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Dose-Response and Efficacy of Spinal Manipulation for Chronic Low-Back Pain: A New Study

November 14, 2013
Josephine P. Briggs, M.D.
Josephine P. Briggs, M.D.

National Center for Complementary and Alternative Medicine

View Dr. Briggs' biographical sketch

Chronic low-back pain is one of the most common and costly health complaints. It can be debilitating, and it remains a tough condition to diagnose, treat, and study. Spinal manipulative therapy is often used to treat a large portion of low-back pain in the United States, and is included in current clinical practice guidelines for treatment of this condition. Yet, recommendations for duration and frequency vary widely and there is no consensus on its efficacy. This is in part because there has been little, if any, evidence from dose-response studies to advise researchers on the average optimal dose, or the number of spinal manipulation sessions provided. A new NCCAM-funded study published in The Spine Journal, led by Mitchell Haas, D.C., is the largest and most rigorous, randomized dose-response study of spinal manipulative therapy for chronic low-back pain, and its findings will help guide future research in this area.

One of the several important findings to note from this study is that all four groups had significant reductions in pain intensity and functional disability by 6 weeks, with the largest reduction occurring at 12 weeks in the group that had received 12 sessions of spinal manipulative therapy. These improvements were sustained out to 52 weeks, and the effects of dose were significant, though modest, on both pain intensity and disability.

It’s hard, also, not to be struck by the fact that over half of the participants in the study did not respond to treatment. Sadly this is a recurrent theme in back pain studies. For those patients, and for the many others who suffer from chronic low-back pain, more effective management strategies are desperately needed. We have a long way to go with research for back pain, but as this study demonstrates, it’s an important investment.

This is just one example of the type of important research that can help inform and provide guidance on health care policy. At NIH, we are committed to building an evidence base to help inform the decisionmaking processes of clinicians, health policymakers, and consumers, particularly in areas such as chronic pain.


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It would be essential to know the effect sizes associated with any statistically significant differences, in order to interprete the results. And whether of not the authors following a conservative intent-to-treat analysis, which is de rigour for RCTs nowadays. I wish a PDF of the full study was posted.  I cannot access it via my university library.

These are important findings i saluit NCCAM, for the continued endurence in resaerch that brings out facts on complementary modes of treatments, this was so neccessory and such amazing programm will help to uplift the standards and instil trust from the generial public about the use,need,and importance of complementary and altanative medicine. Which has been missing for decades. thanks nccam again.

Dr. Briggs,It is not so shocking to me that 50% of the partipants did not respond to manipulation.  This is a recurrent theme because the idea that one type of intervention can be effective in all patients with low back pain is flawed.  There are different pain generators that cause lower back pain which require different management, to include different interventions, different modification of ADL’s to avoid further stress to effected tissues and specific exercise programs based on the co-morbid weaknesses in core stabilization and lower extremity strength that are unique to each patient. Until management of lower back pain is prefaced with the subclassication of lower back pain into the correspondent subcatagories to include discogenic low back pain, facet mediated low back pain, sacroiliac pain, spondylosis, and intervertebral disc herniation to mention a few, and managed uniquely based on presenting pain generator with specific protocols, the healthcare community will continue to be perplexed by lack of progress made in the arena of low back pain.  Thank you for the attention that you focus on this common malady that affects and has an effect on so many people in our country. I welcome further discussion and collaberation to help the cause in any way that I can be of assistance. Sincerely, Eric J. Kirk, D.C., DACOClinical Director of ChiropracticAurora Health Care

It does not surprise me that over half of the participants did not respond to treatment.  It is unrealistic to think that one type of intervention such as spinal manipulation will have an effect on the different pain generators that result in low back pain.  Until we start to subcategorize low back pain and manage patients with protocols that are condition specific, we will continue to see the same results in clinical trial.  Some interventions will be partially effective based on the condition with which the patient presents.  Once patients are correctly diagnosed and subcategorized, then they can be educated for avoidance of pain provoking movements patterns, given specific modification of ADLs to avoid aggravation of injured tissues, treated with appropriate interventions that are condition specific to improve neuromusculoskeletal function, and strengthened with performance of specific exercise that effectively eliminates that specific patient’s weaknesses in their lower extremity and core stability. There is no one intervention that effectively manages lower back pain because lower back injuries are not one dimentional. This is a conundrum that is universal across disciplines because of the starting point that lower back pain is lower back pain and not something more specific.

There was actually more than half that responded favorably to care. The authors just set the bar too high for what they decided was a success threshold (50% improvement was “success.”) They said that they could have gone for 30% improvement in pain, as other studies do, to call the results successful. When I look at the study, I see that everyone responds favorably to some degree, it’s just that some do better than others. 

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