Dc. Cherkin et al., A COMPARISON OF PHYSICAL THERAPY, CHIROPRACTIC MANIPULATION, AND PROVISION OF AN EDUCATIONAL BOOKLET FOR THE TREATMENT OF PATIENTS WITH LOW-BACK-PAIN, The New England journal of medicine, 339(15), 1998, pp. 1021-1029
Background and Methods There are few data on the relative effectivenes
s and costs of treatments for low back pain. We randomly assigned 321
adults with low back pain that persisted for seven days after a primar
y care visit to the McKenzie method of physical therapy, chiropractic
manipulation, or a minimal intervention (provision of an educational b
ooklet). Patients with sciatica were excluded. Physical therapy or chi
ropractic manipulation was provided for one month (the number of visit
s was determined by the practitioner but was limited to a maximum of n
ine); patients were followed for a total of two years. The bothersomen
ess of symptoms was measured on an 11-point scale, and the level of dy
sfunction was measured on the 24-point Roland Disability Scale. Result
s After adjustment for base-line differences, the chiropractic group h
ad less severe symptoms than the booklet group at four weeks (P=0.02),
and there was a trend toward less severe symptoms in the physical-the
rapy group (P=0.06). However, these differences were small and not sig
nificant after transformations of the data to adjust for their non-nor
mal distribution. Differences in the extent of dysfunction among the g
roups were small and approached significance only at one year, with gr
eater dysfunction in the booklet group than in the other two groups (P
=0.05). For all outcomes, there were no significant differences betwee
n the physical-therapy and chiropractic groups and no significant diff
erences among the groups in the numbers of days of reduced activity or
missed work or in recurrences of back pain. About 75 percent of the s
ubjects in the therapy groups rated their care as very good or excelle
nt, as compared with about 30 percent of the subjects in the booklet g
roup (P<0.001). Over a two year period, the mean costs of care were $4
37 for the physical-therapy group, $429 for the chiropractic group, an
d $153 for the booklet group. Conclusions For patients with low back p
ain, the McKenzie method of physical therapy and chiropractic manipula
tion had similar effects and costs, and patients receiving these treat
ments had only marginally better outcomes than those receiving the min
imal intervention of an educational booklet. Whether the limited benef
its of these treatments are worth the additional costs is open to ques
tion. (N Engl J Med 1998;339:1021-9.) (C) 1998, Massachusetts Medical
Society.