by Alan Jordan
In order to determine the benefits of a treatment proper science has established the Randomised Controlled Clinical Trial as its Gold Standard – this is the only truly established method that is universally accepted. This method has its limitations though and as I discussed in a recent article in the Broadgate Journal identifying precisely which tissue is responsible for the patient’s pain can be literally impossible.
Therefore, when we carry out Randomised Clinical Trials on spinal pain patients we inevitably end up with a “mixed bag” of patients in each group. Some have pain emanating from discs, others from muscles and others yet from joints or postural issues. We lump them into groups depending upon the duration and severity of their symptoms and then compare the results of treatment on what cannot be described as a “like for like” patient population. At present, this is the best that we can do.
Most trials on chronic patients therefore – and unsurprisingly – end up with similar results for spinal manipulation, exercise, physiotherapy, and acupuncture – all useful treatments. The reason for this is that each group contains some patients that respond favourably to each treatment and the end results end up rather similar. It strikes me every time I see a clinical trial in which, for example, spinal manipulation and supervised exercise end up with very similar results. This of course does not make any biological sense in as much as the treatment provided is so dissimilar. Each group will contain patients that respond well to manipulation and others that respond well to exercise. The converse is also true. This explains why results are so similar.
The challenge for the coming generation of researchers – and work has begun – is to identify subgroups of patients that are likely or unlikely to benefit from a particular type of treatment and how much treatment they should have. An excellent study by Dr Charlotte LeBeouf carried out in Sweden demonstrated that patients undergoing chiropractic treatment would respond quickly to care and if they did not respond quickly they were unlikely to respond at all. A simple, but brilliant study.
Currently, our knowledge suggests that doctors can suggest spinal manipulative therapy, exercise, or acupuncture for lower back pain. All of these services are provided at the Broadgate Spine Centre. The advantage at our clinic is that we can co-manage patients or switch directions if the expected results are not met within expected time limits. In other words, we do NOT offer a “one size fits all” treatment package. Furthermore, we have a wide range of medical consultants that we can refer to – on site. Typically, patients at our clinic begin treatment with spinal manipulation – because it acts quickly – and then move on to supervised exercise – because we know that tissues need to be strengthened and that exercise has a documented preventative effect.
Explaining this to Patients
Patients understandably want concrete and secure answers when they come to a clinic with a problem. This is certainly what we experience in the City of London where patients are extremely busy, well educated and inclined towards concrete information. It can be challenging to explain to this type of individual that there are limitations as to the precision of the information that we can provide.
Much remains to be “discovered” in the diagnosis and treatment of spinal pain syndromes and there is lots of work for the current generation of research scientists. Chief amongst their tasks are sub-group identification. In other words, which individuals are most likely to benefit from different treatments. Treatment choice by patients has been shown to result in better clinical outcomes. If a patient has, for example, experienced good results with manipulation or acupuncture it makes good sense for them to undergo this type of treatment once again. This is yet another reason why we have such a wide array of health care disciplines at Broadgate Spine & Joint Clinic.