This week from Dr. Cerami and Utah Sports and Wellness
From: PAIN, March 2018
While there has been a long-standing belief that low back pain (LBP) is limited to adults, there is now substantial evidence to the contrary. In fact, research has shown that LBP develops with increasing frequency in adolescence, with prevalence rates reaching that of adults by the late teens. 20-40% of U.S. adolescent LBP sufferers receive an opioid prescription when they seek medical care. This study was conducted using 185 adolescents aged 12-18 years with chronic LBP, comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to exercise therapy alone. The exercise therapy consisted of 8-16, 45 minute sessions with an exercise therapist as well as at home exercises. The spinal manipulation consisted of 8-16 visits, no more than twice a week. The longitudinal omnibus test for pain showed SMT + ET to be significantly superior to ET over a one year period while the SMT + ET group also experienced significantly greater changes in the long term profile of pain severity. Both SMT + ET and ET alone groups reported approximately 80% reduction in medication use at the end of treatment which was sustained during the entire follow up period.
Low back pain (LBP) is common in adolescence, but there is a paucity of high-quality research to inform care. We conducted a multicenter randomized trial comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to ET alone. Participants were 185 adolescents aged 12 to 18 years with chronic LBP. The primary outcome was LBP severity at 12, 26, and 52 weeks. Secondary outcomes included disability, quality of life, medication use, patient- and caregiver-rated improvement, and satisfaction. Outcomes were analyzed using longitudinal linear mixed effect models. An omnibus test assessing differences in individual outcomes over the entire year controlled for multiplicity. Of the 185 enrolled patients, 179 (97%) provided data at 12 weeks and 174 (94%) at 26 and 52 weeks. Adding SMT to ET resulted in a larger reduction in LBP severity over the course of 1 year (P = 0.007). The group difference in LBP severity (0-10 scale) was small at the end of treatment (mean difference = 0.5; P = 0.08) but was larger at weeks 26 (mean difference = 1.1; P = 0.001) and 52 (mean difference = 0.8; P = 0.009). At 26 weeks, SMT with ET performed better than ET alone for disability (P = 0.04) and improvement (P = 0.02). The SMT with ET group reported significantly greater satisfaction with care at all time points (P ≤ 0.02). There were no serious treatment-related adverse events. For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months. These findings warrant replication and evaluation of cost effectiveness.
These authors also note:
- “The United States is in the midst of an unprecedented pain management crisis, with chronic pain impacting over one-third of the US population, and affecting more individuals than heart disease, diabetes, and cancer combined.”
- “LBP is one of the most common and burdensome of the pain conditions with an estimated 40-80% of individuals worldwide experiencing LBP at some point in their lives.”
- LBP related disability has increased an alarming 42% over the past two decades, making it the leading cause of disability globally.”
- “While there has been a long-standing belief that LBP is limited to adults, there is now substantial evidence to the contrary. In fact, research has shown that LBP develops with increasing frequency in adolescence, with prevalence rates reaching that of adults by the late teens.”
- Low back pain (LBP) is common in adolescence.
- “There is a heightened urgency to identify safe and effective nonpharmacological LBP treatments for all ages.”
- “Spinal manipulative therapy (SMT) is the most common provider based complementary [drug free] approach and is often used to treat LBP complaints.”
- “SMT consists of manual techniques including high velocity, low amplitude thrust procedures or low velocity, variable amplitude mobilization maneuvers.”
- “For LBP, SMT is applied to the lumbar vertebral or sacroiliac joints with the aim of restoring mobility and decreasing pain.”
- “Recent guidelines for LBP in adults strongly recommended SMT as well as exercise prior to initiating pharmacologic treatment.”
- “The most commonly reported adverse events were unusual or increased soreness (51-54%) and different type of pain (31-34%).”
- “Side effects were similar in both groups, mild and self-limiting.”
- “There were no serious treatment-related adverse events.”
- The underlying mechanisms of action targeted by SMT and ET appear to be complementary.
- “For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a one-year period, with the largest differences occurring at six months.”
- “With sufficient power and use of standard recommended outcome measures, our study demonstrated that SMT with exercise provides potentially worthwhile long-term benefits for adolescents with LBP that is chronic in nature.”
- “Overall a supervised exercise program with the addition of spinal manipulation appears to be a promising treatment approach for chronic LBP in adolescents.”
- “Given the current limited evidence base to support management of LBP in adolescents, this has important implications for providers who use spinal manipulation and exercise in practice such as chiropractors, physical therapists and osteopaths, and other providers who refer to them.”