The Back Letter 1998: 13 (11): 123 © 1998 Lippincott Williams & Wilkins
A new study shows it is possible to teach primary care physicians how to perform spinal manipulation with a short course of training. Physicians can then use manual therapy techniques in an office setting. But do patients of these MDs experience a significant benefit from this strategy? The answer is no.
"The overall benefit of limited manual therapy in this study appeared to be small," said lead author Timothy Carey, MD. (See Carey et al., 1998.) He presented the new study at the Third International Forum for Primary Care Research on Low Back Pain in Manchester, England.
Carey et al. designed an intervention to test whether primary care doctors could be trained to perform limited manual therapy in their practices and determine whether its use, in concert with quality medical care, could improve the outcome of low back pain.
The research team trained 37 community- based internists and family physicians in basic spinal manipulation techniques "involving muscle energy therapy for the long restrictor muscles, lumbar and sacroiliac areas, plus instruction in high-velocity, low amplitude thrust for the lumbar spine and sacroiliac areas."
The training took place in two one-day sessions and a refresher session, adding up to a grand total of 18 hours of training. The course included personal supervision, frequent practice, skill-testing on simulated patients, and training on how to incorporate these maneuvers in a 20-minute office visit.
After the training was completed, Carey et al. performed a randomized trial to gauge its impact on patients. They randomly assigned 295 patients with back pain to "enhanced medical treatment" or to "enhanced medical treatment plus manual therapy."
The medical treatment included careful low back examination, functional assessment, screening as recommended in the AHCPR guideline, drug therapy, a graded exercise program, and patient educational handouts. The patients ranged in age from 21-65, had a normal neurologic examination, and suffered back pain of no greater than two months' duration.
Patients were randomized at the index visit and had up to four more visits, depending on their rate of recovery. Outcomes were measured several days after enrollment and at two, four, and eight weeks. Carey et al. assessed outcomes via the Roland disability scale, time to functional recovery, days off work, and a measure of patient satisfaction. The researchers obtained full outcome data on 94% of subjects.
"Both groups improved rapidly after randomization," said Carey. There were no statistically significant differences between groups at any outcome point. Patient satisfaction was similarly high in both groups.
However, some outcome trends favored the manual therapy group. For instance, the time to functional recovery was 9.6 days in the manual therapy plus medical care group vs. 11.1 in the medical care only group.
Subgroup analysis revealed an interesting pattern. "We did find that the intensity of manual therapy had an effect on outcome," said Carey. "We defined intensity as the number of manual therapy maneuvers at each visit. One hundred and six received low-intensity therapy (less than four maneuvers per visit) and 46 received high-intensity therapy (four or more maneuvers per visit)," Carey added. Comparing patients who received spinal manipulative therapy of four or more maneuvers per visit, the researchers found an improvement in days to functional recovery (8.2 vs. 15.2) and Roland disability scores (3.4 vs. 5.5).
This pattern could be interpreted in several different ways. Some would argue that the subjects in this trial might have been undertreated -- that the standard protocol didn't call for enough manipulative therapy. Others suggest that the additional benefit provided by high-intensity therapy could simply be a nonspecific "hands-on" or "attention" effect.
Overall, the results do not support training primary care physicians in manipulative techniques. "The incremental effect of adding manual therapy to an approach involving enthusiastic physicians, special evaluation and patient educational skills, standard medication therapies, and exercise prescription appears to be minimal," said Carey. More intense manual therapy might hold promise, but for now the evidence for training physicians in manual therapy remains to be established, said Carey.
Carey described an interesting by-product of the training in manual therapy. "Most of the physicians reported much greater communication with doctors of chiropractic and physical therapists, because they had a common language."
Also, some of these physicians had been studied before in the North Carolina Back Pain Project study. Interestingly, the patients they treated in the new study found the care of these physicians much more satisfying than they did in the previous study -- which took place before the training course in manual therapy.
Carey TS et al.,
Training primary care physicians to perform spinal manipulation:
Patient outcomes in a randomized trial, presented at the Third International Forum for Primary Care Research on Low Back Pain, Manchester, UK, 1998;
as yet unpublished.
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