Spinal Manipulative Therapy for Acute Low Back Pain

I would like to commend Hancock and colleagues on their article entitled ‘Spinal Manipulative ! erapy for Acute Low Back Pain; A Clinical Perspective. ’ My interest in this paper was triggered by their willingness to discuss questions that practitioners in the manual therapy community may be less comfortable with, based on their own commitment to a particular approach or model used in examination and care. e authors did not so much o%er a host of de#nitive answers, but rather provided suggestions in the wake of many unanswered questions. For this they should be thanked, because it could stimulate a healthy surge towards further evaluating the important questions daily confronted by spinal manipulative therapy (SMT) providers. While SMT is an accepted component in the management of acute LBP, one of the greatest challenges is the timing of when a clinician should implement SMT in the management plan. e authors suggested that, prior to SMT implementation, screening should be engaged in order to rule out fracture or serious pathology. Screening is clearly needed as a preliminary component of managing spine pain1. However, greater attention should be given to this practice than is presently exercised, considering the low rate of routine examination for red $ags in primary care practice settings2 using guideline-recommended approaches3,4. e presence of serious examination #ndings such as pulsatile abdominal masses, unexplained neurological de#cits, and recent bowel and bladder changes, suggests serious pathology outside the domain of musculoskeletal disorders and may require immediate intervention by an appropriate specialist1,5. Other #ndings that include a cancer history, long-term corticosteroid use, metabolic bone disorder history, age greater than 50 years, unexplained weight loss, and failure of conservative management require further patient questioning, selected examination methods, and the evaluation of the historical and examination #ndings in clusters. For example, a history of long-term corticosteroid use and an age greater than 50 each do not warrant immediate attention by a specialist. However, when clustered, the likelihood of a spinal compression fracture is dramatically increased, thus suggesting a specialist’s attention6. e authors’ concern over fractures and cancer is well received. However, besides fracture and cancer, acute low back pain patients are at risk for other serious pathologies. For example, pyogenic infectious disease can develop in this region resulting in fever, malaise, potential bowel and bladder disturbances and severe low back pain. Vertebral osteomyelitis and pyogenic spondylodiscitis can develop a&er streptococcal endocarditis, direct inoculation, discography, nucleoplasty, colonoscopy, biopsy, or oocyte retrieval for in-vitro fertilization5,7-12. Spontaneous pyogenic infection can form in the lumbar zygapophyseal joints as well, especially in patients with a history of drug abuse or previous spinal instrumentation13. Serious arthritides can occur in both the zygapophyseal joints and sacroiliac joints, thus meriting a screening process. Rheumatoid arthritis, systemic lupus erythematous, ankylosing spondylitis, brucellosis and Reiter’s syndrome can all produce the same host of symptoms suggesting the need for screening14-17. I was intrigued when the authors suggested that studies evaluating the ef#cacy of SMT have produced small and or contradictory results, and when they reported plausible reasons for these differences. It is apparent that these authors consider the present model of 1st line care that uses advice and appropriately dosed Paracetamol (acetaminophen or Tylenol) as the best choice for the patient. e investigators’ argument regarding the limits to studies involving clinical prediction rules (CPR)-based decisions are reasonable and recommending the global use of CPR as the standard for care should be limited until CPR studies are su"ciently evaluated in a valid fashion for quality. However, putting this limit to CPR-based decisions aside, one is impelled to ask why SMT need be considered 2nd line care. e authors should be cautioned INVITED COMMENTARY