Spinal manipulation alone was no more effective than guideline-recommended medical care for low back pain (LBP), results of a randomized comparison study showed.
Of the first-line nonpharmacologic interventions included in the four-arm trial, clinician-supported self-management offered the most benefit, besting medical care with small but significant improvements in LBP disability over 12 months when used alone or with spinal manipulation.
Patients who received self-management were also more likely to achieve a 50% or greater reduction in disability compared to those who received medical care.
Spinal manipulation alone was not associated with better outcomes than medical care, and combining it with self-management was not better than self-management alone. Pain intensity scores were similar across all four treatment groups.
“For patients with acute or subacute LBP at increased risk of chronic impactful LBP, when compared with medical care, physical therapist- or chiropractor-supported biopsychosocial self-management” showed small but statistically significant improvements in disability outcomes, Gert Bronfort, PhD, University of Minnesota Twin Cities, Minneapolis, and colleagues wrote.
The findings were published online on December 29 in JAMA.
Filling the Gap
Evidence-based recommendations for LBP treatment are to limit opioids, promote remaining active, use nonpharmacologic treatments such as spinal manipulation and acupuncture, or use nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants if a patient prefers medication.
There is no consensus on the most effective initial treatment, and data comparing treatment efficacy are lacking, investigators wrote, adding that most patients with LBP in the US are treated with medication.
To fill the gap in the literature, investigators enrolled 1000 adults (mean age, 47 years; 58% women) with acute or subacute LBP in the PACBACK multicenter randomized trial. All were deemed to be at moderate-to-high risk for chronic disabling LBP based on STarT Back tool scores.
Between 2018 and 2023, participants were randomly assigned to receive:
- spinal manipulation alone (n = 201),
- spinal manipulation plus supported self-management (n = 193),
- self-management alone (n = 305), or
- guideline-based medical care (n = 301).
Standard manual spinal manipulation therapies were performed by clinicians. Clinician-supported self-management consisted of one-on-one sessions focusing on physical, psychological, and social strategies. Medical care included NSAIDs, muscle relaxants, and/or other recommended therapies.
The joint primary outcomes were monthly low back disability on the Roland-Morris Disability Questionnaire (with a score of 0 considered “best” and a score of 24 considered “worst”; mean score at baseline, 11.2) and weekly pain intensity on a numerical rating scale (score of 0 considered “best” and score of 10 considered “worst”; mean score at baseline, 5.4). Both outcomes were averaged over 1 year of follow-up.
The proportion of participants achieving a 50% or greater reduction in either of the primary outcomes was assessed in secondary analyses.
Few Group Differences
Results showed significant improvements in LBP disability (P = .001) for supported self-management alone (mean average score over 12 months, 4.7), self-management plus spinal manipulation (mean score, 4.8), spinal manipulation alone (mean score, 5.5), and guideline-based medical care (mean score, 5.9).
This translated to small but significantly better disability scores for self-management when offered alone (mean difference, -1.2) or when combined with spinal manipulation (mean difference, -1.1) vs medical care. There was no significant difference in disability scores between spinal manipulation alone and medical care.
The mean differences in pain intensity did not differ significantly between the groups.
The proportion of patients achieving a 50% or greater reduction in disability was 67% for self-management alone and 65% for self-management with spinal manipulation, compared with 54% for medical care. The proportion for spinal manipulation alone was also 54%.
For secondary outcomes, supported self-management was associated with greater improvements in physical function, fatigue, and pain interference compared to medical care.
Among all participants, 11% reported an adverse event (AE), but there were no significant differences in AEs between the groups.
Nonpharmacologic Therapy for Back Pain Nonpharmacologic Therapy for Back Pain