A Randomized Controlled Trial Comparing 2 Types of Spinal Manipulation and Minimal Conservative Medical Care for Adults 55 Years and Older With Subacute or Chronic Low Back Pain



      Chiropractic care is used by many older patients for low back pain (LBP), but there are no published results of randomized trials examining spinal manipulation (SM) for older adults. The purpose of this study was to compare the effects of 2 biomechanically distinct forms of SM and minimal conservative medical care (MCMC) for participants at least 55 years old with subacute or chronic nonradicular LBP.


      Randomized controlled trial. The primary outcome variable was low back-related disability assessed with the 24-item Roland Morris Disability questionnaire at 3, 6, 12, and 24 weeks. Participants were randomly allocated to 6 weeks of care including 12 visits of either high-velocity, low-amplitude (HVLA)-SM, low-velocity, variable-amplitude (LVVA)-SM, or 3 visits of MCMC.


      Two hundred forty participants (105 women and 135 men) ages 63.1 ± 6.7 years without significant comorbidities. Adjusted mean Roland Morris Disability change scores (95% confidence intervals) from baseline to the end of active care were 2.9 (2.2, 3.6) and 2.7 (2.0, 3.3) in the LVVA-SM and HVLA-SM groups, respectively, and 1.6 (0.5, 2.8) in the MCMC group. There were no significant differences between LVVA-SM and HVLA-SM at any of the end points. The LVVA-SM group had significant improvements in mean functional status ranging from 1.3 to 2.2 points over the MCMC group. There were no serious adverse events associated with any of the interventions.


      Biomechanically distinct forms of SM did not lead to different outcomes in older LBP patients and both SM procedures were associated with small yet clinically important changes in functional status by the end of treatment for this relatively healthy older population. Participants who received either form of SM had improvements on average in functional status ranging from 1 to 2.2 over those who received MCMC. From an evidence-based care perspective, patient preference and clinical experience should drive how clinicians and patients make the SM procedure decision for this patient population.

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        • Martin BI
        • Deyo RA
        • Mirza SK
        • et al.
        Expenditures and health status among adults with back and neck problems.
        JAMA. 2008; 299: 656-664
        • Koes BW
        • van Tulder MW
        • Ostelo R
        • et al.
        Clinical guidelines for the management of low back pain in primary care: an international comparison.
        Spine. 2001; 26: 2504-2513
        • Burton AK
        • Waddell G
        Clinical guidelines in the management of low back pain.
        Baillieres Clin Rheumatol. 1998; 12: 17-35
        • Bigos S
        • Bowyer O
        • Braen G
        • et al.
        Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Rockville (MD)1994 (December)
        • Klaber Moffett JA
        • Newbronner E
        • Waddell G
        • et al.
        Public perceptions about low back pain and its management: a gap between expectations and reality?.
        Health Expect. 2000; 3: 161-168
        • Hurwitz EL
        • Morgenstern H
        • Kominski GF
        • et al.
        A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study.
        Spine. 2006; 31: 611-621
        • Walker BF
        The prevalence of low back pain: a systematic review of the literature from 1966 to 1998.
        J Spinal Disord. 2000; 13: 205-217
        • Cypress BK
        Characteristics of physician visits for back symptoms: a national perspective.
        Am J Public Health. 1983; 73: 389-395
        • Frymoyer JW
        • Cats-Baril WL
        An overview of the incidences and costs of low back pain.
        Orthop Clin North Am. 1991; 22: 263-271
        • Hart LG
        • Deyo RA
        • Cherkin DC.
        Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey.
        Spine. 1995; 20: 11-19
        • Reid MC
        • Guo Z
        • Towle VR
        • et al.
        Pain-related disability among older male veterans receiving primary care.
        J Gerontol A Biol Sci Med Sci. 2002; 57: M727-M732
        • Vogt MT
        • Lauerman WC
        • Chirumbole M
        • et al.
        A community-based study of postmenopausal white women with back and leg pain: health status and limitations in physical activity.
        J Gerontol A Biol Sci Med Sci. 2002; 57: M544-M550
        • Leveille SG
        • Guralnik JM
        • Hochberg M
        • et al.
        Low back pain and disability in older women: independent association with difficulty but not inability to perform daily activities.
        J Gerontol A Biol Sci Med Sci. 1999; 54: M487-M493
      1. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons.
        J Am Geriatr Soc. 1998; 46: 635-651
        • Wolsko PM
        • Eisenberg DM
        • Davis RB
        • et al.
        Patterns and perceptions of care for treatment of back and neck pain: results of a national survey.
        Spine. 2003; 28: 292-297
        • Gleberzon BJ
        Chiropractic care of the older person: developing an evidence-based approach.
        J Can Chiropr Assoc. 2001; 45: 156-171
        • Bronfort G
        • Haas M
        • Evans R
        • et al.
        Evidence-informed management of chronic low back pain with spinal manipulation and mobilization.
        Spine J. 2008; 8: 213-225
        • Christensen MG
        • Kollasch MW
        • Ward R
        • et al.
        Job analysis of chiropractic 2005: a project report, survey analysis, and summary of the practice of chiropractic within the United States.
        National Board of Chiropractic Examiners, Greeley (Colo)2005
        • Gudavalli MR
        • Rowell RM.
        Three-dimensional quantification of multi-point contact loads during lumbar spinal manipulation.
        in: International Mechanical Engineering Congress and Exposition (Bioengineering Subdivision). Anaheim, CA 13 Nov2004
        • Gudavalli MR
        • Cox J.
        Forces of expert and novice practitioners during flexion-distraction chiropractic treatment.
        in: International Association of Science and Technology (IASTED) Biomechanics Conference; Honolulu, HI2004
        • Hondras MA
        • Long CR
        • Haan AG
        • et al.
        Recruitment and enrollment for the simultaneous conduct of 2 randomized controlled trials for patients with subacute and chronic low back pain at a CAM research center.
        J Altern Complement Med. 2008; 14: 983-992
        • Spitzer WO
        • LeBlanc FE
        • Dupuis M.
        Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders.
        Spine. 1987; 12: S1-S59
        • Beck AT
        • Steer RA
        • Brown GK.
        Manual for the Beck Depression Inventory-Second Edition.
        The Psychological Corporation, San Antonio (Tex)1996
        • Bergmann TF
        Manual force, mechanically assisted articular chiropractic technique using long and/or short level contacts.
        J Manipulative Physiol Ther. 1993; 16: 33-36
        • Beck AT
        • Guth D
        • Steer RA
        • et al.
        Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for primary care.
        Behav Res Ther. 1997; 35: 785-791
        • Beck AT
        • Steer RA
        • Garbin MG.
        Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation.
        Clin Psychol Rev. 1988; 8: 77-100
        • Steer RA
        • Cavalieri TA
        • Leonard DM
        • et al.
        Use of the Beck Depression Inventory for Primary Care to screen for major depression disorders.
        Gen Hosp Psychiatry. 1999; 21: 106-111
        • Scheinthal SM
        • Steer RA
        • Giffin L
        • et al.
        Evaluating geriatric medical outpatients with the Beck Depression Inventory-Fastscreen for medical patients.
        Aging Ment Health. 2001; 5: 143-148
        • Steer RA
        • Rissmiller DJ
        • Beck AT
        Use of the Beck Depression Inventory-II with depressed geriatric inpatients.
        Behav Res Ther. 2000; 38: 311-318
        • Steer RA
        • Brown GK
        • Beck AT
        • et al.
        Mean Beck Depression Inventory-II scores by severity of major depressive episode.
        Psychol Rep. 2001; 88: 1075-1076
        • Ware JE
        • Sherbourne CD
        The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
        Med Care. 1992; 30: 473-483
        • McHorney CA
        • Ware JE
        • Raczek AE
        The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.
        Med Care. 1993; 31: 247-263
        • Roland M
        • Morris R
        A study of the natural history of low-back pain. Part II: development of guidelines for trials of treatment in primary care.
        Spine. 1983; 8: 145-150
        • Roland M
        • Morris R
        A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain.
        Spine. 1983; 8: 141-144
        • Deyo RA
        • Centor RM
        Assessing the responsiveness of functional scales to clinical change: an analogy to diagnostic test performance.
        J Chronic Dis. 1986; 39: 897-906
        • Roland M
        • Fairbank J
        The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire.
        Spine. 2000; 25: 3115-3124
        • Pope MH
        • Phillips RB
        • Haugh LD
        • et al.
        A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain.
        Spine. 1994; 19: 2571-2577
        • Stratford P
        • Gill C
        • Westaway M
        • et al.
        Assessing disability and change on individual patients: a report of a patient specific measure.
        Physiother Canada. 1995; 47: 258-263
        • Stratford PW
        • Binkley JM
        • Riddle DL
        • et al.
        Sensitivity to change of the Roland-Morris Back Pain Questionnaire: part 1.
        Phys Ther. 1998; 78: 1186-1196
        • Stratford PW
        • Binkley J
        • Solomon P
        • et al.
        Defining the minimum level of detectable change for the Roland-Morris questionnaire.
        Phys Ther. 1996; 76: 359-365
        • Waddell G
        • Newton M
        • Henderson I
        • et al.
        A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.
        Pain. 1993; 52: 157-168
        • Woby SR
        • Watson PJ
        • Roach NK
        • et al.
        Adjustment to chronic low back pain–the relative influence of fear-avoidance beliefs, catastrophizing, and appraisals of control.
        Behav Res Ther. 2004; 42: 761-774
        • Burton AK
        • Waddell G
        • Tillotson KM
        • et al.
        Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care.
        Spine. 1999; 24: 2484-2491
        • Jacob T
        • Baras M
        • Zeev A
        • et al.
        Low back pain: reliability of a set of pain measurement tools.
        Arch Phys Med Rehabil. 2001; 82: 735-742
        • Wewers ME
        • Lowe NK
        A critical review of visual analogue scales in the measurement of clinical phenomena.
        Res Nurs Health. 1990; 13: 227-236
        • Mantha S
        • Thisted R
        • Foss J
        • et al.
        A proposal to use confidence intervals for visual analog scale data for pain measurement to determine clinical significance.
        Anesth Analg. 1993; 77: 1041-1047
        • Miller MD
        • Ferris DG
        Measurement of subjective phenomena in primary care research: the Visual Analogue Scale.
        Fam Pract Res J. 1993; 13: 15-24
        • Patrick DL
        • Deyo RA
        • Atlas SJ
        • et al.
        Assessing health-related quality of life in patients with sciatica.
        Spine. 1995; 20: 1899-1908
        • Beaton DE
        Understanding the relevance of measured change through studies of responsiveness.
        Spine. 2000; 25: 3192-3199
        • Ostelo RW
        • Deyo RA
        • Stratford P
        • et al.
        Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change.
        Spine. 2008; 33: 90-94
        • Chou R
        • Huffman LH
        Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.
        Ann Intern Med. 2007; 147: 505-514
        • Haldeman S
        • Dagenais S
        A supermarket approach to the evidence-informed management of chronic low back pain.
        Spine J. 2008; 8: 1-7
        • Haldeman S
        • Dagenais S
        What have we learned about the evidence-informed management of chronic low back pain?.
        Spine J. 2008; 8: 266-277