Do manual therapies help low back pain? A comparative effectiveness meta-analysis. (2014)

Abstract
STUDY DESIGN:
Meta-analysis methodology was extended to derive comparative effectiveness information on spinal manipulation for low back pain.

OBJECTIVE:
Determine relative effectiveness of spinal manipulation therapies (SMTs), medical management, physical therapies, and exercise for acute and chronic nonsurgical low back pain.

SUMMARY OF BACKGROUND DATA:
Results of spinal manipulation treatments of nonsurgical low back pain are equivocal. Nearly 40 years of SMT studies were not informative.

METHODS:
Studies were chosen on the basis of inclusion in prior evidence syntheses. Effect sizes were converted to standardized mean effect sizes and probabilities of recovery. Nested model comparisons isolated nonspecific from treatment effects. Aggregate data were tested for evidential support as compared with shams.

RESULTS:
Of 84% acute pain variance, 81% was from nonspecific factors and 3% from treatment. No treatment for acute pain exceeded sham’s effectiveness. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% of 98% was nonspecific, but treatments influenced 32% of outcomes. Chronic pain treatments also fit within 95% confidence bands as predicted by natural history. Though the evidential support for treating chronic back pain as compared with sham groups was weak, chronic pain seemed to respond to SMT, whereas whole systems of clinical management did not.

CONCLUSION:
Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority matched a binomial random process. Treatments serve to motivate, reassure, and calibrate patient expectations–features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain. [emphasis mine]

My comments:
This was an great paper and I think better than the Cochrane reviews I blogged on recently that questioned the effectiveness of spinal manipulation for both acute and chronic low back pain. In this paper the author J. Michael Menke, DC, PhD (I like pointing out that he’s a chiropractor) actually has both the intelligence and intestinal fortitude to follow the findings all the way towards their logical conclusion. Rather than calling for yet more research and a cost analysis, he basically said enough’s enough and why bother. He had some great quotes that I don’t think I can word any better.

“…96% (81/84) of acute pain improvement in the first 6 weeks was unrelated to treatment. Attention placebo nearly doubled the pB [probability of recovery] shown in the difference between attended and unattended physiotherapies…”

“Acute pain treatment evidence never exceeded sham”

“NMC analysis of chronic pain established 98% of outcome variance, of which 32% was from treatment and 66% from everything else. Furthermore treatment evidence beat shams. Figure 2 illustrates the comparative effectiveness in g for 6 treatments of chronic pain.”

“From 1974 to 2010, 8400 SMT patients were observed at least 13,000 times in research costing from $32 to $80 million.”

“More research is not the answer. That which is already known about SMT for back pain is quantifiably all that is worth knowing.”

“When all treatments seem equally effective but none stands out, more research will not help. Under these conditions cheap treatments will always be the most cost effective. But for cost-effectiveness you first need effectiveness. What decision can be made when ineffective chiropractic care is more cost effective than ineffective medical care?”

“Social support is the long ignored link between personal responsibility and professional care. For patients coping with pain and change, psychological support is necessary. The difference between sham effect size g = 0.77 and waiting list g = -0.13 illustrates the difference between attention and neglect.”[emphasis mine]

I don’t have a lot to add, good exercise with social support seems the way to go. I think that social support should include a fair amount of patient education about environmental influences to low back pain, how to avoid pathological stresses with better postures and motor control, both of which can be influenced positively with exercise as already mentioned.