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Comparing outcomes in patients with back-related leg pain (BRLP) using spinal manipulation (SMT), home exercises and advice or home exercise and advice (HEA) alone

Date Posted:27/03/2015
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Publication: Annals of Internal Medicine, 2014: 161: 381 - 391. doi: 10.7326/M14-0006

Authors: Bronfort G, Hondras MA, Schulz CA, et al


Although, BRLP has a poorer prognosis (long-term outcome) than low back pain (LBP) alone very few studies have been done in terms of effective care. Compared to LBP, BRLP also has more pain severity, results in more time of work and poorer quality of life.

Concerns have been growing with respect to the adverse effects of current treatment of medication and surgery.

The Purpose of the Study

The study was to done to compare outcomes in people treated with a combination of spinal manipulation (SMT) in conjunction with home exercise and advice (HEA) and those given HEA alone.

The Study

  • was carried out at 2 chiropractic institutions
  • 192 participants were selected to take part in the trial.
  • 90% had chronic BRLP
  • all were aged 21 years or over
  • all had BRLP of more than 4 weeks duration
  • all had been taking medication for BRLP in the previous 4 weeks
  • the study was and randomised clinical trial (RCT): participants were randomly assigned to one of 2 groups

group 1: participants received SMT and HEA

group 2: participants were given HEA alone

Strengths and Weaknesses of the Study
Strengths Weaknesses
rigorous method in a real-life treatment setting the clinician was unable to be 'blinded' to the treatment given
participants of over 65 years were incluced, leading to greater generalisation the study does not provide conclusions for the effectiveness of SMT alone

Data collected

  • 99% of the participants provided 12-week follow-up data
  • 93% of the participants provided 52-week follow-up data
  • attendance for appointment (indicating compliance to the treatment plan given) was 90%
  • the mean average number of treatments given was 14.6


1. Primary outcomes:

  • at  12 weeks, the SMT with HEA group reported significantly lower BRLP
  • 37% reported a 75% reduction in leg pain, compared to 19% in the HEA alone group
  • a further 20% reported 100% reduction in leg pain, compared to 5% in the HEA alone group

2. Secondary outcomes (other benefits):

More improvement was noted by the participants of the SMT with HEA group for the following factors:

  • low back pain
  • disability
  • general satisfaction with outcome
  • global difference

3. Use of medication:

56% of participants of the SMT with HEA group were still taking medication at 12 weeks, compared to 63% of the HEA alone group.

4. Outcomes at 52 weeks:

Outcomes were more likely to be sustained for the participants from the SMT with HEA group for global improvement and general satisfaction.


SMT and HEA is a safe and effective approach in the first 12 weeks of injury in subacute and chronic BRLP patients.

Glossary of Terms

chronic: a disease process or illness lasting 3 months or more, often affecting quality of life

prognosis: prospect of recovery from a disease process

RCT: the NICE definition: A study in which a number of similar people are randomly assigned to 2 (or more) groups to test a specific drug or treatment. One group (the experimental group) receives the treatment being tested, the other (the comparison or control group) receives an alternative treatment, a dummy treatment (placebo) or no treatment at all. The groups are followed up to see how effective the experimental treatment was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias.

subacute: recent onset of symptoms (as opposed to acute, meaning a very sudden and very recent onset of symptoms)

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