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Spinal manipulation as a treatment for back pain has been practiced for over 100 years. Different schools of manual treatment have evolved. In the United States, most spinal manipulation is provided by chiropractors. The focus of chiropractic care is on the nervous system with adjustments of the spinal vertebra to improve joint, nerve and muscle function. Osteopathic care uses spinal manipulation in combination with conventional treatment methods.
These modalities all recognize that low back pain is not an isolated pathology (as is the case with many conventional approaches). It sees the musculoskeletal system as a unified structure that needs all parts functioning well for there to be proper physiology and a chance for an absence of pain. These therapeutic approaches therefore emphasize treatment of low back pain not just of the low back, but of the spine as a whole.
To date, the data from scientific trials on the effectiveness of manipulation for acute back pain show it to be an effective therapy (Shekelle, 1992). However, studies for chronic low back pain are not yet clear and there are insufficient high quality studies to support or refute its use for this condition. In a systematic review of 81 trials of manipulation for chronic low back pain, however, 25% were high quality studies showing strong evidence that manipulation was effective, especially for specific structural conditions. Studies also suggest that when improvement occurs it is usually early in the course of treatment (after 6 treatments) so that if there is no improvement in symptoms by that point, manipulative intervention may be ineffective in that case (Berman, 1998).
Further research is needed to clarify the characteristics of patients who have a high probability of benefiting from spinal manipulation, the optimal dose response of this type of therapy, the potential long-term effect, and its possible role in the prevention of new episodes of low back pain. Studies that confine manipulative therapies only to the low back and restrict use in other areas as part of the treatment regimen (as is common practice) may be less likely to show benefit.
- Chiropractic. Many studies and reviews have evaluated the use of manual
therapy, including manipulation, for the treatment of chronic low
back pain. There is moderate evidence for the effectiveness of manipulation
for chronic low back pain. In a 1997 systematic review, strong evidence
was found that spinal manipulation for chronic low back pain was better
than placebo treatment and moderate evidence that it was better than
treatment by a general practitioner, massage, bed rest and analgesics
(van Tulder, 1997)
In another review of chiropractic spinal manipulation for chronic low back pain, nine out of fourteen studies reported positive benefits for manipulation over other interventions, three showed improvement comparable to other interventions and two were negative (Vernon, 1999).
- Osteopathy. Osteopathic care includes standard methods of
treatment and manual care involving the neuro-musculo-skeletal system.
In a randomized controlled clinical trial of patients with chronic
and subchronic low back pain (back pain for at least three weeks but
less than six months), osteopathic manual care was compared to standard
medical care. Both types of treatment had similar clinical results
in terms of pain relief, function and satisfaction in patients with
subacute low back pain. However the osteopathic treatment group receiving
manual care required significantly less medication (analgesics, anti-inflammatory
agents and muscle relaxants) and used less physical therapy (Andersson,
1999).
- Massage. Massage therapy is widely used by patients for the treatment of chronic low back pain. Despite this widespread use there has been little randomized, controlled research evaluating massage as the main treatment option for back pain. Most studies have used massage for comparison purposes (as a control) while evaluating the effectiveness of spinal manipulation, TENS, or a lumbar corset.
A recent randomized study compared the effectiveness of acupuncture, therapeutic massage and self-care education for chronic low back pain. It found that therapeutic massage was effective for persistent low back pain in terms of improvement of symptoms and function and that it provided long-lasting benefits. This study used only massage techniques that were limited to manipulation of the soft tissues (the muscles and fascia that surround the muscles) (Cherkin, 2001).
In a randomized study comparing massage therapy and progressive muscle relaxation for chronic low back pain, the massage therapy group reported experiencing less pain, depression, anxiety, improved sleep, improved trunk and pain flexion performance and higher levels of serotonin and dopamine. Massage therapy was found to be effective in reducing pain, stress hormones, and symptoms associated with chronic low back pain (Hernandez-Reif, 2001).
Thus, despite the need for more high quality research studies to evaluate massage as a main treatment option, it would seem reasonable to include massage in a multi-modal treatment approach for certain types of chronic low back pain conditions.
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