Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: A randomized, observer-blinded clinical trial

Objectives: To study the relative efficacy of three different treatment regimens for chronic low back pain (CLBP). Two preplanned comparisons were made: (a) Spinal manipulative therapy (SMT) combined with trunk strengthening exercises (TSE) vs. SMT combined with trunk stretching exercises, and (b) SMT combined with TSE vs. nonsteroidal anti-inflammatory drug (NSAID) therapy combined with TSE. Study Design: Interdisciplinary, prospective, observer blinded, randomized clinical trial with a 1-yr follow-up period. The trial evaluated therapies in combination only and was not designed to test the individual treatment components. Setting: Primary contact, college out- patient clinic. Patients: In total, 174 patients aged 20-60 yr were admitted to the study. Main Outcome Measures: Patient-rated low back pain, disability, and functional health stains at 5 and 11 wk. Interventions: Five weeks of SMT or NSAID therapy in combination with supervised trunk exercise, followed by an additional 6 wk of supervised exercise alone. Results: Individual group comparisons after 5 and 11 wk of intervention on all three main outcome measures did not reveal any clear clinically important or statistically significant differences. There seemed to he a sustained reduction in medication use at the 1-yr follow-up in the SMT/TSE group. Continuance of exercise during the follow-up year, regardless of type was associated with a better outcome. Conclusion: Each of the three therapeutic regimens was associated with similar and clinically important improvement over time that was considered superior to the expected natural history of long-standing CLBP. For the management of CLBP, trunk exercise in combination with SMT or NSAID therapy seemed to be beneficial and worthwhile. The magnitude of nonspecific therapeutic (placebo) effects, cost-effectiveness and relative risks of side effects associated with these types of therapy need to be addressed in future studies.