Acute Back Pain Treatment Rationale Should Be Clear



Acute Back Pain Treatment Rationale Should Be Clear

March 1996

Vert Mooney, MD, is professor of orthopedic surgery at the University of California, San Diego. He also serves as medical director of the clinical facility for the orthopedic faculty. This facility includes the Spine and Joint Conditioning Centers. He is currently president of the International Intradiscal Therapy Society.

The success rate in treating acute back pain is very difficult to establish because the percentage of spontaneous resolution is so high. Thus, the treatment that should be advocated is one which is definable in terms of rationale, projection of efficacy and cost effectiveness. An argument against manipulative care can be made on these three grounds.

The rationale for back care should be based on an understanding of the pathophysiology being treated. There is, however, no uniform opinion as to what is accomplished in manipulative care. The recent book chapter by Haldeman and Phillipps—certainly authorities in the field, describes four different theories as to what is being accomplished in manipulation backed up by 13 references. Without a clear rationale, this treatment becomes an art form based on experience and personal charisma.

Manipulative therapy, though not well understood, has been purported to be more successful than other treatments. The problem is scientific; manipulation has been compared to poorly described alternatives with inconsistent monitoring and patient compliance. A good example is the recent article by Meade et al. This compared chiropractic manipulation to hospital-based outpatient physical therapy in Britain. The type of physical therapy was largely passive, modality care with no monitoring as to patient interface and compliance. Indeed, what is chiropractic care in the community? A recent publication funded by the Ontario Ministry of Health advocated the cost effectiveness of chiropractic management of low back pain. However, it was difficult to identify what chiropractic treatment might entail. There were 12 different types of treatment used on patients more than 70% of the time. These, in addition to manipulations, included corrective exercises (96%), bracing (91%) and ice packs (93%). If chiropractic manipulation were so valuable, why use such a hodge podge of alternative treatments?

To my knowledge there has never been a published report of pure chiropractic compared to a well-described, consistent and definable method of care. Currently, there is a comparison between chiropractic and McKenzie physical therapy care in Seattle. This study reports equal efficacy and about equal costs at one month. McKenzie care is definable and measurable. Its efficacy can be predicted after a few visits. From my view it is the most reproducible method of back care.

Although this randomized prospective blinded study documented equal efficacy of chiropractic with another treatment program, it cannot be advocated if the other treatment program is more economically viable. It is for this reason, I believe the other treatment program should be one which is definable, teachable, testable and can document whether efficacy is to be expected in a few sessions. Moreover, the method of treatment should be one that requires less use of future health care resources. A method of treatment that always requires the assistance of a health care provider cannot be advocated when the alternative is one that does not and thus potentially is less costly. The McKenzie method teaches self care and prophylactic postural control. To be the favored treatment, chiropractic manipulation must be significantly better in both short term and long term outcomes than all other practitioner-directed treatments, of which self care is not.

For more information:


OPPOSING VIEW: Spinal Manipulation: How Did It Get So Accepted?
   by Scott Haldeman, MD, PhD


INTRODUCTION: Spinal Manipulation for Low Back Pain:
Charlatan, Chicanery or Scientifically-tested Treatment?


Copyright 1996, SLACK Incorporated. Revised 14 March 1996.