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: 2.3). 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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    • "The majority of clinical studies conducted thus far have showed that SM conveys a mild to moderate therapeutic effect in treating LBP, comparable to other non-invasive treatment methods such as McKenzie therapy and structured exercise (Lawrence et al., 2008; Rubinstein et al., 2011; Standaert et al., 2011; Goertz et al., 2012). "
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    ABSTRACT: Low back pain (LBP) is a major health problem in industrialized societies. Spinal manipulation (SM) is often used for treating LBP, though the therapeutic mechanisms remain elusive. Research suggests that sensorimotor changes may be involved in LBP. It is hypothesized that SM may generate its beneficial effects by affecting sensorimotor functions. To compare changes in sensorimotor function, as measured by postural sway and response to sudden load, in LBP patients following the delivery of high-velocity low amplitude (HVLA)-SM or low-velocity variable amplitude (LVVA)-SM versus a sham control intervention. A three-arm (1:1:1 ratio) randomized controlled trial. A total of 221 participants who were between 21 and 65 years, having LBP intensity (numerical rating scale) ≥4 at either phone screen or the first baseline visit and ≥2 at phone screen and both baseline visits, and Quebec Task Force diagnostic classifications of 1, 2, 3 or 7 were enrolled to receive four SM treatments over two weeks. Study outcomes were measured at the first and fifth visits with the examiners blinded from participant group assignment. The LVVA-SM group demonstrated a significant increase in medial-to-lateral postural excursion on the soft surface at the first visit when compared to the control group. No other significant between-group differences were found for the two sensorimotor tests, whether during the first visit or over two weeks. It appears that short-term SM does not affect the sensorimotor functions as measured by postural sway and response to sudden load in this study. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Manual therapy 08/2015; DOI:10.1016/j.math.2015.08.001 · 1.71 Impact Factor
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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 · 1.71 Impact Factor
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    • "Therefore, these groups can have specific or nonspecific LBP. For this reason we included studies that examined nonspecific LBP in pregnant and postpartum women, but presented these results as separate comparisons, even though other systematic reviews have excluded this subgroup without clear justification [32, 33]. "
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    ABSTRACT: Background: Nonspecific back pain is common, disabling, and costly. Therefore, we assessed effectiveness of osteopathic manipulative treatment (OMT) in the management of nonspecific low back pain (LBP) regarding pain and functional status. Methods: A systematic literature search unrestricted by language was performed in October 2013 in electronic and ongoing trials databases. Searches of reference lists and personal communications identified additional studies. Only randomized clinical trials were included; specific back pain or single treatment techniques studies were excluded. Outcomes were pain and functional status. Studies were independently reviewed using a standardized form. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated at 3 months posttreatment. GRADE was used to assess quality of evidence. Results: We identified 307 studies. Thirty-one were evaluated and 16 excluded. Of the 15 studies reviewed, 10 investigated effectiveness of OMT for nonspecific LBP, 3 effect of OMT for LBP in pregnant women, and 2 effect of OMT for LBP in postpartum women. Twelve had a low risk of bias. Moderate-quality evidence suggested OMT had a significant effect on pain relief (MD, -12.91; 95% CI, -20.00 to -5.82) and functional status (SMD, -0.36; 95% CI, -0.58 to -0.14) in acute and chronic nonspecific LBP. In chronic nonspecific LBP, moderate-quality evidence suggested a significant difference in favour of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). For nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favour of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23), whereas moderate-quality evidence suggested a significant difference in favour of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35) in nonspecific LBP postpartum. Conclusion: Clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women at 3 months posttreatment. However, larger, high-quality randomized controlled trials with robust comparison groups are recommended.
    BMC Musculoskeletal Disorders 08/2014; 15(1):286. DOI:10.1186/1471-2474-15-286 · 1.72 Impact Factor
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