Publisher's Note: An article in The Back Letter deals with a randomized trial published in 2000 studying osteopathic manipulation vs. "standard care" in treating patients with subacute back pain. The following is a response from the chiropractic viewpoint from Dr. Anthony L. Rosner, FCER Director of Research and Education.

RESPONSE TO OSTEOPATHIC STUDY¹

Andersson's recently published study comparing osteopathic and standard medical therapies¹ demonstrates the continuing challenges of mounting definitive randomized clinical trials addressed to physical methods of intervention with the patient. It is practice-based in that it allows the treating physician a variety of techniques used in osteopathy [thrust, muscle energy, counterstrain, articulation, and myofascial release] to be used at the clinician's discretion. For the most part, the trial appears to have matched the key baseline characteristics of the patients rather well.

However, this study does not provide osteopaths with the use of such adjuvant modalities as diathermy, ultrasonography, hot or cold packs [or both], or transcutaneous electrical stimulation--which are instead relegated to the allopathic arm of the trial. Since these particular modalities are often used in chiropractic and which may enhance the effects achieved with manipulation, assigning them to the medical arm may diminish such enhanced effects as more rapid relief of pain and recovery of function that were sought through osteopathic treatments. This problem is reminiscent of the stripping away of important adjuvant techniques from the side-posture spinal manipulative techniques employed in the previously published Cherkin study, a paper which incorrectly attempted to equate the one-dimensional manipulative technique used with all of chiropractic.² To their credit, the authors of the present study do take pains to explain that "osteopathic manual care involves much more than manipulation, which should be viewed as one part of a larger philosophy of care." That said, there needs to be an instrument which clearly verifies that the osteopathic treatment employed in this study actually and accurately reflects what is followed in practice.

Secondly, a reference in the Methods section of the article to the effect that osteopathic physicians "provided additional treatment in the form of manipulation" is troubling. In addition to what? Presumably, this particular experimental group is denied those modalities identified within the standard allopathic arm of the trial, leaving little to the imagination as to what may have been relegated to the osteopath in addition to manipulation.

Finally, there is a major inaccuracy in the introduction of this paper--which suggests that "although manipulation may be effective in alleviating pain and improving functions in patients with acute, uncomplicated back pain, its effectiveness has not been proved [sic] in patients with symptoms of longer duration." According to a systematic review by van Tulder which takes into account the most recent studies, however, the situation is precisely the opposite. With regards to acute low-back pain, Van Tulder states that "there is limited evidence that manipulation is more effective than a placebo treatment." Although contradictory results did not allow van Tulder to compare manipulation to other physiotherapeutic applications, there was no such uncertainty regarding chronic low-back pain. Here van Tulder unequivocally states that "there is strong evidence that manipulation is more effective than a placebo treatment.... There is moderate evidence that manipulation is more effective for chronic LBP than usual care by the general practitioner, bed-rest, analgesics, and massage."³

Despite these flaws, it is important to note that at least comparable outcomes were obtained using either the osteopathic or allopathic approaches in the trial--despite the fact that the use of medications was sharply lower [sometimes less than half] by the osteopathic patients. The results of this trial suggest that it is possible to obtain similar therapeutic relief from back pain with substantially less medication, a highly significant finding in light of the well-known and sometimes fatal side-effects obtained with NSAIDs.^4,5 Being able to reduce the use of medications may also significantly lower treatment costs--especially when the costs of side-effects and iatrogenesis are factored in. These considerations would bode well for the practice of spinal manipulation for the management of back pain.

Anthony L. Rosner, Ph.D.
June 26, 2000

REFERENCES:

¹Andersson GBJ, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgan S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. New England Journal of Medicine 1999; 341(19): 1426-1431.

²Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. Comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998; 339(14): 1021-1029.

³van Tulder M, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: A systematic review of randomized controlled trials of the most common interventions. Spine 1997; 22(18): 2128-2156.

⁴Roth S. Non-steroidal anti-inflammatory drugs: Gastropathy, deaths and medical practice. Annals of Internal Medicine 1988; 109: 353-354.

⁵Gabriel S, Jaakimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis. Annals of Internal Medicine 1991; 115: 787-796.

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