Elsevier

The Spine Journal

Volume 8, Issue 1, January–February 2008, Pages 213-225
The Spine Journal

Intervention Review Article
Evidence-informed management of chronic low back pain with spinal manipulation and mobilization

https://doi.org/10.1016/j.spinee.2007.10.023Get rights and content

Abstract

Editors' preface

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Section snippets

Terminology

For the purpose of this review, spinal manipulative therapy (SMT) is defined as the application of high-velocity, low-amplitude manual thrusts to the spinal joints slightly beyond the passive range of joint motion [1]. Spinal mobilization (MOB) is defined as the application of manual force to the spinal joints within the passive range of joint motion that does not involve a thrust.

History

Although the practice of spinal manipulation is now frequently associated with chiropractic—which began as a

Mechanism of action

Many hypotheses related to the mechanism of action for SMT and MOB focus on the immediate consequences of applying external force to the tissues of the spine. It is thought that if target tissues are relatively rigid (eg, bone), the applied force may cause the tissue to displace, whereas if the target tissue is relatively nonrigid, the applied force may cause it to deform. Several studies related to SMT and MOB have examined the immediate effects of tissue displacement or deformation, including

Review methods

The purpose of this study was to assess the efficacy of SMT and MOB for the management of CLBP by updating a previous systematic review that included literature published through 2002 [3]. An updated literature search (through 2006) for RCTs evaluating the therapeutic efficacy of SMT or MOB for CLBP was performed using the same strategy [3]. Additionally, citation tracking of references in relevant publications was used, including the nonindexed chiropractic, osteopathic, physical therapy, and

Harms

SMT can be associated with relatively benign temporary side effects including mild localized soreness or pain, which typically does not interfere with activities of daily living [64]. A large, prospective observational study of 1,058 patients who received 4,712 sessions of SMT from 102 DCs in Norway reported the following common adverse events (AEs): local discomfort (53%), headache (12%), tiredness (11%), radiating discomfort (10%), and dizziness (5%) [65]. Most of these AEs occurred within 4

Summary

For CLBP, there is moderate evidence that SMT with strengthening exercise is similar in effect to prescription nonsteroidal anti-inflammatory drugs with exercise in both the short term and long term. There is also moderate evidence that flexion-distraction MOB is superior to exercise in the short term and superior/similar in the long term. There is moderate evidence that a regimen of high-dose SMT is superior to low-dose SMT in the very short term. There is limited to moderate evidence that SMT

References (95)

  • T. Ritvanen et al.

    Dynamic surface electromyographic responses in chronic low back pain treated by traditional bone setting and conventional physical therapy

    J Manipulative Physiol Ther

    (2007)
  • C.E. Coxhead et al.

    Multicentre trial of physiotherapy in the management of sciatic symptoms

    Lancet

    (1981)
  • T. Gibson et al.

    Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain

    Lancet

    (1985)
  • H.M. Hemmilä et al.

    Does folk medicine work? A randomized clinical trial on patients with prolonged back pain

    Arch Phys Med Rehabil

    (1997)
  • H.M. Hemmilä et al.

    Long-term effectiveness of bone-setting, light exercise therapy, and physiotherapy for prolonged back pain: a randomized controlled trial

    J Manipulative Physiol Ther

    (2002)
  • E.L. Hurwitz et al.

    Second prize—the effectiveness of physical modalities among patients with low back pain randomized to chiropractic care: findings from the UCLA low back pain study

    J Manipulative Physiol Ther

    (2002)
  • K. Dickersin

    Why register clinical trials?—Revisited

    Control Clin Trials

    (1992)
  • K. Dickersin et al.

    Publication bias and clinical trials

    Control Clin Trials

    (1987)
  • R. Rosenthal

    The “file drawer problem” and tolerance for null results

    Psychol Bull

    (1979)
  • D. Oliphant

    Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment

    J Manipulative Physiol Ther

    (2004)
  • M.S. Goldstein et al.

    The impact of treatment confidence on pain and related disability among patients with low-back pain: results from the University of California, Los Angeles, low-back pain study

    Spine J

    (2002)
  • J. Nyiendo et al.

    Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians

    J Manipulative Physiol Ther

    (2001)
  • M. Haas et al.

    A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up

    J Manipulative Physiol Ther

    (2004)
  • K.L. Beyerman et al.

    Efficacy of treating low back pain and dysfunction secondary to osteoarthritis: chiropractic care compared with moist heat alone

    J Manipulative Physiol Ther

    (2006)
  • M.J. Ongley et al.

    A new approach to the treatment of chronic low back pain

    Lancet

    (1987)
  • M.L. Ferreira et al.

    Does spinal manipulative therapy help people with chronic low back pain?

    Aust J Physiother

    (2002)
  • S. Haldeman et al.

    Spinal manipulative therapy in the management of low back pain

  • G. Wiese et al.

    History of spinal manipulation

  • D.H. Peterson et al.

    Chiropractic technique

    (2002)
  • A. Unsworth et al.

    ‘Cracking joints’. A bioengineering study of cavitation in the metacarpophalangeal joint

    Ann Rheum Dis

    (1971)
  • P. Watson et al.

    A study of the cracking sounds from the metacarpophalangeal joint

    Proc Inst Mech Eng [H]

    (1989)
  • P.G. Shekelle et al.

    Spinal manipulation for low-back pain

    Ann Intern Med

    (1992)
  • T.W. Meade et al.

    Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up

    BMJ

    (1995)
  • T. Meade et al.

    Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment

    BMJ

    (1990)
  • D.C. Cherkin et al.

    A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain

    N Engl J Med

    (1998)
  • E.I. Skargren et al.

    Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain. Six-month follow-up

    Spine

    (1997)
  • UK BEAM Trial Team

    United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care

    BMJ

    (2004)
  • P.G. Shekelle

    Spinal manipulation

    Spine

    (1994)
  • Bigos S, Bowyer O, Braen G, Brown K, Deyo R, Haldeman S. Acute low back problems in adults. Clinical Practice Guideline...
  • Institute for Clinical Systems Improvement (ICSI)

    Adult low back pain

    (2006)
  • J.D. Childs et al.

    A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study

    Ann Intern Med

    (2004)
  • R.E. Slavin

    Best-evidence synthesis: an alternative to meta-analytic and traditional reviews

    Educ Res

    (1986)
  • W.O. Spitzer et al.

    Links between passive smoking and disease: a best-evidence synthesis. A report of the Working Group on Passive Smoking

    Clin Invest Med

    (1990)
  • B.W. Koes et al.

    Spinal manipulation and mobilisation for back and neck pain: a blinded review

    BMJ

    (1991)
  • W.J.J. Assendelft et al.

    The effectiveness of chiropractic for treatment of low back pain: an update and attempt at statistical pooling

    J Manipulative Physiol Ther

    (1996)
  • G. Bronfort et al.

    Trunk exercise combined with spinal manipulative or NSAID therapy for chronic low back pain: a randomized, observer-blinded clinical trial

    J Manipulative Physiol Ther

    (1996)
  • A.K. Burton et al.

    Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation

    Eur Spine J

    (2000)
  • Cited by (0)

    FDA approval status: not applicable.

    Author GK acknowledges research funding: Federal/state agency.

    Nothing of value received from a commercial entity related to this manuscript.

    View full text