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Manipulative therapy or NSAIDS do not provide additional benefit to quality baseline care for acute back pain.

Summary of: Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, Spindler MF, McAuley JH (2007) Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. The Lancet 370: 1638-1643. [Prepared by Julia Hush, CAP Editor.]


This high quality randomised controlled trial (RCT) addressing a general practitioner (GP) clinical question (refer or don't refer?) reported results that are challenging for manual therapists treating people with acute nonspecific low-back pain (ANSLBP). It concluded that people with ANSLBP attending a GP who provided guideline-recommended treatment (advice plus paracetamol) received no additional benefit from a physiotherapist providing SMT.

There are several issues to consider before drawing conclusions about clinical practice from the results of this trial. First, participants typically had a pain duration of approximately 1 week, so these results do not apply to patients with longer lasting pain. Second, the trial's randomisation schedule determined which patients would receive manual therapy or not, rather than a clinician's judgement deciding this. Perhaps only some ANSLBP patients respond favourably to manual therapy. However, there are currently no reliable methods to determine which patients will respond to particular treatments (Billis et al 2007). Third, only 5% of participants received high velocity SMT. Although there is no clear evidence that high velocity SMT is more effective than mobilisation (Assendelft et al 2004), proponents of the former will claim that this study did not test the effectiveness of this technique. Fourth, it would have been interesting to see a 'GP only' group. Perhaps there is something gained from being referred to a physiotherapist, even if the treatment itself is a placebo.

Finally, the question remains, if a patient with ANSLBP consults a GP, will guideline-recommended treatment be provided? The evidence suggests otherwise and best practice is not guaranteed (Buchbinder and Jolley 2007). In the Hancock RCT, GPs were given training to deliver best care. Perhaps patients in the 'real world' would not receive this quality care from their GP.

This trial does not bring the world crashing down for manual therapists as some press reports have stated, but the treatment these therapists provide does need to be considered carefully in light of the trial results.

Simon French

Monash Institute of Health Services Research, Australia


Assendelft WJ et al (2004) Cochrane Database Syst Rev 1: CD000447.

Billis EV et al (2007) European Spine Journal 16: 865-879.

Buchbinder R, Jolley D (2007) Spine 32: E156-E162.
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Title Annotation:Appraisal: Critically Appraised Papers; nonsteroidal anti-inflammatory agents
Author:Hush, Julia
Publication:Australian Journal of Physiotherapy
Article Type:Report
Geographic Code:8AUST
Date:Mar 1, 2008
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