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


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.

    • "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.
    No preview · Article · Aug 2015 · Manual therapy
    • "Physical therapy is one conservative treatment used for patients with chronic LBP. Several therapeutic approaches including lumbar spinal manipulation (Rubinstein et al., 2011), exercises (Haladay et al., 2013), soft tissue manual therapy (Brosseau et al., 2012), and neurophysiology education (neuroscience education) (Clarke et al., 2011) are typically used for management of this condition; however, further studies investigating the effects of interventions targeted soft tissues and neurophysiology pain education are needed (Clarke et al., 2011). The relevance of soft tissue interventions is related to the hypothesis that muscle trigger points (TrP) can be involved in centrally mediated pain mechanisms observed in patients with chronic LBP (Roussel et al., 2013). "
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    ABSTRACT: The objective of the current study was to determine the short-term effects of trigger point dry needling (TrP-DN) alone or combined with neuroscience education on pain, disability, kinesiophobia and widespread pressure sensitivity in patients with mechanical low back pain (LBP). Twelve patients with LBP were randomly assigned to receive either TrP-DN (TrP-DN) or TrP-DN plus neuroscience education (TrP-DN + EDU). Pain intensity (Numerical Pain Rating Scale, 0-10), disability (Roland-Morris Disability Questionnaire-RMQ-, Oswestry Low Back Pain Disability Index-ODI), kinesiophobia (Tampa Scale of Kinesiophobia-TSK), and pressure pain thresholds (PPT) over the C5-C6 zygapophyseal joint, transverse process of L3 vertebra, second metacarpal, and tibialis anterior muscle were collected at baseline and 1-week after the intervention. Patients treated with TrP-DN + EDU experienced a significantly greater reduction of kinesiophobia (P = 0.008) and greater increases in PPT over the transverse process of L3 (P = 0.049) than those patients treated only with TrP-DN. Both groups experienced similar decreases in pain, ODI and RMQ, and similar increases in PPT over the C5/C6 joint, second metacarpal, and tibialis anterior after the intervention (all, P > 0.05). The results suggest that TrP-DN was effective for improving pain, disability, kinesiophobia and widespread pressure sensitivity in patients with mechanical LBP at short-term. The inclusion of a neuroscience educational program resulted in a greater improvement in kinesiophobia. Copyright © 2014 Elsevier Ltd. All rights reserved.
    No preview · Article · Jul 2015 · Journal of bodywork and movement therapies
    • "Spinal manipulation is a form of manual therapy used most frequently to treat musculoskeletal complaints (Hawk et al., 2001; Sorensen et al., 2006). It is most readily differentiated from spinal mobilization by use of an applied thrust and there is rationale to think that these two forms of treatment may not be equivalent either clinically (Cleland et al., 2009; Rubinstein et al., 2013; but see; Cook et al., 2013) or in their mechanisms of action (Bolton and Budgell, 2006) and therefore they should be studied individually. Utilization data indicate most patients who receive spinal manipulation receive a manual procedure relatively high in velocity and low in amplitude (HVLA-SM) (Shekelle et al., 1992; Eisenberg et al., 1998; Christensen et al., 2005). "
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    ABSTRACT: Systematic investigations are needed identifying how variability in the biomechanical characteristics of spinal manipulation affects physiological responses. Such knowledge may inform future clinical practice and research study design. To determine how contact site for high velocity, low amplitude spinal manipulation (HVLA-SM) affects sensory input to the central nervous system. HVLA-SM was applied to 4 specific anatomic locations using a no-HVLA-SM control at each location randomized in an 8×8 Latin square design in an animal model. Neural activity from muscle spindles in the multifidus and longissimus muscles were recorded from L6 dorsal rootlets in 16 anesthetized cats. A posterior to anterior HVLA-SM was applied through the intact skin overlying the L6 spinous process, lamina, inferior articular process and L7 spinous process. HVLA-SMs were preceded and followed by simulated spinal movement applied to the L6 vertebra. Change in mean instantaneous discharge frequency (ΔMIF) was determined during the thrust and the simulated spinal movement. All contact sites increased L6 muscle spindle discharge during the thrust. Contact at all L6 sites significantly increased spindle discharge more than at the L7 site when recording at L6. There were no differences between L6 contact sites. For simulated movement, the L6 contact sites but not the L7 contact site significantly decreased L6 spindle responses to a change in vertebral position but not to movement to that position. This animal study showed that contact site for an HVLA-SM can have a significant effect on the magnitude of sensory input arising from muscle spindles in the back. Copyright © 2015 Elsevier Ltd. All rights reserved.
    No preview · Article · Mar 2015 · Manual therapy
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