Medical Research Council trial finds adding spinal manipulation and exercise to GP care provides relief for back pain - A
Medical Research Council (MRC) trial to assess the effectiveness of adding different treatments to 'best care' in general
practice for patients with lower back pain has found that spinal manipulation, in the form of chiropractic, osteopathy, or
manipulative physiotherapy, followed by a programme of exercise, provides significant relief of symptoms and improvements in
general health. The results of the trial are published online today, Friday 19 November, in the British Medical Journal.
Lower back pain is one of the most common ailments general practitioners (GPs) have to treat. The condition is painful for
patients and costly to the National Health Service (NHS) and society. Until now, the benefit of different physical treatments
has been unclear. 'Best care' in general practice for simple lower back pain is based on 'active management' which encourages
patients to continue with normal activities and avoid rest.
The trial recruited more than 1,300 patients from across the UK, whose back pain had not improved after receiving 'best care'
in general practice, to assess the effectiveness of three different treatments. The treatments were:
-- A class-based physical exercise programme
-- Spinal manipulation, which is a 'hands on' approach administered by qualified therapists to move the joints of the back
-- A combined package of spinal manipulation followed by a programme of exercise
The results showed that patients in all treatment groups reported improved back function and reduced pain over time, but to
varying degrees. On average, patients assigned to exercise classes in addition to GP care reported a small benefit at three
months but not at one year. Those assigned to spinal manipulation in addition to GP care reported a small to moderate benefit
at three months and a small, on average, benefit at one year. The greatest improvement was found in the patients assigned to
combined manipulation and exercise in addition to GP care. They reported a moderate, on average, improvement at three months
and a smaller average improvement at one year. These benefits were the same whether treatment was delivered using private or
NHS premises.
An economic analysis was also carried out. It showed that the cost to the NHS of all three treatments was modest. It also
showed that both spinal manipulation and the combined package of spinal manipulation and exercise achieved similar benefits
to patients at similar cost to the NHS. The results of this analysis, together with the local availability of physical
therapists, will inform the NHS on how best to improve care for patients with lower back pain.
Patients eligible for the trial were randomly assigned to one of six groups. Five groups received 'best care' in general
practice plus an intervention - exercise, manipulation in private or NHS premises, or manipulation in private or NHS premises
followed by exercise. Trial participants in the sixth, or control, group only received 'best care' from their GPs. After
giving informed consent to take part in the trial, participants completed questionnaires on their general health, back pain,
beliefs and psychological well-being before being randomly assigned to a treatment. They completed further questionnaires at
one, three and 12 months after assignment.
Martin Underwood, Professor of General Practice at Queen Mary, University of London, was one of the lead researchers in the
trial team. He said:
"One of the commonest health problems I'm asked to treat as a GP is back pain. This trial has shown that physical treatments
- a combined package of spinal manipulation and exercise in particular - may offer relief to the large numbers of patients
whose back pain persists after they've received best care from their GP."
Ian Russell, Professor of Public Health & Director of the Institute of Medical and Social Care Research at the University of
Wales Bangor, was another of the lead researchers in the trial team. He said:
"Though the average benefit to patients was only moderate in size, back pain is so widespread and so costly to society that
these benefits add up to substantial economic benefits across the UK. Our analysis also showed that the cost to the NHS was
modest. Added to GP 'best care', spinal manipulation gives the best value for money."
For more information, or to arrange an interview, contact the MRC Press Office on 020 7 637 6011.
Notes to editors
Full title of papers:
UK Back pain Exercise And Manipulation (UK BEAM) randomised trial:
1.effectiveness of physical treatments for back pain in primary car
2. cost-effectiveness of physical treatments for back pain in primary care
Information about the interventions:
-- 'Best care' in general practice - the 'comparator' treatment
The UK national acute back pain guidelines advise continuing normal activities and avoiding rest. To base the 'comparator'
treatment on these guidelines, clinical and support staff from all participating practices were invited to training sessions
on the 'active management' of back pain. Copies of 'The Back Book', the popular booklet for patients, were provided for
practice reception areas and for patients with back pain.
-- Exercise programme
Physiotherapists with at least two years clinical experience were trained to deliver the 'Back to Fitness' exercise
programme. Classes ran in local community facilities, with up to ten people in each session. Participants were invited to
attend an initial individual assessment, followed by up to eight one-hour sessions over four to eight weeks and a 'refresher'
class 12 weeks after recruitment.
-- Spinal manipulation package
A multi-disciplinary group developed a package of techniques representative of those used by the UK chiropractic, osteopathy
and physiotherapy professions. The three professional associations agreed to the use of this package in this trial. Similar
numbers of qualified manipulators from each of these professions treated participants. They all had a minimum of two years
clinical experience. Participants randomised to private manipulation received treatment in manipulators' own consultation
rooms. Those randomised to NHS manipulation saw the same manipulators in NHS premises. We invited participants to attend up
to eight 20-minute sessions, if necessary over 12 weeks.
-- Combined treatment
Participants were invited to attend eight sessions of manipulation over six weeks, eight sessions of exercise in the next six
weeks, and a 'refresher' class at 12 weeks. Other aspects of treatment were identical to those in manipulation or exercise
only groups.
About the MRC
The Medical Research Council (MRC) is a national organisation funded by the UK tax-payer. Its business is medical research
aimed at improving human health; everyone stands to benefit from the outputs. The research it supports and the scientists it
trains meet the needs of the health services, the pharmaceutical and other health-related industries and the academic world.
MRC has funded work which has led to some of the most significant discoveries and achievements in medicine in the UK. About
half of the MRC's expenditure of пїЅ430 million is invested in its 40 Institutes, Units and Centres. The remaining half goes in
the form of grant support and training awards to individuals and teams in universities and medical schools.
MEDICAL RESEARCH COUNCIL, UK
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