MANUAL THERAPY IN PRIMARY CARE OF ACUTE LOW BACK PAIN

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Low back pain carries a burden of suffering (symptoms and disability) and heavy costs to society related to medical care, lost work, and compensation. Two professions, allopathic physicians and chiropractors, provide most care for patients with acute low back pain. The role of manual therapies, such as spinal manipulative therapy (SMT), has been controversial. Randomized trials have demonstrated some benefit to manual therapy, but the role of these therapies in the allopathic system has not been evaluated. We propose a novel training and evaluative study to determine whether allopathic physicians can effectively integrate manual therapy, including simple spinal manipulation, into primary care practice. The site of the research will be the state of North Carolina, where successful practice- based research has been conducted in many areas, including back pain research. We propose two research questions: RQI: Can physicians reliably learn the approach to manual therapy, including spinal manipulation? RQ2: Can use of simple spinal manipulation therapy improve the clinical outcomes of patients with acute back pain? Twenty-five primary care physicians will be recruited to participate in a training program to teach manual therapy. The training will involve hands- on experience in spinal manipulative therapy. Following training, the physicians will enroll 320 patients in their practices into a randomized trial of spinal manipulative therapy. Sequential patients with acute low back pain will be randomized to receive up to 5 SMT treatments from the primary physician over a three week period; control patients will receive an equal number of visits as usual therapy. Subjects will be interviewed at baseline and at 2,4, and 8 weeks. The primary outcome measure will be patient function as measured by the Roland- Morris functional status scale specific for low back pain. Other outcomes will be time to improvement, return to work and patients satisfaction. Evaluation of the effectiveness of spinal manipulation by primary care physicians will allow the assessment of a therapy prior to wide use by the allopathic medical community.