Low back pain (LBP) is very common and is a great burden to society in terms of human suffering, disability and lost productivity, as well as associated direct and indirect monetary costs. A number of treatment guidelines have been developed, yet the way patients with LBP are cared for is inconsistent between professions, as well as between geographic areas.
From 13% to 49% of older adults are affected by LBP, yet very few studies have considered the available treatments for the condition in this age group. In particular, there have been no randomized controlled trials involving chiropractic care for older adults.
Therefore, the purpose of this study was to compare the effects of high-velocity, low-amplitude spinal manipulation (HVLA-SM); low-velocity, variable-amplitude spinal mobilization (LVVA-SM) [i.e., flexion-distraction technique]; and minimal conservative medical care (MCMC) in patients who had subacute or chronic non-radicular LBP and were 55 years of age or older.
Pertinent Results:
1849 potential subjects were screened for participation by phone interviews and 964 were determined to be eligible. However, 724 of them were excluded at the initial visit for various reasons (ex. SM within past month, no current LBP, current LBP episode less than 1 month, etc.). Ultimately, 240 subjects were randomly assigned to one of 3 active care groups and 205 of them completed the 5 week regimen. 96 subjects were assigned to the HVLA-SM group, 95 to LVVA-SM, and 49 to MCMC.
The percentage of subjects where follow-up data was available was high (90%) among those who received spinal mobilization or manipulation, whereas it was low (ranging from 50% to 76%) for those who received MCMC.
Adjusted mean Roland Morris Disability (RMD) questionnaire change scores from baseline to the end of care were as follows:
LVVA-SM group 2.9 (95% confidence interval [CI], 2.2 to 3.6)
HVLA-SM group 2.7 (95% CI, 2.0 to 3.3)
MCMC group 1.6 (95% CI, 0.5 to 2.8)
These findings suggest that both SM procedures were associated with clinically important differences by the end of treatment, but there was not a significant difference between the LVVA-SM group and the HVLA-SM group.
RMD scores for the LVVA-SM group ranged from 1.3 to 2.2 points over the MCMC group, which were considered statistically significant at all end points.
RMD scores for the HVLA-SM group were significantly better than the MCMC group at the third week, but not at the other end points.
Side effects in the HVLA-SM and LVVA-SM groups were mostly mild, involving increased low back pain soreness or stiffness for the most part. There were 10 (10.4%) reported side effects in the HVLA-SM group, 6 (6.3%) in the LVVA-SM group, and 4 (8.2%) in the MCMC group. One subject from the MCMC group reported slurred speech and sought care from another medical provider.
Clinical Application & Conclusions:
There were no real differences in the outcomes between the LVVA-SM and HVLA-SM groups in this study. Therefore, there does not appear to be a clear advantage of using one of these types of mobilization or manipulation over the other in patients from this age group. Patient and doctor preferences would likely be the best basis for choosing between these types of mobilization/manipulation.
Further, there were no serious side effects in subjects receiving mobilization or manipulation, and reasonably few of the minor variety. Consequently, the results of the study point to the safety of both in patients older than 55 years.
The authors conservatively concluded that, similar to what has been reported by other researchers who have studied the effect of SM on LBP, in this study SM appeared to confer a mild treatment effect advantage when compared to another therapy, this time in older adults.
Study Methods:
There were 3 groups of subjects in this study who received HVLA-SM, LVVA-SM or MCMC. Subjects were recruited via a number of avenues from the community surrounding Palmer College of Chiropractic and then randomized to the groups.
Patients were included in this study if they:
were at least 55 years old,
had experienced non-specific LBP for at least the previous 4 weeks,
met the Quebec Task Force on Spinal Disorders diagnostic criteria which included pain with or without radiation to the leg.
Patients were excluded if they had:
frank radiculopathy or neurological signs,
comorbid conditions or general poor health,
major clinical depression,
bone or joint pathology that contraindicated SM,
a pacemaker,
current or pending litigation related to the LBP,
disability for any health-related condition,
received SM within the past month,
been unwilling to postpone the use of manual therapies,
been unable to read or comprehend English.
The subjects were treated at the research clinic located at Palmer College by 4 chiropractors who each had at least 6 years of clinical practice experience. A board-certified medical neurologist with more than 10 years practice experience delivered the medical care.
The HVLA-SM that was utilized in this study was the typical side-lying diversified lumbar adjustment. The LVVA-SM was flexion-distraction or Cox technique. The chiropractors attempted to direct the adjustive force to a specific level of the spine, but it was not clear how the segment was selected. The treating clinicians were limited to the area between T12 and L5. Treatment was scheduled for a maximum of 12 visits, not to exceed 3 times per week for the first two weeks, 2 times per week for the third and fourth weeks, and once per week thereafter.
Subjects in the MCMC group were provided an initial consultation with the medical provider that was scheduled within 7 days of their random allocation to treatment. Visits were then scheduled at weeks 3 and 6 where they completed questionnaires and were evaluated by the medical provider.
All subjects were provided standardized exercise instructions at week 3 that they were to carry out at home.
The primary outcome measure was the 24-item RMD questionnaire. Other outcome measures included the Fear-Avoidance Beliefs Questionnaire (FABQ), a 100 mm horizontal Visual Analogue Scale, and the physical function subscale of the SF-36.
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