Chiropractic, Exercise Back Pain

Previous studies have shown that chiropractic can be an effective treatment for some patients with low back pain. This new study looked at patients with chronic back pain, with the aim of determining which subgroups of patients find chiropractic beneficial.

For the study, the authors recruited patients from a Chicago suburb; a total of 225 patients met the study requirements. The patients were then randomly assigned to the flexion/distraction (FD) group (123 patients), or the active trunk exercise protocol (ATEP) group (112 patients).

To be included in the study, the subjects had to have pain between L1 and S1 that had lasted at least 3 months.

The authors describe the treatment the subjects received during the study:

“The FD technique was performed on a specially constructed table with a moveable headpiece, a stationary thoraco-lumbar piece, and a moveable lower extremity piece. With the subject lying prone, the clinician placed one hand over the lumbar region at the level of interest and used the other hand to flex, laterally flex, and/or rotate the lower extremity section of the table. FD consisted of two biomechanical components. The first component was a series of traction procedures using the flexion range of motion directed at a specified joint level. The motion from the traction procedure resulted in opening of the posterior joint space and a consequent reduction in intradiscal pressure. The second component was a series of mobilization procedures using a possible combination of ranges of motion targeted again at a specific joint level. Most patients moved from the traction component to the mobilization component within 4 weeks of care.”

“ATEP was administered by licensed physical therapists and consisted of flexion or extension exercises, weight training, flexibility exercises, and cardiovascular exercises dependent on patient symptoms. The aim of the program was to strengthen the muscles surrounding the spine and increase flexibility. Methods used to develop stabilizing exercises were consistent with those of O’Sullivan and colleagues. The therapists in the study met as a group to choose the specific exercise regime for study purposes and met monthly to reinforce treatment consistency. Biomechanically, the ATEP did not concentrate on a specific joint level but sought to impact the lumbar spine as a whole.”

After the course of treatment, the authors examined the data to see how each group fared. They found the following:

• Both sets of patients experienced improvement of their pain and symptoms.
• Subjects in the chiropractic group “had significantly greater relief of pain than those allocated to the exercise program.”
• Patients who had chronic pain categorized “with moderate to severe symptoms, improved most with the flexion-distraction protocol.”
• Patients with recurrent pain and moderate to severe symptoms fared best with ATEP.
• The chiropractic treatment was more effective for patients with radiculopathy.
• “Overall, flexion-distraction provided more pain relief than active exercise…”
• Chiropractic patients were more likely to finish the treatment protocol: 13 patients dropped out from the chiropractic group, while 25 dropped out from the ATEP group.

This study shows that low back pain patients cannot be simply lumped into one group and all treated in the same manner:

“The differences in treatment results according to subgroup analyses make biological sense. The FD intervention was intended to provide motion and forces directed at specific intervertebral level. The ATEP on the other hand was intended to concentrate more on strengthening the muscles surrounding the spine and increasing flexibility. As such, a greater decrease in VAS among patients with radiculopathy should be expected for the FD group where changes in disc pressure may be most important.”

These findings can be helpful to clinicians who are trying to determine the best treatment choice for patients.

Gudavalli MR, Cambron JA, McGregor M, et al. A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. European Spine Journal.