Editor's Note: The following is a commentary by DC columnist Dr. James Lehman on the study discussed in this month's staff article, "Are PTs and DOs Lousy at Spinal Manipulation?".
Dear Editor:
I found your comments regarding a new JAMA article, "Effect of Spinal Manipulative and Mobilization Therapies in Young Adults with Mild to Moderate Chronic Low Back Pain: A Randomized Clinical Trial,"1 to be of interest and felt compelled to share my opinions of the paper.
Possibly, the providers of the spinal manipulation and spinal mobilization were competent and experienced with the application of these manual medicine interventions. Since chiropractic physicians provide the vast majority of spinal manipulation for low back pain, I agree that they would be more competent than the osteopaths and therapists. Yet, the reason I claim the study is simplistic and non-specific has nothing to do with the quality of the interventions, but everything to do with the diagnoses.
"Most spinal manipulations are done by chiropractors (chiropractic treatment often involves spinal manipulation), although other licensed professionals including osteopathic physicians and physical therapists also do spinal manipulations."2
The diagnoses of mild or moderate chronic low back pain do not indicate the need for either spinal manipulation or spinal mobilization. Chiropractic physicians are charged with making a specific, neuromusculoskeletal diagnosis that would indicate the need for spinal manipulation and/or spinal mobilization. Through the use of physical examination, the chiropractic physician must reproduce the patient's pain with any combination of procedures that compress, contract, or stretch the pain-generating tissues.
This study determined the vertebral segment in need of treatment with the use of only decreased range of motion at one segment or more and/or reduced hip range of motion, without determining the specific pain-generating tissues. The protocol to determine the need for spinal manipulation or spinal mobilization was simplistic and non-specific.
First, how was reduced range of motion of one vertebral segment determined? Without the use of motion imaging to determine reduced range of motion of one vertebral segment is a fallacy. As we know the use of motion palpation to determine reduced vertebral segment range of motion is not reliable.
"Regardless of the degree of standardization, interrater reliability of motion palpation of the thoracic spine for identifying pain and motion restriction performed by experienced examiners was poor and often not better than chance. These findings question the continued use of motion palpation as part of the clinical assessment as an isolated tool to detect loss of intersegmental joint play."3
Second, the diagnoses of mild or moderate chronic low back pain do not indicate the need for spinal manipulation or spinal mobilization. The cause of the pain may have nothing to do with vertebral segment range of motion. If the patient is experiencing a chronic pain syndrome, the pain should have centralized in the central nervous system. Hence, this patient may actually require behavioral health care, medications, exercise and the use of chiropractic medicine.
Next, I question why the investigators did not use the definition of chronic pain offered by the National Pain Strategy:
"Chronic pain is pain that occurs on at least half the days for six months or more."4
Finally, as a chiropractic specialist who focuses care on chronic pain patients within a Federally Qualified Health Center, I do not recall patients with chronic low back pain presenting on their initial visit with a pain scale of 2/10, 3/10 or even 4/10. Patients with chronic low back pain seeking chiropractic care requiring spinal manipulation and/or spinal mobilization initially present with a pain rating of 5/10 or higher.
This study offers a simplistic diagnosis that does not indicate the need for manual medicine interventions. Hence, in my opinion, this study does nothing to indicate the validity for the use of spinal manipulation or spinal mobilization for patient suffering with chronic low back pain.
References
- Thomas JS, et al. Effect of spinal manipulative and mobilization therapies in young adults with mild to moderate chronic low back pain: a randomized clinical trial. JAMA Open Network, Aug. 5, 2020.
- National Center for Complementary and Integrative Health. Spinal Manipulation: What You Need to Know.
- Walker BF, et al. Interrater reliability of motion palpation in the thoracic spine. Evid Based Complement Alternat Med. 2015 Jun 11: 815407.
- NIH Interagency Pain Research Coordinating Committee. National Pain Strategy: A Comprehensive Population Health Level Strategy for Pain.