Archief Roodbont

Editor's Note

The following is a commentary from Carlo DiMarco, DO, President, American Osteopathic Association on the Best Evidence Review "NSAIDs and Manipulation Ineffective for Acute Low Back Pain" (http://cme.medscape.com/viewarticle/572783).

Commentary

After reading "NSAIDs and Manipulation Ineffective for Acute Low Back Pain: A Best Evidence Review"^[1] by Charles M. Vega, MD, I am concerned about the implication that spinal manipulation is viewed as a treatment with adverse consequences.

The study selected for this online educational activity suggests that "adverse events associated with spinal manipulation therapy are not justified by more rapid improvement in low back pain."^[2] However, I would argue that there is a conclusive amount of research suggesting that adverse events associated with osteopathic manipulation treatment (OMT) of the lumbar spine are rare, and benefits tend to outweigh these risks. For instance, a 1999 study in The New England Journal of Medicine^[3] shows OMT to be an effective form of medical treatment for low back pain. In this study, participants were divided into 2 groups: 1 treated with standard care for low back pain and the other treated with standard care and OMT. While both groups showed improvement over a 12-week period, the patients who received OMT required significantly less medication and used less therapy. Furthermore, adverse events for osteopathic manipulative treatment of the lumbar spine for patients with low back pain have not been reported in controlled clinical trials, and rarely will you find an incidence documented in the literature or in court cases^[4] over the past century.

Dr. Vega also argues that time is the best therapy for low back pain and goes on to state that most patients notice improvements in 2 weeks and 90% of patients report significant improvement in 2 months without any type of treatment. The problem with this statement is that as a recurrent illness, low back pain most likely would take more than 2 months to heal itself. In fact, Richard Deyo, MD, MPH, and James Weinstein, DO, dispute claims that low back pain resolves within 2 months in an article entitled "Low Back Pain" in the February 1, 2001, issue of The New England Journal of Medicine.^[5] They point out that recurrences are common and that low back pain is a "chronic problem with intermittent exacerbations, analogous to asthma, rather than an acute disease that can be cured." As for Dr. Vega's argument about the cost of spinal manipulation, DOs can provide spinal manipulation as part of an office visit without referral to another provider, thereby potentially reducing treatment costs by relying less on prescription drugs and physical therapy.

I encourage physicians to review the literature about the effective use of OMT to treat low back pain published in other journals, including the August 2005 issue of the BMC Musculoskeletal Disorders, which features an article entitled "Osteopathic Manipulative Treatment for Low Back Pain: a Systematic Review and Meta-Analysis of Randomized Controlled Trials,"^[6] by John C. Licciardone, DO, and colleagues. This article summarizes the results of clinical trials suggesting the potential utility of OMT in both acute and chronic low back pain. Another article of note is "Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline,"^[7] by Roger Chou, MD, and Laurie Hoyt Huffman, MS. This article from the October 2007 issue of Annals of Internal Medicine cites evidence for efficacy of spinal manipulation in treating low back pain.

Carlo J. DiMarco, DO
President, American Osteopathic Association, Chicago, Illinois

Author Response

I welcome the comments from Dr. DiMarco. Low back pain can be a difficult condition to treat, and patients need every resource they can garner to achieve analgesia and better function. There is certainly evidence that spinal manipulation therapy can be effective for acute low back pain, but the nature of this pain, the interventions offered, and the various study methodologies have created a heterogenous body of literature around this subject. While the study by Hancock and colleagues did not find that nonsteroidal anti-inflammatory drugs or spinal manipulation therapy were superior to paracetamol and physician advice for acute low back pain, these modalities certainly continue to merit consideration for the care of individual patients. Further research focused on which patients might respond better to different treatment methods will help clinicians to determine the best therapy for individuals with acute low back pain.

Charles M. Vega, MD