Troy Brown, RN
September 16, 2014
In patients with back-related leg pain (BRLP), spinal manipulative therapy (SMT) plus home exercise and advice (HEA) provided more short-term improvement in pain and function than HEA alone, according to a recent study.
Gert Bronfort, DC, PhD, from the Center for Spirituality & Healing, University of Minnesota, Minneapolis, and colleagues present their findings in an article published in the September 16 issue of the Annals of Internal Medicine.
“Most patients with BRLP are treated with prescription medications and injections, although little to no evidence supports their use,” the authors write. “Surgical approaches are also commonly applied, although there is only some evidence for short-term effectiveness compared with less invasive treatments.” Clinicians are increasingly recommending SMT, exercise, and education.
The researchers compared short-term (12 weeks) and long-term (52 weeks) effects of SMT plus HEA with HEA alone in 192 patients with BRLP. They randomly assigned the patients to receive either HEA alone (n = 96) or HEA plus SMT (n = 96). Patients in the HEA group received 4 hour-long sessions of home exercise and advice — designed to help them manage existing pain, prevent pain recurrences, and increase their engagement in daily activities — over the course of 12 weeks. Patients in the SMT plus HEA group received the same intervention as well as up to 20 sessions of spinal manipulation therapy by a chiropractor.
The primary outcome was pain; secondary outcomes were self-reported low back pain, disability, global improvement, satisfaction, medication use, and general health status.
The researchers used questionnaires to measure self-reported outcomes at the baseline visit and at 3, 12, 26, and 52 weeks. Independent examiners assessed patients at the baseline visit and at 12 weeks.
SMT plus HEA demonstrated a clinically significant advantage over HEA after 12 weeks (10 percentage points; 95% confidence interval, 2 – 19 percentage points; P = .008), but not at 52 weeks (7 percentage points; 95% confidence interval, −2 to 15 percentage points; P = .146).
At 12 weeks, the SMT plus HEA group experienced more improvement in low back pain, disability, physical component score, global improvement, and satisfaction compared with the HEA group. There were no significant differences between the groups for mental health component score.
“At 12 weeks, 37% of patients receiving SMT plus HEA had at least a 75% reduction in leg pain, compared with 19% in the HEA group,” the authors write. Pain was completely relieved in 20% of those in the SMT plus HEA group compared with 5% in the HEA group.
At 12 weeks, 56% of patients in the SMT plus HEA group reported using medication for their symptoms compared with 63% in the HEA group.
At 52 weeks, the SMT plus HEA group experienced more improvement than the HEA group in global improvement, satisfaction, and medication use only. Medication use was reported by 42% of those in the SMT plus HEA group compared with 66% of those in the HEA group.
“For patients with subacute and chronic BRLP, SMT in addition to HEA is a safe and effective conservative treatment approach, resulting in better short-term outcomes than HEA alone,” the authors conclude.
Dr. Evans reports receipt of grants from the US Health Resources and Services Administration for this work. The other authors have disclosed no relevant financial relationships.
Ann Intern Med. 2014;161:381-391. Abstract