MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

A meta-analysis compared the effectiveness of spinal manipulation therapies (SMT), medical management, physical therapies, and exercise for acute and chronic low back pain. Studies were chosen based on inclusion in prior evidence syntheses. Effect sizes were converted to standardized mean effect sizes and probabilities of recovery. Nested model comparisons isolated non-specific from treatment effects. Aggregate data were tested for evidential support as compared to shams.

The results suggest that, of 84% acute pain variance, 81% was from non-specific factors and 3% from treatment. No treatment was better than sham. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% out of 98% was non-specific, but treatments influenced 32% of outcomes. Chronic pain treatments also fitted within 95% confidence bands as predicted by natural history. The evidential support for treating chronic back pain as compared to sham groups was weak, but chronic pain appeared to respond to SMT, while whole systems of chiropractic management did not.

The authors of this intriguing paper conclude: Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority between treatment arms was equivalent to that expected by random selection. Treatments serve to motivate, reassure, and calibrate patient expectations – features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

This essentially indicates that none of these treatments for low back pain are convincingly effective. In turn this means we might as well stop using them. Alternatively, we could opt for the therapy that carries the least risks and cost. As the authors point out, this treatment is exercise.

14 Responses to Which therapy is best for low back pain?

  • An interesting report on the Osteopathic treatment of chronic low back pain…http://www.hsc.unt.edu/ORC/Files/AFMPressRelease_2013_03_18_FINAL.pdf

  • Painkillers while waiting for the injury to subside enough to begin exercise is helpful. 🙂

  • This is an interesting paper although the methods used to conduct the meta-analysis are somewhat unconventional. Interestingly the author qualified as a chiropractor so I am surprised that you have not been more critical.

  • Andy – leopards and spots. Anyone can open their mind to their own biases and choose to walk away from the historic practices and move on into scientifically sound evidence based practice. Whatever the best current iteration of that might be. Re-assure and encourage to move may be difficult to earn a living off though. And the powerful historical memes are going to be difficult to dislodge from the high street and hospital alike.

    Great spot Edzard – this is a really interesting piece of work and may contain a statistical technique to glean the bigger picture out of other areas where lots of small studies give vague ‘hopeful but barely better than placebo’ effects.
    My patch is PT and this article is being discussed by anyone who does not have ‘ostrich’ tendencies – all the rest of manual therapy should be looking hard at this work too.

    !!!!!! 3% !!!!!!

    Kind thoughts,
    Steve

  • Time and time again the literature has failed to show what occurs in clincal practice. Daily I have patients walk in entirely dysfunctional only to walk out transformed subjectively and objectively. The literature certainly does not represent my practice nor do I bet the practices of many other practitioners of various disciplines.

    • that could be because your practice includes: placebo-effects, regression to the mean, natural history, social desirability and a myriad of other elements.

    • And Waine’s particular brand of patient care consists of… ? I wish the “alternative” commenters would stop expecting every other reader to have paranormal, mind reading abilities.

      But what happens after you get the LBP patient up and walking? Some get better and happily promote their “saviour”, but what is the true proportion? Most of them had gotten better anyway, wouldn’t they? Like me, except that time I went and saw the chiro. That was my longest bout and the only improvement I could define was in his bank-balance.

      What about those who only get temporary relief?
      Time and time again, emergency room physicians are seeing patients, not only dysfunctional but sometimes crying from pain who have been at the chiropractors or some other quack who temporarily got them mobilised by power of persuasion and suggestion but then relapsed. Just last week I spoke to one of them about this and why they didn’t keep a special registry of cases after failed CAM. The problem is that very few of them think of asking the patients if they had been to see a CAM artist and the patients seldom talk about such things spontaneously.

    • Wayne – I doubt the literature shows what happens in any clinical practice. The moral of the story seems to be: if you want help, see a practitioner. If you want “the sky is falling! the sky is falling!”, talk to researchers.

      • LONG LIVE ANTI-SCIENCE!

      • You should read the literature before talking about it because you are just embarassing yourself right now.

        • “This essentially indicates that none of these treatments for low back pain are convincingly effective. In turn this means we might as well stop using them.” No…they should be used when they are appropriate to the condition. Treat what presents. Alternatively, we could opt for the therapy that carries the least risks and cost. As the authors point out, this treatment is exercise.”

          That’s the essence of traditional medicine practice that is routinely mocked on this site as being ‘outdated’ and ‘unscientific’. It’s not the specifics of the treatment, it’s the treatment as a whole…and totally dependant on patient involvement.

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