One of the most common reasons people go to the doctor is lower back pain, and one of the most common reasons doctors prescribe powerful, addictive narcotics is lower back pain.
Now, research published Tuesday in the Journal of the American Medical Association offers the latest evidence that spinal manipulation can offer a modestly effective alternative.
Researchers analyzed 26 studies involving more than 1,700 patients with lower back pain. The analysis found spinal manipulation can reduce lower back pain as measured by patients on a pain scale — like this one — from zero to 10.
Spinal manipulation, which is typically done by chiropractors, physical therapists, osteopaths, massage therapists and some other health providers, involves applying pressure and moving joints in the spine.
Patients undergoing spinal manipulation experienced a decline of 1 point in their pain rating, says Dr. Paul Shekelle, an internist with the West Los Angeles Veterans Affairs Medical Center and the Rand Corp. who headed the study.
"So if it had been a 7 it would be a 6, or if it had been a 5 it would be a 4," Shekelle says. That's about the same amount of pain relief as from NSAIDs, over-the-counter nonsteroidal anti-inflammatory medication, such as ibuprofen.
The study also found spinal manipulation modestly improved function. On average, patients reported greater ease and comfort engaging in two day-to-day activities — such as finding they could walk more quickly, were having less difficulty turning over in bed or were sleeping more soundly.
It's not clear exactly how spinal manipulation relieves back pain. But it may reposition the small joints in the spine in a way that causes less pain, according to Dr. Richard Deyo, an internist and professor of evidence-based medicine at the Oregon Health and Science University. Deyo wrote an editorial published along with the study.
Another possibility, Deyo says, is that spinal manipulation may restore some material in the disk between the vertebrae, or it may simply relax muscles, which could be important.
There may also be mind-body interaction that comes from the "laying of hands" or a trusting relationship between patients and their health care provider, he says.
Deyo notes that there are many possible treatments for lower back pain, including oral medicine, injected medicine, corsets, traction, surgery, acupuncture and massage therapy. But of about 200 treatment options, "no single treatment is clearly superior," he says. The findings of this study may slightly shift that evaluation of benefits.
The findings are in line with guidelines the American College of Physicians released recently. Those guidelines suggest people with low back pain use techniques that may help speed up the healing process, including heat wraps, massage, acupuncture and spinal manipulation. The bottom line message, says Deyo, is to try to avoid medication.
"Even over-the-counter medications have some important side effects and complications," Deyo says. "Spinal manipulation seems to be quite safe when it's done in the lower back."
Medications can cause gastritis, an upset stomach and a rise in blood pressure. And if patients are prescribed stronger medication, such as opioids, they risk long-term use and even addiction.
Dr. Steven Atlas, an internist and associate professor at Harvard Medical School who practices at Massachusetts General Hospital, says the study offers "more support for alternative treatments," particularly for patients who are not getting better with self-care techniques such as heating pads, exercise and yoga.
Atlas says further research could help identify patients who would benefit most from spinal manipulation therapy. This could make it easier for doctors to refer patients for treatment by a chiropractor or physical therapist, he says.
ARI SHAPIRO, HOST:
Lower back pain is one of the most common reasons people go to the doctor. It's also one of the most common reasons doctors give for prescribing pain-relieving narcotics. Now growing evidence shows that medication may not be the best option.
NPR's Patti Neighmond reports on a new study in this week's Journal of the American Medical Association.
PATTI NEIGHMOND, BYLINE: For many people, lower back pain goes away on its own in a few days, maybe a week. But when back pain lingers, it can be debilitating. People search for treatment, and they have lots of options, according to Dr. Richard Deyo with Oregon Health and Science University.
RICHARD DEYO: We have oral medications. We have injected medications. We have corsets. We have traction. We have surgery, of course. We have acupuncture. We have spinal manipulation. We have massage therapy.
NEIGHMOND: Lots of therapies, but not one of them has been shown to be much better than the others. The findings of this study, says Deyo, may change that a little bit.
Researchers compared results of 26 studies involving more than 1,700 patients with lower back pain. Internist Paul Shekelle with the VA West Los Angeles Medical Center headed the study, which found spinal manipulation - putting pressure and moving joints in the spine - modestly reduced pain as measured by patients on a scale of zero to 10.
PAUL SHEKELLE: Basically one point on the numeric rating scale - so if their pain had been a 7, then it would be a 6. Or if it had been a 5, it would be a 4.
NEIGHMOND: Now, that may not sound like much, but it's about the same amount of pain relief as over-the-counter non-steroidal anti-inflammatory medication like ibuprofen. The study also found spinal manipulation improved function - again, modestly. Patients reported greater ease and comfort engaging in about two activities.
SHEKELLE: For example, walk more quickly than they would because of their back pain. They would not have as much difficulty turning over in bed because of their back pain. They slept better because of their back.
NEIGHMOND: Spinal manipulation is typically done by chiropractors and physical therapists. Back specialist Deyo says it's not clear exactly how spinal manipulation relieves back pain, but there are some ideas.
DEYO: It may be that spinal manipulation moves the small joints in the spine in such a way that they are repositioned, in a sense, and cause less pain.
NEIGHMOND: Or it may restore some material on the discs that lie between the vertebrae.
DEYO: Others have suggested it's simply a matter of muscle relaxation, which could be important.
NEIGHMOND: It could also have to do with mind-body interaction, laying of hands, for example, or a trusting relationship between patients and their health care provider. The findings of this study are in line with guidelines from the American College of Physicians which were released just over a month ago. Those guidelines suggest people with low back pain use techniques to speed up the healing process, things like heat wraps, massage, acupuncture and spinal manipulation, and avoid medication. Richard Deyo.
DEYO: Even over-the-counter medications have some important side effects and complications. And the spinal manipulation seems to be quite safe when it's done in the lower back.
NEIGHMOND: Medications can cause gastritis, stomach upset and a rise in blood pressure. And if patients are prescribed stronger medication, like opioids, they risk long-term use and even addiction. Patti Neighmond, NPR News. Transcript provided by NPR, Copyright NPR.