Outcomes/Effectiveness Research

Training primary care physicians in manual therapy gives them another way to treat back pain patients, but benefits are modest

Controversy continues about the benefit of spinal manual therapy (a sequence of maneuvers that adjust and stretch joints and soft tissues) in the care of low back pain. Continuing medical education in manual therapy is increasingly offered to primary care physicians (PCPs) to give them an additional strategy to improve back pain care.

Apparently, limited training in manual therapy offers only modest benefit compared with high-quality conventional care for acute low back pain. However, in an exploratory analysis, patients who received more intense manual therapy (four or more maneuvers) from their PCPs recovered normal functioning more quickly than those who received less intense therapy, according to a study supported by the Agency for Healthcare Research and Quality (HS08293).

Researchers led by Timothy S. Carey, M.D., M.P.H., of the University of North Carolina, examined the outcomes of 295 patients with acute low back pain receiving care from 31 generalist physicians randomized to either optimal low back care (enhanced care) or enhanced care and a sequence of eight standard manual therapy techniques. Patients were interviewed by phone at 1, 2, 4, and 8 weeks after their initial back pain visit. More patients receiving manual therapy had completely recovered after the first visit compared with the control group (14 vs. 6 percent). However, 2 and 4 weeks later, the proportion of fully recovered patients was nearly identical for the two groups.

During the 8-week followup period, there were no differences in levels of pain, days absent from work, and overall patient satisfaction between the two groups, after controlling for other factors such as functional status at the initial visit, duration of pain prior to randomization, and differences in drug therapy. However, there was some evidence that intensity of manual therapy may affect outcome. Mean time to functional recovery was 11.1 days for patients receiving only enhanced care, 10.4 days for the low-intensity, and 7.8 days for the high-intensity manual therapy groups. Despite some concerns about using manual therapy in practice, physicians were very positive that its use had improved patient care.

See "Training primary care physicians to give limited manual therapy for low back pain," by Peter Curtis, M.D., Dr. Carey, Paul Evans, D.O., and others, in Spine 25(22), pp. 2954-2961, 2000.

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