Ann Intern Med. 2014;161(6):I-15. doi:10.7326/P14-9031
What is the problem and what is known about it so far?
Back-related leg pain (BRLP), such as sciatica, is often disabling and causes more work loss, medication use, and health-related costs than uncomplicated low back pain. Nonpharmacologic interventions, including spinal manipulation, exercise, and education promoting self-management, are increasingly recommended as low-risk treatment strategies. The comparative effectiveness of these interventions for reducing pain and improving function is unclear.
Why did the researchers do this particular study?
To find out whether spinal manipulation therapy (SMT) plus home exercise and advice (HEA) is more effective than HEA alone for treating BRLP.
Who was studied?
192 adults, aged 21 years or older, with subacute or chronic BRLP lasting at least 4 weeks. Patients could not be receiving ongoing treatment of leg or low back pain by other health care providers; have evidence of substance abuse; or have current or pending litigation for worker’s compensation, disability, or personal injury.
How was the study done?
The trial took place at 2 research centers from 2007 to 2011. Patients were randomly assigned to receive 12 weeks of HEA alone or SMT plus HEA. Patients assigned to HEA alone met with a chiropractor, exercise therapist, or personal trainer for four 1-hour sessions to receive individualized education on simple pain management techniques and instruction and practice on ways to improve mobility and increase trunk endurance. They were instructed to do various home exercises every other day and were given printed materials to take home and review. For the SMT intervention, patients received the HEA intervention and also visited a chiropractor up to 20 times for 10 to 20 minutes of spinal manipulation at each visit. Outcomes, including self-reported pain and disability, were assessed at 12 and 52 weeks.
What did the researchers find?
Spinal manipulative therapy plus HEA provided more relief from BRLP than HEA alone at 12 weeks but not at 52 weeks. Patients in the SMT group were also less likely to have low back pain and disability at 12 weeks but not at 52 weeks. They were also less likely to use pain medications and reported more global improvement and higher satisfaction with care at both 12 weeks and 52 weeks than the patients in the group that received only HEA. No serious treatment-related adverse events occurred in either group.
What were the limitations of the study?
Patients and their providers were aware of which intervention patients received. The study could not differentiate between the specific effects of treatment and the effects of interactions between patients and providers.
What are the implications of the study?
Spinal manipulative therapy plus HEA improves short-term pain and function outcomes more than HEA alone in patients with subacute or chronic BRLP. Benefits seen at 12 weeks were not all sustained at 52 weeks.