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Am Fam Physician. 2000;62(11):2414-2415

to the editor: In the article entitled, “Diagnosis and Management of Acute Low Back Pain,”1 the authors did not mention the role of osteopathic medicine in a multidisciplinary approach to managing this health care enigma. Therapeutic manipulation is only one component of the osteopathic medical philosophy; thus, it should be considered unique from the chiropractic manipulation that was included in the review.

In addition to conventional diagnostic methods, the osteopathic physician uses palpatory skills to diagnose barriers to joint range of motion and asymmetry within the musculoskeletal system. Fundamental to osteopathy is the recognition of the body's inherent ability to restore homeostasis. In addition to manipulation, the osteopathic physician will use various soft tissue techniques to relax contracted muscles.

In a recently published randomized, controlled trial,2 osteopathic medical care, which included conventional medicine (i.e., analgesics, nonsteroidal anti-inflammatory drugs, muscle relaxants and physical therapy) plus manipulative medicine, was compared with conventional medical approaches in the treatment of subacute low back pain (i.e., pain lasting longer than three weeks and less than six months). Patients in the osteopathic care group required less medication and physical therapy than those in the standard care group. These results correlated with a significant cost difference between treatment groups.

The guidelines3 from the Agency for Health Care Policy and Research (now known as the Agency for Healthcare Quality and Research) for treating patients with low back pain include manipulative medicine as one component of a comprehensive clinical approach to improving function while preventing debilitation. The guidelines only recommend the use of manipulation in acute pain. The efficacy of this modality in chronic low back pain has not been proved.4

The safety of spinal manipulation has been reviewed in the literature. The most frequently reported complications include vertebrobasilar accidents and cauda equina syndrome; however, the complication rate is low, at one complication per 1 million treatments.5 The safety of spinal manipulation can be improved by properly selecting patients and recognizing contraindications.

Most nonspecific low back pain should be managed by primary care physicians. Referral to a subspecialist should be limited to patients with severe spinal disease and/or neuropathology. Primary care physicians should recognize the variety of treatment modalities available and understand the differences between osteopathic medical care and chiropractic care.

in reply: We wholeheartedly concur with Dr. Newswanger's assertion that an examination should “diagnose … barriers to joint range of motion and asymmetry within the musculoskeletal system,” as evidenced by the recommendation in our article1 for evaluation of gait, stance, posture, and joint and muscle flexibility.

Our article1 also indicates (as does Dr. Newswanger) that the Agency for Health Care Policy and Research (AHCPR)2 reports a potential role for spinal manipulation in acute back pain. Nowhere in our article do we recommend this treatment modality for chronic pain; indeed, the article is about (and entitled) “Diagnosis and Management of Acute Low Back Pain.”

Finally, it was indeed our intent to emphasize the role of the primary care physician in the evaluation and management of these patients while highlighting signs and symptoms that would necessitate referral to a subspecialist for a small number of patients.

Back pain is a common but complete malady, and we attempted to delineate a comprehensive, evidence-based and widely accepted approach to help these patients recover their previous level of function as soon as possible.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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