Spinal Manipulative Therapy for Chronic Low-Back Pain An Update of a Cochrane Review

Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
Spine (Impact Factor: 2.45). 06/2011; 36(13):E825-46. DOI: 10.1097/BRS.0b013e3182197fe1
Source: PubMed

ABSTRACT Systematic review of interventions.
To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain.
SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention.
Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. The primary outcomes were pain, functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence.
We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief (mean difference -4.16, 95% confidence interval -6.97 to -1.36) and functional status (standardized mean difference -0.22, 95% confidence interval -0.36 to -0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.
High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.

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    • "Spinal manual techniques such as manipulation and mobilization are frequently recommended for treating mechanical cervical pain and dysfunctions. These manual therapeutics methods demonstrated comparable or better improvements of symptoms, function, quality of life and patient satisfaction compared with conventional medical management (Gross et al., 2010; Rubinstein et al., 2011). Additionally, recent studies emphasized the use of upper cervical spine (UCS) manipulation in combination with thoracic thrust manipulation for patients with mechanical cervical pain (Dunning et al., 2012). "
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    ABSTRACT: Studies reporting spine kinematics during cervical manipulation are usually related to continuous global head–trunk motion or discrete angular displacements for pre-positioning. To date, segmental data analysing continuous kinematics of cervical manipulation is lacking. The objective of this study was to investigate upper cervical spine (UCS) manipulation in vitro. This paper reports an inter- and intra-rater reliability analysis of kinematics during high velocity low amplitude manipulation of the UCS. Integration of kinematics into specific-subject 3D models has been processed as well for providing anatomical motion representation during thrust manipulation. Three unembalmed specimens were included in the study. Restricted dissection was realized to attach technical clusters to each bone of interest (skull, C1 to C4 and sternum). During manipulation, bone motion data was computed using an optoelectronic system. The reliability of manipulation kinematics was assessed for three experimented practitioners performing two trials of 3 repetitions on two separate days. During UCS manipulation, average global head-trunk motion ROM (±SD) were 14±5°, 35±7° and 14±-8° for lateral bending, axial rotation and flexion-extension, respectively. For regional ROM (C0-C2), amplitudes were 10±5°, 30±5° and 16±4° for the same respective motions. Concerning the reliability, mean RMS ranged from 1° to 4° and from 3° to 6° for intra- and inter-rater comparisons, respectively. The present results confirm the limited angular displacement during manipulation either for global head-trunk or for UCS motion components, especially for axial rotation. Additionally, kinematics variability was low confirming intra- and inter-practitioners consistency of UCS manipulation achievement.
    Manual Therapy 10/2014; 19(5). DOI:10.1016/j.math.2014.04.017 · 1.76 Impact Factor
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    • "The between-group differences of 8.6 in pain and 7.5 in disability scores at a primary end point are certainly marginal, but it is not clear yet whether effects of this magnitude constitute a degree of clinical relevance. The associated number needed to treat for pain (55) may actually indicate a meaningful effect [12] [38]. "
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    ABSTRACT: There have been no full-scale trials of the optimal number of visits for the care of any condition with spinal manipulation. To identify the dose-response relationship between visits to a chiropractor for spinal manipulation and chronic low back pain (cLBP) outcomes and to determine the efficacy of manipulation by comparison with a light massage control. Practice-based randomized controlled trial. Four hundred participants with cLBP. The primary cLBP outcomes were the 100-point modified Von Korff pain intensity and functional disability scales evaluated at the 12- and 24-week primary end points. Secondary outcomes included days with pain and functional disability, pain unpleasantness, global perceived improvement, medication use, and general health status. One hundred participants with cLBP were randomized to each of four dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for 6 weeks. At sessions when manipulation was not assigned, they received a focused light massage control. Covariate-adjusted linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 18, 24, 39, and 52 weeks. For the primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks and sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per six manipulation sessions at 12 and 52 weeks for both variables (p<.025). At 12 weeks, the greatest differences from the no-manipulation control were found for 12 sessions (8.6 pain and 7.6 disability points, p<.025); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points, p<.025). The number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.
    The spine journal: official journal of the North American Spine Society 10/2013; 14(7). DOI:10.1016/j.spinee.2013.07.468 · 2.80 Impact Factor
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    • "High-quality evidence suggests that there is no clinically relevant difference between the efficacy of spinal manipulative therapy (SMT) and other interventions for reducing pain and improving function in patients with chronic NS-LBP. Determining cost-effectiveness of care is of high priority (Rubinstein et al, 2011). Risk of serious complications after spinal manipulation is low (estimated risk: cauda equina syndrome, less than one in one million). "
    Evidence Based Medicine - Closer to Patients or Scientists?, 04/2012; , ISBN: 978-953-51-0504-6
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