Hello and welcome back to the blog. I thought the subject this round might examine a topic that I covered briefly in a previous post. Though it is re-examination of a previous topic, I feel the subject matter is very important.
In addition, I recently discovered an interesting article that further accentuates these points while surfing PubMed the other night.
Who has two thumbs and likes to spend his Saturday evenings rifling through the National Library of Medicine’s research database….
Annnyyway….today I’d like to discuss the subject of pain relief as it pertains to the medication vs. manipulation argument.
Are the two similarly effective? What side effects are presented with both? Is there a difference in outcomes in patients who seek treatment for pain with medication vs. those who seek care with manipulation?
Today I will be referencing research from Pain Journal, Cochrane Database, European Journal of Pain, American Family Physician, JMPT, Spine, and a systemic review of over 200 other articles funded by the Dept. of Health and Human Services. This may seem like a bit of overkill but I believe it is important to highlight that this subject has been thoroughly researched by multiple entities, all with similar conclusions:
- SMT (spinal manipulative therapy) is an effective and safe treatment for neck and low back pain (6).
- NSAIDs/Muscle Relaxants/Anticonvulsants/Opioids are largely ineffective in the treatment of neck and low back pain and are frequently associated with increased risks of adverse events or side effects (1-5).
So what are we talking about here? Certainly I have had situations where an ache or pain has been alleviated by a trip to the medicine cabinet.
Similarly, I have had patients who have managed their pain before and during treatment with NSAIDs with some success. Ibuprofen is often one of my recommendations to those acute patients who are suffering early on in a treatment protocol.
NSAIDs remain the de facto treatment option for people with back pain, with over 30 billion doses taken each year alone. But why do we do this?
First and foremost, it is easy. Taking a pill for something is the lowest bar of effort a patient must undertake. Let’s face it, in terms of healthcare nothing is more easy or convenient.
I also think it is in part because that is what we have always been told. Whether it was mom, a school nurse, athletic trainer or your primary care physician…
“Have you tried some Tylenol?” almost certainly leads off the conversation.
It has become the common sense answer and engrained long enough in our heads it’s become associated with a cure-all for pain and not the bandage it actually is.
But how can I classify it as a bandage if I get relief when I take it? Whats the difference?
Well, the difference here is that the data examines the use of these drugs and others like them in the context of recovery. In other words, do they lead to resolution of injury and a return to normal for the patient.
The short answer is no.
Like the misconception that back pain is self limiting, the myth that medication is the solution to pain rather than a temporary reprieve is still a battle I have to fight every week.
Thankfully, each year I’m given more ammunition in that fight by way of clinical research.
As the infographic below explains, when we examine the data it becomes clear that our best alternative to masking our symptoms with medication involves conservative therapies like SMT and PT (1-5):
As the image above indicated, these medications are largely ineffective and sometimes even dangerous. Adverse and unattended effects often accompany these types of treatment with little benefit.
Unfortunately, manipulation vs. medication is rarely studied in direct comparison to one another. That is until a few years ago:
SPINE published a randomized, double-blinded, placebo-controlled, parallel trial to compare spinal manipulation against NSAIDs for low back pain. In this landmark study, the group that received spinal manipulation showed both statistical and clinically relevant benefits compared to NSAIDs (7):
“This is the first time that spinal manipulation was investigated in a double-blinded randomized controlled design showing clear superiority compared with placebo and NSAID use.”
“HVLA manipulation can be recommended for the therapy for acute nonspecific low back pain.”
“Final evaluation showed manipulation being significantly better than NSAID and clinically superior to placebo.”
Not only is this significant in its set up as a direct comparison, but this study was significant in its format. A double blinded, placebo controlled study is the sort of clinical research that is considered to be the gold standard. Unless you had some science/statistics in your background you may be wondering what the hell those words mean.
Essentially, this means both those administering care and the patients with whom they treat were blinded to the intervention they were providing and receiving respectively. It is considered the gold standard because it prevents bias from occurring in either group, ensuring the results are statistically more significant.
So what did the researchers find?
As you have likely guessed at this point, manipulation outperformed NSAIDs and placebo in reported pain levels. While improvements were comparable (slight edge to manipulation) up to week 4, it was long term relief – weeks 4 to 9 – where manipulation really outperformed NSAIDs.
Now who’s the nerd for spending his Saturday night reading research journals!?
It is my hope that research like this will continue. Providing further examples of why, when it comes to resolution of pain with next to no side-effects, spinal manipulative therapy is one of the best choices you can make.
My name is Kyle Jensen and thank you for reading the blog. I hope you have found it informative and easy to read. If you have any feedback, questions or are interested in seeing if we can do something for that ache or pain you are experiencing, please feel free to reach out to frontdesk@methodchiropractic.com
Thanks again for reading and have an excellent week!
References
- Schreijenberg M, Lin CW, Mclachlan AJ, Williams CM, Kamper SJ, Koes BW, Maher CG, Billot L. Paracetamol is ineffective for acute low back pain even for patients who comply with treatment: complier average causal effect analysis of a randomized controlled trial. Pain. 2019 Dec 1;160(12):2848-54. Link
- 52. van der Gaag WH, Roelofs PD, Enthoven WT, van Tulder MW, Koes BW. Non‐steroidal anti‐inflammatory drugs for acute low back pain. Cochrane Database of Systematic Reviews. 2020(4). Link
- Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: systematic review and meta‐analysis. European Journal of Pain. 2017 Feb;21(2):228-37. Link
- Ebell MH. Gabapentin and Pregabalin Not Effective for Low Back Pain with or Without Radiculopathy. American family physician. 2019 Mar 15;99(6). Link
- Ashworth J, Green DJ, Dunn KM, Jordan KP. Opioid use among low back pain patients in primary care: Is opioid prescription associated with disability at 6-month follow-up?. PAIN®. 2013 Jul 1;154(7):1038-44.
- LinkSkelly AC, Chou R, Dettori JR, et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Apr. (Comparative Effectiveness Review, No. 227.) Link
- von Heymann WJ, Schloemer P, Timm J, Muehlbauer B. Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo. Spine (Phila Pa 1976). 2013 Apr 1;38(7):540-8. doi: 10.1097/BRS.0b013e318275d09c. PMID: 23026869. Link
