The debate what might be the optimal treatment of back pain has been going on for many years. This new study provides important further insights.
The RCT assessed the comparative effectiveness of adding spinal manipulative therapy (SMT) or supervised rehabilitative exercise to home exercise in adults 65 or older suffering from sub-acute or chronic low back pain (LBP). Treatments were provided over 12-weeks and self-report outcomes were collected at 4, 12, 26, and 52 weeks. The primary outcome was pain severity. Secondary outcomes included back disability, health status, medication use, satisfaction with care, and global improvement. Linear mixed models were used to analyse outcomes. The primary analysis included longitudinal outcomes in the short (week 4–12) and long-term (week 4–52). An omnibus test assessing differences across all groups over the year was used to control for multiplicity. Secondary analyses included outcomes at each time point and responder analyses. This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration.
A total of 241 participants were randomized and 230 (95%) provided complete primary outcome data. The primary analysis showed group differences in pain over the one-year were small and not statistically significant. Pain severity was reduced by 30 to 40% after treatment in all 3 groups with the largest difference (eight percentage points) favouring SMT and home exercise over home exercise alone. Group differences at other time points ranged from 0 to 6 percentage points with no consistent pattern favouring one treatment. One-year post-treatment pain reductions diminished in all three groups. Secondary self-report outcomes followed a similar pattern with no important group differences, except satisfaction with care, where the two combination groups were consistently superior to home exercise alone.
The authors concluded that adding spinal manipulation or supervised rehabilitative exercise to home exercise alone does not appear to improve pain or disability in the short- or long-term for older adults with chronic low back pain, but did enhance satisfaction with care.
It is rare to find such a well designed, conducted and reported study in the realm of SCAM. Its results are clear and show that SMT offers no benefit over exercise in this LBP population. The better satisfaction rate with SMT is to be expected; it is probably due to the extra attention this option offers. The most recent systematic review addressing non-pharmacologic treatments for chronic LBP has found evidence of modest short-term improvements in function and/or pain for both exercise and SMT when compared to usual care, attention control, sham, or placebo, and no clear differences between exercise and SMT. In view of the facts that
- SMT might cause adverse effects,
- exercise is cheaper,
- exercise conveys benefits beyond back pain,
the new findings are a very clear verdict: exercise is preferable to SMT in the treatment of LBP.