a 10-minute educational video on low back pain. The treatments for both groups occurred weekly for four weeks, then every other week for four weeks, for a total of eight visits. At 12 weeks, the patients were reevaluated by an evaluator who was blinded to the treatment assignments. Patient outcomes including pain relief were assessed by three separate scoring systems—pain drawings by the patient, the degree to which the straight leg could be used and measurements of range of motion.
After almost 1,200 patients were screened, 178 were determined to be eligible. In all, 155 patients completed the study (83 in the osteopathic-treatment group and 72 in the standard care-treatment group). No significant differences between the groups in terms of education, work-related factors, income, age or severity of back pain were apparent. Improvements in pain scores, assessed by all three scoring scales, improved in both groups with no statistically significant difference. Functional assessments were also essentially the same in both groups. The use of medications (with marked differences for nonsteroidal anti-inflammatory drugs [NSAIDs]) was significantly greater in the standard-treatment group. NSAIDs were prescribed at 54.3 percent of patient visits to standard-care physicians compared with 24.3 percent of patient visits to osteopathic-treatment physicians. Muscle relaxants were prescribed in a similar manner (25.1 percent by standard-care physicians and 6.3 percent by osteopathic-treatment physicians). More than 90 percent of the patients from both groups reported that they were satisfied with their treatment.
The authors conclude that osteopathic manual treatments have similar efficacy compared to standard therapies in patients with low back pain of more than three weeks' duration. However, use of medications was significantly lower in patients in the osteopathic-treatment group. The data from this study suggest that osteopathic treatment that results in the use of less medication and less need for physical therapy could result in significant cost savings. They propose that a formal cost-benefit analysis be conducted to determine if this is indeed true.
Andersson GB, et al. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med. November 4, 1999;341:1426–31.
Copyright © 2000 by the American Academy of Family Physicians.
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