Letters to the Editor
Spinal Manipulative Therapy in the Treatment of Low Back Pain
TO THE EDITOR: The review of the evidence in the article "Evaluation and Treatment of Acute Low Back Pain" is succinct and laudable.1 However, one implication should be corrected to avoid engendering further confusion on an already hotly debated topic.
In the "SORT: Key Recommendations for Practice" table, Dr. Kinkade accurately states: "Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care."1 However, the implication that spinal manipulation shows improvements when compared with sham or ineffective treatments, but does not show any benefit when compared with usual care, could be misleading. The articles Dr. Kinkade cited in support of this recommendation clearly show that although spinal manipulation did not yield superior outcomes compared with usual care, it did produce equivalent benefits.2-5
I encourage physicians to review the literature on this topic published in past issues of American Family Physician as well as articles published in other journals. For example, an article in the November 2004 supplement of the JAOA-Journal of the American Osteopathic Association summarizes the results of the three major clinical trials suggesting the potential utility of osteopathic manipulative treatment in acute and chronic low back pain.6
The phrasing in Dr. Kinkade's article could potentially mislead physicians and may prevent physicians who use spinal manipulation in their practices from obtaining reimbursement for this procedure.
Author disclosure: Nothing to disclose.
REFERENCES
1. Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. 2007;75(8):1181-1188.
2. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;(1):CD000447.
3. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004;4(3):335-356.
4. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Efficacy of spinal manipulative therapy for low back pain of less than three months' duration. J Manipulative Physiol Ther. 2003;26(9):593-601.
5. van Tulder MW, Koes B, Malmivaara A. Outcome of non-invasive treatment modalities on back pain: an evidence-based review. Eur Spine J. 2006;15(suppl 1)S64-81.
6. Licciardone JC. The unique role of osteopathic physicians in treating patients with low back pain. J Am Osteopath Assoc. 2004;104(11 suppl 8):S13-18.
Effectiveness of Physical Therapy for Low Back Pain
TO THE EDITOR: I read with interest the article by Dr. Kinkade on the evaluation and treatment of acute low back pain in the April 15, 2007, issue of American Family Physician.1 The article did an excellent job of reminding us of the small subgroup of "red flag" patients who have serious or life-threatening disease.1 However, I think he missed the opportunity to identify the large and growing body of evidence regarding the sizeable subgroup of "green flag" patients who benefit from mechanical diagnosis and treatment.
More than 25 years ago, Dr. James Cyriax from Great Britain taught me that many patients could benefit from spinal manipulation, which could help get disks back into place and take pressure off the dura of the nerve roots. I then learned about the physical therapy approaches of Robin McKenzie from New Zealand, called the McKenzie Method of Mechanical Diagnosis and Therapy (MDT). A large number of physical therapists in this country know about his techniques, which begin with an initial patient assessment to reliably identify characteristic patterns of the underlying pain source. Most patients have pain that centralizes or is abolished with a single direction of lumbar exercises-i.e., they have a directional preference-which leads to patient-specific treatments. Many patients experience prompt pain relief with extension maneuvers and exercises, which decrease or eliminate the need for analgesics or nonsteroidal anti-inflammatory drugs.
Four randomized controlled trials2-5 have documented the effectiveness of MDT in this subgroup, but guidelines fail to cite these trials or the many supportive cohort studies. I think the absence of subgroup analysis in most randomized controlled trials accounts for Dr. Kinkade's conclusion that the McKenzie method is not superior to usual therapy. The book, "Rapidly Reversible Low Back Pain: An Evidence-Based Pathway to Widespread Recoveries and Savings," by orthopedic surgeon Ronald Donelson, MD, MS, provides an excellent summary of this evidence of benefit from MDT.6
There is now sufficient evidence that we can reliably identify, validate, and effectively treat certain patients with low back pain rather than continuing to address most of these patients as having a nonspecific problem with one-size-fits-all treatments.
Author disclosure: Nothing to disclose.
REFERENCES
1. Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. 2007;75(8):1181-1188.
2. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: results of a randomized clinical trial. Spine. 2006;31(6):623-631.
3. Browder DA, Childs JD, Cleland JA, Fritz JM. Effectiveness of an extension-oriented treatment approach in a subgroup of patients with low back pain: a randomized clinical trial. Phys Ther. 2007;87(12):1608-1618.
4. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2004; 29(23):2593-2602.
5. Schenk RJ, Jozefczyk C, Kopf A. A randomized trial comparing interventions in patients with lumbar posterior derangement. J Manual Manip Ther. 2003;11:95-102.
6. Donelson R. Rapidly Reversible Low Back Pain: An Evidence-Based Pathway to Widespread Recoveries and Savings. Gardners Books; 2007.
in reply: I agree with Dr. Ajluni that spinal manipulative therapy for acute low back pain is a heavily debated topic. The difference between Dr. Ajluni's statement that manipulation produced "equivalent benefits" to usual care and the statement in my article that manipulation does not show benefit when compared with usual care is only semantic. In trials comparing spinal manipulation with sham or ineffective therapies, spinal manipulation usually shows superiority. In trials comparing spinal manipulation with usual care, manipulation usually has similar results. Although my review article did not focus on costs, several trials that show equivalent outcomes between usual care and manipulation also provide economic analysis. In these trials, manipulation typically costs more than usual care.1-3
Of the three trials reviewed in the article by Licciardone4, one includes only chronic pain patients, one is a high quality trial of subacute/chronic back pain (three weeks to six months) that shows equivalence to usual care, and one is a low quality trial of mixed acute and chronic patients that showed equivalence to sham treatment.
I thank Dr. Kollisch for describing the McKenzie method of therapy for back pain. It may very well be helpful to a subgroup of patients. Trials in patients with acute low back pain are lacking. Two of the trials mentioned by Dr. Kollisch involved patients with chronic back pain (mean duration two to four months).5,6 The study by Schenk and colleagues is a small, low-quality trial of patients with back pain ranging from seven days to seven weeks. It was included in both of the systematic reviews I cited. Although the study by Brennan and associates enrolled patients with acute back pain (less than 90 days, but median duration about two weeks), it did not show a benefit for patients assigned to receive McKenzie therapy.7
Author disclosure: Nothing to disclose.
REFERENCES
1. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. N Engl J Med. 1995;333(14):913-917.
2. Cherkin DC, Deyo RA, Battié M, Street J, Barlow W. 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. 1998;339(15):1021-1029.
3. Eisenberg DM, Post DE, Davis RB, et al. Addition of choice of complementary therapies to usual care for acute low back pain: a randomized controlled trial. Spine. 2007;32(2):151-158.
4. Licciardone JC. The unique role of osteopathic physicians in treating patients with low back pain. J Am Osteopath Assoc. 2004;104(11 suppl 8):13S-18.
5. Browder DA, Childs JD, Cleland JA, Fritz JM. Effectiveness of an extension-oriented treatment approach in a subgroup of subjects with low back pain: a randomized clinical trial. Phys Ther. 2007;87(12):1608-1618.
6. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2004; 29(23):2593-2602.
7. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: results of a randomized clinical trial. Spine. 2006;31(6):623-631.
The article "Cysticercosis: An Emerging Parasitic Disease" (July 1, 2007, page 91) contained an error in Figures 2 and 3 on page 94. These figures were inadvertently switched, so Figure 2 shows a magnetic resonance image rather than a computed tomography scan and Figure 3 shows a computed tomography scan rather than a magnetic resonance image. This article has been corrected online.
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