by Daniel J. Murphy, DC, FACO

Vice President of ICA

 

          In this column, I will review some important studies that conclude spinal manipulation is superior to other health care methods.

            1. Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain A Randomized, Controlled Trial. [from: Hiving et al. Annals of Internal Medicine, Vol. 136 No. 10, Pages 713-722, May 21, 2002]

            This study was conducted to determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner for patients with acute neck pain. It is a randomized, controlled trial that used 183 patients.

            Six weeks of manual therapy consisting of specific mobilization techniques once per week, physical therapy directed exercise therapy twice per week, or continued care by a general practitioner were utilized.

            The success rate for manual therapy was 68.3%. The success rate for physical therapy was 50.8%. The success rate for continued physician care was 35.9%.

            The manual therapy group had statistically significant differences in pain intensity with compared with continued physician care or physical therapy care. Disability scores also favored manual therapy.

            The authors conclude that: (1) “Manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.” (2) “Primary care physicians should consider manual therapy when treating patients with neck pain.”

            The authors also state:

            “This randomized, controlled trial of manual therapy, physical therapy, and continued care by a doctor confirms the superiority of manual therapy and physical therapy over continued [physician] care.”

            These authors note that between 10% and 15% of the general population have neck pain, and that neck pain is more common in women than in men. They note that neck pain can be accompanied with headache, arm pain, and dizziness.

            These authors state: (1) “Physical therapists can specialize in passive manual (or ‘hands-on’) techniques, including mobilization or manipulation (high-velocity thrust techniques), also referred to as manual therapy.” (2) “According to the International Federation of Orthopedic Manipulative Therapies, ‘Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.’”

            [Statements like these often insult chiropractors, and have important political and economic implications. These statements should remind all chiropractors that our practice rights depend on the efforts of our National and State organizations, and that all chiropractors should join both a State and National organization. I am the current vice president of the International Chiropractic Association].

            In this study, manual therapy was defined as the “use of passive movements to help restore normal spinal function.” Spinal manipulation was not used in this study. The physical therapy used consisted primarily of active exercise, therapeutic exercises, postural exercises, and stretching. [This is important, because it adheres to what the 1993 Mercy Guidelines refers to as “active” treatment]. Continued care was given by a general practitioner and included advice, home exercises, ergonomics advice, and some non-steroidal anti-inflammatory drugs.

 

RESULTS

            “The success rate at 7 weeks was twice as high for the manual therapy group (68.3%) as for the continued [physician] care group (35.9%).”

            “Physical dysfunction, pain, and functional disability were less severe in the manual therapy group than in the continued care and physical therapy groups.”

            “At 3 weeks, more patients worsened with continued [physician] care (n = 9) than with physical therapy (n = 3) or manual therapy (n = 0).”

            “The success rates for manual therapy were statistically significantly higher than those for physical therapy.”

            “Manual therapy scored better than physical therapy on all outcome measures...”

            “Range of motion improved more markedly for those who received manual therapy or physical therapy than for those who received continued care.”

            General health perception showed a statistically significant difference in favor of manual therapy compared with continued care and physical therapy. [This is important because it supports the chiropractic premise that improved spinal function and mobility improves one’s general health].

            “Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care.”

            “Manual therapy and physical therapy each resulted in statistically significantly less analgesic use than continued [physician] care.”

            “Manual therapy was more effective than continued [physician] care, and our results consistently favored manual therapy on almost all outcome measures.”

            “Although physical therapy scored slightly better than continued [physician] care, most of the differences were not statistically significant.”

            “The postulated objective of manual therapy is the restoration of normal joint motion, was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”

            This study confirms that of Koes (1992), “that manual therapy and physical therapy are superior to continued [physician] care.”

            “In the physical therapy and manual therapy groups, the hands-on approach, frequent visits, and opportunities for intensive patient-therapist interaction may have contributed to the observed [superior] effects.”

            “In our study, mobilization, the passive component of the manual therapy strategy, formed the main contrast with physical therapy or continued care and was considered to be the most effective component.” [This is very important because since the 1993 Mercy Document, passive care has been criticized as leading to “physician dependence” while this study showed superiority of passive treatment over active treatment].

 

SUMMARY POINTS

            (1) These patients had generalized nonspecific neck pain that was primarily acute and non traumatic.

            (2) These manual therapy patients were not manipulated, but mobilized to restore normal joint range of motion.

            (3) The mobilization techniques used did improve the cervical range of motion significantly.

            (4) The success rate for 6 visits of manual therapy over 7 weeks was 68%, meaning that 32% were not successful with that treatment and in that time frame.

            (5) Manual therapy was significantly superior to physical therapy, and physical therapy was clearly superior to physician care.

            (6) The physical therapy patients achieved significantly worse success rates while using twice the number of patient visits as manual therapy.

            (7) The physical therapy was primarily active exercise, while the manual therapy was primarily passive joint mobilization.

            (8) VERY IMPORTANTLY, PASSIVE joint mobilization was significantly superior to ACTIVE exercise physical therapy.

            (10) NOTE: Physical therapists are trained to and do manipulate joints to improve “neuro-musculo-articular dysfunction in the spine and extremities.”

            (12) Only the manual therapy group had no patients worse after 3 weeks of treatment, while physician care scored 9/64 worse = 14%.

            (13) INCREDIBLY, the high success rates of the manual therapy group was attributed to its hands-on, frequent visit, passive approach, ability to restore the cervical range of motion.

            (14) Manual therapy is a superior treatment for patients with neck pain.

            (15) Primary care physicians should consider manual therapy when treating patients with neck pain.

 

            2. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. [from: Ingeborg BC et al. British Medical Journal;326:911; April 26, 2003]

            This study was conducted on the same 183 patients as the previous study. Importantly, this study included an economic evaluation along with the randomised controlled trial. Both the direct and indirect costs associated with manual therapy, physical therapy, and continued general practitioner care, were assessed.

            As noted in the previous study, the “Manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group.”

            In addition, in this study the authors note:

            “The total costs of manual therapy were around one third of the costs of physiotherapy and general practitioner care.”

            “... manual therapy was less costly and more effective than physiotherapy or general practitioner care.”

            “Manual therapy is more effective and less costly than physiotherapy or care by a general practitioner for treating neck pain.”

            “Patients undergoing manual therapy recovered more quickly than those undergoing the other interventions.”

            These authors also note that:

            “Chiropractors, osteopaths, and physiotherapists use mobilisation and manipulation techniques.”

            “Manual therapy is associated with a larger improvement in pain and lower costs.”

            “Manual therapy had significantly lower costs and slightly better effects at             52 weeks compared with physiotherapy and general practitioner care.”

 

SUMMARY POINT

            (1) Manual therapy achieves the best recovery rates, the lowest use of drugs, the least time off work, and is more cost effective compared to drugs and physiotherapy directed active exercises.

 

            3. Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation. [from: Giles LGF, Muller R. Spine July 15, 2003; 28(14):1490-1502]

            Similar to the previous two studies, this study is a randomized controlled clinical trial. Unlike the previous two studies, this manual therapy used in this study was spinal adjustments performed by chiropractors rather than joint mobilization performed by physical therapists. Also, all patients in this study suffered from chronic spinal pain syndromes (both neck and back) rather than acute neck pain as noted in the previous two studies. The medication used was primarily the Cox-2 inhibitors Celebrex and Vioxx.

            Patients were assessed before treatment using the Oswestry Back Pain Disability Index (Oswestry), the Neck Disability Index (NDI), the Short-Form-36 Health Survey questionnaire (SF-36), visual analog scales (VAS) of pain intensity and ranges of movement. These were administered at 2, 5, and 9 weeks after the beginning of treatment.

            The authors note:

            “The highest proportion of early (asymptomatic status) recovery was found           for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).

            Chiropractic spinal adjustments achieved the best overall results, with improvements of 50% on the Oswestry scale, 38% on the NDI, 47% on the SF-36, and 50% on the VAS for back pain, 38% for lumbar standing flexion, 20% for lumbar sitting flexion, 25% for cervical sitting flexion, and 18% for cervical sitting extension. This shows subjective improvement, functional improvement, objective improvement in range of motion, and significant improvement in general health status. Consistent with the previous two studies, this study documents improvement in general health status as a consequence of improved spinal biomechanics and range of motion.

            The authors conclude that in patients with chronic spinal pain, manipulation, results in greater short-term improvement than acupuncture or medication.

            Importantly, these authors also note:

            “A pathologic cause cannot be identified for most episodes of spinal pain.”

            “Only about 15% of patients receive a definitive diagnosis because it often           is impossible to reach specific diagnosis.” [Statements like this would             question the emphasis on diagnostic efforts on such patients].

            “Numerous studies have shown that patients with low back pain do exhibit           abnormal spinal motion.”

            “The proportion of primary care patients with uncomplicated spinal pain who have poor outcomes appears to be higher than generally recognized.”

            “Adverse reactions to nonsteroidal antiinflammatory (NSAID) medication have been well documented.”

            “Gastrointestinal toxicity induced by NSAIDs is one of the most common serious adverse drug events in the industrialized world.”

            “The newer COX-2-selective NSAIDs [Celebrex, Vioxx and paracetamol] are less than perfect, so it is imperative that contraindications be respected.”

            There is “insufficient evidence for the use of NSAIDs to manage chronic low back pain, although they may be somewhat effective for short-term symptomatic relief.”

            In this study, spinal adjustments were performed by a chiropractor at the spinal level of involvement to mobilize the spinal joints. Two treatments per week were given.

            The chiropractic group suffered from chronic spinal pain for an average of 8.3 years, while the medication and acupuncture groups were less, at 6.4 or 4.5 years. Consequently, the chiropractic group sustained the greatest benefit, yet they began the study with the greatest average years of chronicity. This makes the results of this study even more impressive as compared to drugs and acupuncture.

            These authors also found that confounding of variables such as age, gender, body mass index, pain duration, and involvement in litigation were not correlated with the main outcome measures.

            The drugs (Celebrex and Vioxx) did not achieve a marked improvement in chronic spinal pain and caused adverse reactions in 6.1% of the patients. Importantly, acupuncture and acupuncture caused no adverse events.

            The SR-36 measures general health status. The improvement documented for chiropractic was 47%. This was greater than drugs (18%) and acupuncture (15%) combined.

            In their summary, the authors state:

            “The significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

 

Summary POINTS

            (1) It is impossible to reach specific diagnosis for the pathologic cause for 85% of those with an episode of spinal pain.

            (2) Patients with low back pain do exhibit abnormal spinal motion.

            (3) There is insufficient evidence for the use of NSAIDs to manage chronic low back pain.

            (4) The new COX-2 nonsteroidal antiinflammatory (NSAIDs) have problems and significant contraindications.

            (5) Gastrointestinal toxicity induced by NSAIDs is one of the most common serious adverse drug events in the industrialized world.

            (6) In this study, in the medication group, more patients experienced adverse events (6.1%) than recovered from their spinal complaints (5%).

            (7) Even though the chiropractic treatment group was the most chronic (8.3 years), 27.3% recovered with 18 spinal adjustments over a period of 9 weeks, or less. This means that better than every fourth patient became asymptomatic with 9 weeks or less of chiropractic manipulation, even though they had been chronic for more than 8 years.

            (8) The chiropractic treatment group showed significantly greater improvement in subjective complaints, functional abilities, objective range of spinal motion, and in general health status than acupuncture and medication.

            (9) In this study, patient involvement in litigation did not influence the outcome measures.

            (10) In the treatment of chronic spinal pain, chiropractic manipulation is superior to acupuncture and medication.