The first study to properly evaluate current practice guidelines for the management of low back pain was recently published in The Spine Journal. The authors state:

“Evidence-based clinical practice guidelines (CPGs) for the management of patients with acute mechanical low back pain (AM-LBP) have been defined on an international scale. Multicenter clinical trials have demonstrated that most AM-LBP patients do not receive CPG-based treatments. To date, the value of implementing full and exclusively CPG-based treatment remains unclear.”

They set out to…

“…determine if full CPGs-based study care (SC) results in greater improvement in functional outcomes than family physician–directed usual care (UC) in the treatment of AM-LBP.”

The authors employed a two-arm, parallel design, prospective, randomized controlled clinical trial using a blinded outcome assessment. Interventions were administered in a hospital-based spine program outpatient clinic to 92 patients aged 19 to 59 years with low back pain of 2 to 4 weeks’ duration. After assessment by a spine physician, the subjects were randomized to SC (reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar CSMT [chiropractic spinal manipulative therapy], and return to work within 8 weeks), or family physician–directed UC [usual care], the components of which were recorded. The subjects were then examined for improvement from baseline in disability, bodily pain and physical functioning at 8, 16, and 24 weeks. What did the data show?

“The primary outcome, the unadjusted mean improvement in RDQ [disability] scores, was significantly greater in the SC group than in the UC group…Similarly, improvements in SF-36 PF [physical functioning] scores favored the SC group at all time points; however, these differences were not statistically significant. Improvements in SF-36 BP [bodily pain] scores were similar between groups. In repeated-measures analyses, global adjusted mean improvement was significantly greater in the SC group in terms of RDQ, nearly significantly greater in terms of SF-36 PF, but similar between groups in terms of SF-36 BP.”

This is evidence that CSMT (spinal manipulative therapy administered by chiropractors) reduces disability more than ‘usual care’. The authors conclude:

“This is the first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician–directed UC in the treatment of patients with AM-LBP. Compared to family physician–directed UC, full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.“

This study recently published in the journal Clinical Rehabilitation compared the outcomes for three of the most common therapies:

“Objective: To compare spinal manipulation, back school and individual physiotherapy in the treatment of chronic low back pain.”

This was a randomized trial involving 210 patients with chronic, non-specific low back pain over a 12 month follow-up period. Here’s what the respective treatment plans involved:

“Back school and individual physiotherapy scheduled 15 1-hour-sessions for 3 weeks. Back school included: group exercise, education/ ergonomics; individual physiotherapy: exercise, passive mobilization and soft-tissue treatment. Spinal manipulation, given according to Manual Medicine, scheduled 4 to 6 20’-sessions once-a-week.”

What did the data lead the researchers to conclude?

“Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.”