It’s no secret that low back pain is a significant contributor to the burden of disease worldwide, or that the condition has a significant impact on quality of life. While large sections of the developed world grapple with the issue of prescription drug dependency, its a good time to talk about spinal manipulation compares with prescription drug therapy when it comes to quality of life, or satisfaction with care. This topic is what a recent paper examined, specifically in older Medicare beneficiaries and it turned up some interesting findings.
Currently it is estimated that about 19% of people over the age of 65 have experienced low back pain over a 3-month period. Currently, both spinal manipulative therapy (administered by chiropractors and other manual therapists) and prescription drug therapy are both treatment strategies supported by evidence and used under Medicare. Additionally, both are widely used for the short-term treatment of the chronic form of low back pain.
In terms of pharmaceutical interventions, opioid analgesics are typically prescribed although they generally perform poorly with regard to patient satisfaction and health-related quality of life. Interestingly, research has indicated that patients receiving various treatments for chronic low back pain (cLBP) have reported higher satisfaction with chiropractic care than with medical care, but for long-term supportive care of cLBP the benefits of continuing these therapies are uncertain.
Currently the relationship between treatment beliefs and patient experience, such as adherence and satisfaction with treatment of cLBP are unknown. Research continues to examine the role beliefs may play a role in treatment selection and outcomes, and thus the present study is significant when it comes to growing our understanding of how chiropractic stacks up against pharmaceuticals long term.
The Current Study
A survey was conducted among older (65-84) Medicare beneficiaries with chronic low back pain (pain lasting 3 months or longer). Over 28,000 Medicare beneficiaries met the inclusion criteria and were further sorted into 4 groups:
- Primary cohort (Spinal Manipulative Therapy): This group began long term management with spinal manipulative therapy but no prescribed drugs.
- Primary cohort (Prescription Drug Therapy): This group began long term management with prescription drug therapy but no spinal manipulation.
- Crossover cohort (Spinal Manipulative Therapy): This group comprised any occurrence of spinal manipulative therapy for cLBP, followed by initiation of long-term management with prescription drug therapy in the same year.
- Crossover cohort (Prescription Drug Therapy): This ground comprised any occurrence of prescription drug therapy for cLBP followed by initiation of long-term management with spinal manipulative therapy in the same year.
1986 surveys were sent out and a total of 195 participants completed the survey. The respondents were predominantly female and white, with a mean age of approx. 77-78 years.
Outcome measures for both treatment types were captured on a scale of 0-10, with 10 being very satisfied. Participant beliefs about the types of treatment they received were captured on a likert scale which examined the following beliefs on a scale of strongly agree to strongly disagree. “I think spinal manipulation is pretty useless for people with back pain” and “I believe prescription drug therapy is pretty useless for people with back pain.” The participants also undertook a modified version of the 12-item short form health survey (SF-12) was used. It is a validated health related quality of life survey and is designed to be able to measure physical and mental health.
When the results were collated, the following was found:
- 84% of the primary spinal manipulative therapy (SMT) cohort reported being very satisfied with SMT while only 50% of the primary prescription drug therapy (PDT) cohort reported being very satisfied with PDT. This difference was found to be statistically significant.
- There were no significant differences between the two crossover cohorts in terms of reported rates of satisfaction with PDT, but there was a significant difference for reported rates of satisfaction with SMT.
- 60% of the SMT crossover cohort reported being very satisfied with SMT.
- 80% of PDT crossover cohort reported being very satisfied with SMT.
- 25% and 15% of the SMT and PDT crossover cohorts said they were very satisfied with PDT. Again, this represents a significant difference in favour of spinal manipulative therapy.
Other findings that are worth noting includes the fact that there were differences between the two primary cohorts for agreement with the first item “spinal manipulation for LBP makes a lot of sense” with 96% for the SMT group and 35% for the PDT group agreeing with the statement. Compare this with the other statement, “taking /having prescription drug therapy for LBP makes a lot of sense” and we see that only 13% of the SMT cohort agreed with, 95% of the PDT cohort agreed. This indicates a strong bias towards the type of therapy that each person had chosen. Unsurprising though this may be, it does prove interesting when compared with the results shown above.
The crossover cohorts did not seem to differ significantly, with large proportions of each group disagreeing with statements “I think spinal manipulation is pretty useless for people with low back pain.”
When we begin to examine the findings for health-related quality of life, there are also some notable results. There were significant differences between groups were observed for both the SF-12 and physical and mental health scores, with significantly higher mean scores for the SMT cohort than the PDT cohort. Participants who received SMT had higher self-reported physical and mental health on average than those who received PDT.
Overall the results support the hypothesis that among older Medicare beneficiaries with cLBP, long-term recipients of SMT have higher self-reported rates of satisfaction with care received than do long-term recipients of PDT. While further research is required to nail down the exact cause for these differences, the study did raise the possibility that the hands on nature of SMT may be a factor, as well as the patient-practitioner relationship. The results suggest that people who have experienced long-term management of care are more likely to have positive attitudes and beliefs toward that mode of care.
Based on this study, it seems further research is required but that SMT stacks up strongly against PDT based treatment. Furthermore, understanding the treatment beliefs of patients with low back pain will help develop evidence-based recommended interventions and thus may improve treatment effectiveness and patient outcomes. This is important as beliefs about treatment for cLBP may affect treatment selection, adherence, and satisfaction with care.
There is more work to be done, as any study has limitations. But it is encouraging to know that spinal manipulative therapy is better regarded in the older population that we often give ourselves credit for.
- Kizhakkeveettil A. et al. Spinal manipulation vs prescription drug therapy for chronic low back pain: beliefs, satisfaction with care, and quality of life among older Medicare beneficiaries. Journal of Manipulative and Physiological Therapeutics. 2022. 00(00)