Program of Care Derived from Pain Data Reported in RCTs on Low Back Pain
John K Maltby, DC, Donald D. Harrison, Ph.D, DC, MSE, Deed Harrison, DC Joseph Betz BS, DC, Joseph R. Ferrantelli BS, DC Gerard W. Clum, DC
Journal of Vertebral Subluxation Research ~ February 14, 2009 ~ Pages 1-16
Background: Many US insurance companies, managed care organizations, chiropractic researchers, and chiropractic academics claim that, if low back pain resolves with Spinal Manipulative Therapy (SMT), it does so in 6 to 12 visits.
Objective: To determine the validity of claims that low back pain should resolve in 6 to 12 visits with Spinal Manipulative Therapy and to derive a Program of Care based on RCT pain data.
Methods: Searches were performed in PubMed, CINAHL, Mantis, and the Index of Chiropractic Literature (ICL) for Randomized Clinical Trials (RCTs) on low back pain for which the treatment was SMT and/or Mobilization. From these low back pain RCTs, data on the number of subjects, number of visits, and pain outcomes of VAS (visual analogue scale) or NRS (numerical rating scale) were analyzed.
Results: Seventy-four RCTs with SMT as the treatment for low back pain were located. Nine of these were follow-up studies, which resulted in 65 RCTs to be analyzed. Studies with less than 10 subjects were not included. The total NRS data indicated only a 43% (77.51/176.54) improvement in 8.4 average visits. Using a constant linear extrapolation of dose response in studies with chiropractors as the treating doctors, an average of 20.5 visits was needed to resolve low back pain with SMT. Using an initial examination visit, linearly extrapolated visits, once per week stabilization care for 4 weeks, and 2 follow-up examination visits, provides 28 visits needed to document and resolve the average low back pain case.
Conclusion: Data from RCTs did not support claims of restricting Chiropractic care to 6-12 visits for low back pain. In fact, assuming a constant linear dosage response curve, in studies with chiropractors as the treating doctors it was estimated that 28 visits were needed to document, resolve, and stabilize this condition.
Key Words: Low Back Pain, Spinal Manipulation, Spinal Manipulative Therapy, Randomized Clinical Trials, Chiropractic, Frequency and Duration