Introduction
When a person is in pain it does not matter if he is rich or has attained a high level of success; everything ceases to matter as the single most consuming preoccupation is finding relief from that unceasing and numbing discomfort. In the industrialized world, one of the most common problems is back pain, specifically low back pain as a result of stress and work-related injury. And since pain alleviation has become the number one priority for a person suffering low back discomfort, then it follows that the patient will try to find out the most effective treatment modalities available. In this regard two major groups of treatment need to be examined: 1) spinal manipulation and 2) standard medical therapy or standard conservative therapy and find out which one is better.
This paper will take a closer look at spinal manipulation therapy and standard medical therapy as the two major popular treatment modalities used for treating back pain. This can be achieved by conducting a review of related literature, the majority of which will be coming from papers published in medical journals. Moreover, aside from providing general information about the two major treatment modalities, this study will also attempt to find out if spinal manipulation is better than standard medical therapies.
Background
As the back portion of the person’s body is responsible for holding the upper body erect when sitting, standing, or walking one could just imagine the kind of trouble this condition brings to the patient. For those suffering low levels of pain, life becomes difficult as the pain becomes bothersome. For those suffering high levels of pain work and even leisurely activities can become increasingly impossible to perform without the aid of medication or some form of treatment. A grim prognosis by Koes et al. is stated as follows, “About 80% of people in Western countries will experience back pain at some time during their lives … Most patients recover from an attack of back pain within six weeks, irrespective of the type of treatment given, although recurrence rate is high” (1991).
According to John Licciardone, “Low back pain is a common and costly condition in industrialized nations” (S13, 2004). This has many implications, first of all, one wonders why there is a higher prevalence of the said medical problem in industrialized countries, and immediately one is reminded of the high-stress levels and the type of working conditions workers in these territories are subjected to. It will no longer come as a surprise to many that working long hour in the office, hunched back in front of the computer is just one of the many reasons why citizens of supposedly advanced nations are more and more complaining about back pain.
A second implication with regards to the high incidence of low back pain in developed societies is the high cost in terms of healthcare expenses and lost productivity. There is therefore another motivation in finding out the most effective and cost-efficient treatment as patients would like to save money and at the same time insurance companies are worried about runaway costs.
Now, another implication of the above-mentioned statements is the fact that there is such a huge demand for treatment. This great need will result in the development of various treatment modalities. As mentioned there is the standard medical therapy which is familiar to many who had to go visit a physician for acute back pain problems. On the other hand for those who are no longer satisfied with conventional means of alleviating back pain, had come across the more sophisticated-sounding procedure also known as spinal manipulation.
Before going any further it is important to understand that as much as 97% of low back pain can be described as “mechanical”, which means that the underlying cause is an anatomic or functional abnormality (Licciardone, S13, 2004). This has to be differentiated from the pain caused by inflammation, malignant neoplasm, or the manifestation of visceral disease. And one last thing before going into the details of treatment modalities. The term “back pain” that will be used throughout the discussion actually refers to chronic back pain and not just the temporary kind resulting from minor injuries.
Standard Treatment
Standard treatment includes massages, rest, the use of analgesics, etc. A more comprehensive listing of conventional treatment methods was listed by Licciardone (2004) where he pointed out the popularity of the following techniques used by those treating back pain:
- educational interventions;
- exercise;
- weight reduction;
- various classes of analgesics;
- nonsteroidal anti-inflammatory drugs (NSAIDs);
- muscle relaxants;
- antidepressants;
- physical therapy;
- behavioral therapy; and
- surgery.
Spinal Manipulation
Under this major category called spinal manipulation treatments, one can also find a host of distinct types of treatment. One example is the Osteopathic manipulative treatment (“OMT”). But there is really nothing new with spinal manipulation except perhaps having a new label like OMT or SMT. There is evidence supporting the fact that spinal manipulation may have become an acceptable form of treatment as early as 1895. But this is only true in the Western world because there is also evidence to show that spinal manipulation has been practiced in China as far back as 2700 B.C.
For Bronfort et al., spinal manipulation is technically called spinal manipulative therapy (“SMT”) and it is defined as the application of high-velocity low amplitude manual thrusts to the spinal joints slightly beyond the passive range of joint motion (2008). For Gunnar et al. spinal manipulation involves primarily, “… short-lever, high-velocity spinal adjustments applied to specific contact points on the spinous process” (1999).
Methodology
A review of papers published in legitimate medical journals followed by an unblinded assessment of the methodology behind these studies. In Koes et al., the research team had three blinded reviewers score the thirty (30) randomized clinical trials (“RTCs”) focusing on chronic back pain. The reviewers will use a scoring system that is based on a list of criteria which is in turn based on generally accepted principles of intervention research. Each criterion has a corresponding weight in the scoring system and the maximum score was set at 100 points. All publications were blinded with regards to the author(s), name of journal, and outcome.
In Licciardone et al. the research team conducted randomized controlled trials to determine the efficacy of osteopathic manipulative treatment as a complementary treatment for chronic nonspecific low back pain. This trial was conducted in a university-based clinic from the year 2000 up to 2001. There were 199 subjects, 91 met the eligibility criteria. They were randomly selected to join three groups. There were 82 patients who were randomized to join the 1-month follow-up evaluation, and 71 patients were randomized to go through a 3-months evaluation, and finally, 66 patients were randomized to join the 6-month evaluation. The 199 subjects were randomized to osteopathic manipulative treatment, sham manipulation, or a no-intervention control group. All subjects were allowed to continue their usual care for low back pain.
In Gunnar, et al., the research team conducted a randomized control trial involving patients who had back pain for at least three weeks but less than six months. There were 1193 patients that were scanned and from that group 178 were eligible and were randomized to treatment groups where 23 of these patients dropped out of the study. But the rest of the group, 72 were assigned to the group receiving standard medical therapies, and the other 83 patients were assigned to the group receiving osteopathic manual therapy. Now, outcome measures that were used are Roland-Morris and Oswestry questionnaires, a visual analog pain scale, and measurements of range of motion and straight-leg raising. All these measurements were put into use after a 12-week treatment period.
Results
Limitations in Both Treatment Modalities
With all published papers consulted for this study, there is a general consensus with regards to the effectiveness of the two types of treatment modalities. Numerous studies pointed to one conclusion: uncertainty. In other words, there is no drug, manipulation techniques, or traditional cure such as taking long periods of rest that could eliminate chronic back pain. This means that there is no treatment modality that could promise significant reduction of pain all the time and every time this form of treatment is used. There is also no assurance that chronic back pain will not recur once the patient experiences relief from previous treatment. The following pages will discuss these in detail.
Aside from the fact that there will never be a high level of certainty when it comes to the two major groups of treatment modalities, there are also other variables that must be considered in order to improve the success rate of using these two kinds of treatments for chronic back pain. In fact, “There are just too many relevant variables in clinical practice” (Chaitow, et al., ******). And the following variables will definitely affect treatment outcomes:
- expertise and training of the medical practitioner
- clinical background and experience of medical practitioners
- pathology of the patient
- age, gender, fitness, and other physical characteristics of the patient
It is very important for those who will design any form of study to determine the efficacy of any treatment modality for chronic back pain to carefully consider the above-mentioned variables. It must also be noted that since there are simply too many variables to consider, that there is no way that one study will be able to speak for the effectiveness of a particular treatment.
Limitations of RCT’s
In trying to find out the effectiveness of the treatment modalities described above the proponent of this paper decided to look into the randomized controlled trials already available in some respected journals dealing with back pain issues. By performing statistical analysis of the said RCTs it will be found out if there is indeed significant change between the use of spinal manipulation versus standard treatments.
Efficacy of Spinal Manipulation
For Koes et al, the results show that among the thirty trials on low back pain treatment, the blinded reviewers discovered that no trial scored 60 or more points and that there were only three trials that scored more than 50 points. This means that spinal manipulation does not work.
Aside from the low scores, there are other problems that surfaced after the blinded reviewers went into the details of the methodology. They found out that the study population was small and that there was no proper description of the drop-outs. Furthermore, there was no placebo group that would have helped substantiate the RCTs (Koes, 1991).
In Licciardone et al, (2005) there was a significant reduction in low back pain when osteopathic manual treatment (OMT) was used. The result was substantiated when the OMT technique was tested against active treatment, placebo control, and OMT vs. no treatment control. There were also significant pain reductions during short, intermediate, and long-term follow-up. The only problem from a scientific point of view is the admission of Licciardone et al., that OMT was used in conjunction with conventional primary care approaches. This simply means that a new study is needed where the sole focus is on OMT and its ability to reduce pain without the help of other treatment modalities.
In Gunnar et al, there was no significant difference between the two groups receiving different types of medical care for low back pain. The first group receiving standard medical care has the same positive response as the group receiving OMT. The research team even included the following results in their report, “More than 90 percent of the patients in each group were satisfied with their care. There were no statistically significant differences … Answers to a quality-of-life question that was asked at the final visit – ‘If you had to spend the rest of your life this way, how would you feel?’ – indicated that 80 percent of the patients in both groups accepted their back problem well” (Gunnar et al., 1999).
Conclusion
There is no need to elaborate on the fact that low back pain, especially chronic back pain is one of the most significant problems faced by those who are living in the 21st century. Most of those who are suffering from this ailment belong to citizens of highly industrialized countries. There is of course the reason for stress and other work-related injuries. Since there is a high prevalence of such problems there is a need to solve them right away. If there is no resolution then the high cost of health care plus the significant loss in terms of productivity will be a burden too heavy to bear.
As a result of the great demand for relief from low back pain, there are now many types of treatment modalities. But as of recent count, there are at least two major groups of medical care procedures with regards to back pain. The first one is called standard medical therapy and this includes the use of drugs, exercise, massages, stretching, etc. The second major group is called spinal manipulation.
There is a need to find out which one is better because there is also a need to find out the most cost-efficient method of treating chronic back pain. Thus, there were many studies and blinded reviews conducted in the latter part of the 20th century up to the early part of the 21st century. There were mixed results but the common consensus is that of uncertainty. It was discovered that there is no easy way to measure the efficacy of the two major types of treatment on low back pain.
First of all low back pain is in itself a difficult malady to describe, identify, and isolate, It is not like any other disease where the medical practitioner can easily identify the pathogen that is causing havoc in the person’s immune system. With back pain, there can be many causes including stress, fatigue, psychological problems, diet, obesity, etc. Secondly, the standard treatment is also composed of many techniques including exercise and medication. Aside from all these, there are a host of other variables that are so complicated and therefore difficult to control such as age, gender, a physical feature of the patient, and at the same time differences in terms of experience, education, and training on the part of the medical practitioner.
It is therefore not surprising that generally, results indicated poor methodology and also no significant difference between standard medical therapy and spinal manipulation. There is a need to design more scientific studies or experiments in order to obtain more reliable results. There is also a need to come up with a way to control the various variables. There is also a need to isolate different treatment modalities such as spinal manipulation vs. exercise, spinal manipulation vs. drugs, or spinal manipulation vs. weight reduction, etc.
References
Gunnar, B.J. et, al. (1999). A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. The New England Journal of Medicine. 341(19): 1426-1431.
Koes, B.W. et al. (1991). Spinal manipulation and mobilization for back and neck pain: a blinded review. British Medical Journal. 303:1298-1303.
Licciardone, J.C. et al. (2003). Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine. 28(13): 1355-62.
Licciardone, J.C. (2004). The unique role of osteophatic physicians in treating patients with low back pain. JAOA. 104(11): S13-S17.
Licciardone J.C. et al. (2005). Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BioMed Central Ltd. 6(43): 1471-2474.