Eighty percent of the people in the United States report low back pain at some point in their lives. It is one of the top 10 reasons for visits to family physicians and is responsible for one third of all US disability costs. Direct costs of diagnosis and treatment were $25 billion in 1991, in addition to the cost of lost earnings.1-3 The natural history of acute low back pain in those presenting for care is for half to recover in 1 to 2 weeks and 90% in 1 month.4 In a cohort of 1246 patients presenting for treatment of acute low back pain, approximately 100 patients (8%) went on to have chronic continuous symptoms for 3 months, and two thirds of these patients had disabling symptoms at 22 months (almost 5% of the original cohort), although many were employed.5
Therapy
What is known about therapy for low back pain? The author of an evidence-based systematic review of randomized control (RCTs) trials7 reported that nonsteroidal anti-inflammatory drugs (NSAIDs) and staying active are beneficial for acute low back pain; analgesics and spinal manipulation are likely to be beneficial; muscle relaxants are likely to have benefits and harms; and bed rest and traction are likely to be ineffective. The following were of unknown effectiveness: antidepressants, epidural steroids, trigger point injections, back schools, behavioral therapy, back exercises, multidisciplinary treatment programs, lumbar supports, and acupuncture. For chronic low back pain, back exercises and multidisciplinary programs are beneficial; analgesics, NSAIDs, back schools, trigger point injections, behavioral therapy, and spinal manipulation are likely to be beneficial; bed rest, biofeedback, and traction are unlikely to be beneficial; and other treatments are of unknown effectiveness.
Given the nature of the pain and the lack of curative medical therapies, it is not surprising that low back pain is one of the most common reasons people give for using alternative therapies. In a 1997 national telephone survey, 24% of the respondents reported a history of back pain in the preceeding 12 months. Of these, 48% used an alternative therapy in the previous 12 months; 30% saw an alternative practitioner; and 39% saw a physician and an alternative practitioner. Chiropractic and massage were the most common alternative therapies.8
Several well-done investigations of manipulative therapy have been reported. These include an observational study of chiropractors and physicians, a randomized trial of osteopathic manual therapy versus standard medical therapy, and a randomized trial comparing chiropractic, physical therapy, and an education booklet.9-11 These studies generally show that manual therapy (including physical therapy) is associated with greater patient satisfaction, higher health care costs, and at best marginally improved functional outcomes compared with traditional medical therapy. This should not be surprising since the natural history of back pain is for it to resolve relatively quickly.
To further investigate the potential benefits of manual therapy, Curtis and colleagues recently conducted an RCT of low back pain management in which family physicians and internists received special training in the care of low back pain (enhanced care) and simple manual therapy techniques (enhanced care plus). After the training, the physicians reported increased confidence in managing low back pain, and all subsequently used manual therapy in their practices. These same physicians were then involved in a trial in which they randomly assigned their acute back pain patients to receive enhanced care or enhanced care plus. The complete results of that study will be reported elsewhere.12
Patient Satisfaction
In this issue of the Journal Curtis and colleagues13 compare the outcomes of those patients treated in their manual therapy RCT to the outcomes of patients treated by primary care clinicians in their previously reported observational study comparing chiropractic, orthopedic, and primary care. To do this, the authors focused on the 13 generalists (presumably family physicians and internists) who participated in both studies. They hoped to determine if training in enhanced care and manual therapy skills would improve patient outcomes and satisfaction.
For this study, the authors used the patients of the 13 physicians in the original observation study as the control group and the patients treated in the RCT as the intervention group. Their results showed that patients treated in the RCT assessed physicians’ skills in history taking, examination skills, patient education, overall treatment, provision of pain relief, and success in getting patients to engage in social activities more highly. The differences in outcomes between the 2 treatment methods in the RCT (enhanced care and enhanced care plus) were relatively small. Functional outcomes as measured by scores on the Roland-Morris questionnaire (a standardized tool used in back pain research) showed a significant difference in favor of the intervention patients over the control patients at 2, 4, and 8 weeks. Time to functional recovery also showed that both groups in the RCT improved more quickly, although the confidence intervals around the hazard ratios included 1, and therefore were not significantly different.