Review ArticleNASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain
Introduction
Low back pain (LBP) is a common and often disabling condition. The cumulative 1-year incidence of LBP is approximately 20% [1], [2], with most initial episodes being mild [2]. The reported prevalence of LBP varies greatly. The point prevalence ranges from 6% to 33% [3], [4] and the 1-year prevalence from 22% to 65% [4]. The lifetime prevalence of LBP is even more variable, likely because of differences in the definitions of LBP used, the populations studied, and the study methodology [5]. There has been a recent effort to promote a common definition of LBP that will allow comparisons to be made between studies [6].
Low back pain is commonly classified as acute (<3 months) or chronic (>3 months) based on its duration [7]. These temporal definitions appear to be based on studies that showed that almost all persons with LBP returned to work within 90 days [8], [9]. Although acute LBP does tend to improve with time and generally has a good prognosis, improvement in pain and disability does not correlate well with return-to-work rates [10]. Furthermore, recent studies have shown that a significant proportion of acute LBP sufferers will develop recurrent or chronic LBP. A survey of persons 35 to 45 years old found that LBP resolved quickly in only 27% of subjects, whereas 40% developed persistent LBP [5]. Even among those whose LBP had initially resolved, 29% had recurrent (usually mild) LBP within 6 months [5]. Other studies have found similar trends for recurrence of LBP [2], [11]. Although it is difficult to predict who among those with first episodes of LBP will develop recurrent or chronic symptoms, factors related to the determinants of disability and to the prediction of chronic disability appear by 14 days after the onset of pain, supporting that as a cutoff point in the transition from acute to subacute pain [12]. Psychological factors appear to play an important role in that transition and related disability [13].
Low back pain is a significant societal burden. Persons seeking care for LBP constitute a substantial proportion of patients seen in primary care offices. Direct and indirect costs for LBP have been reported in studies from many countries, but differences in methodology make it difficult to compare the results. A recent review suggested that, although the total yearly cost of LBP (direct and indirect costs) in the United States has been reported to be between $19.6 and $118.8 billion per year, the true cost may be much higher [14].
Much can be learned from a brief but thorough history and examination of patients with LBP. Clinical practice guidelines from the United States and various European groups suggest that, in the absence of any “red flags” for serious spinal pathology, advanced diagnostic studies are not needed in the initial evaluation of acute LBP [15], [16]. Red flags for LBP are symptoms, findings, or other characteristics that may be indicative of rare but potentially serious spinal pathology, such as spinal tumor, infection, fracture, or cord compromise [17]. Examples of red flags include unexplained weight loss, loss of bowel or bladder function, saddle anesthesia, widespread neurologic symptoms in the lower extremities, recent trauma with osteoporosis or prolonged corticosteroid use, immune suppression, and systemic unwellness [17]. Such an evaluation should be based on the symptoms of the patient and the diagnostic concerns of the physician but may include X-ray; advanced imaging (bone scan, computed tomography, or magnetic resonance imaging); laboratory studies; or electrophysiological studies.
In most cases of acute LBP, an objective cause cannot be found. Such cases are, therefore, described as “nonspecific.” Despite this lack of knowledge regarding the etiology of LBP, there are many interventions available, and many providers who are willing to use them [18]. The provider’s training often biases the choice of treatment for acute LBP. Common primary care approaches include education, reassurance, return to activities, nonsteroidal anti-inflammatory drugs (NSAIDs), and simple analgesics. Patients with acute LBP who do not improve quickly often seek additional care from both surgical and nonsurgical specialists. One of the most common treatments used in North America and Europe is spinal manipulation therapy (SMT) [19]. Practitioners have used some form of SMT to treat LBP for thousands of years [20].
In North America, SMT is usually provided by Doctors of Chiropractic (DCs) [21]. However, in other countries, particularly in Europe and Australia, it is commonly used by physical therapists (PTs), Doctors of Osteopathy (DOs), and medical doctors (MDs) trained in manual therapy. How SMT works is not completely understood, but there is growing evidence that its effects result from a combination of mechanical, neurological, and biochemical changes in various structures [19]. Like many therapies administered for acute LBP, SMT has a diminishing effect size as the duration of follow-up increases. As a result, its clinical efficacy for acute LBP is still debated despite many randomized controlled trials (RCTs), systematic reviews (SRs), and meta-analyses.
The North American Spine Society (NASS) Contemporary Concepts are a series of evidence-based reviews of contemporary issues in spine care, intended to provide spine clinicians with a general understanding about current practices. Because of the uncertainty of the role of SMT in the care of acute LBP within the community of spine care providers at large, a Complementary Medicine Task Force composed of NASS members (primarily members of the former NASS Complementary Medicine Committee, see Acknowledgments) was appointed to develop a Contemporary Concepts article on SMT for acute LBP.
Section snippets
Eligibility criteria
The eligibility criteria were based on the Population, Intervention, Control, Outcomes, Study design (PICOS) principle [22] as follows:
Population: adults with acute LBP (ie, pain lasting <12 weeks);
Intervention: SMT or mobilization (MOB);
Control: any control group that did not receive SMT or MOB or allowed for evaluation of the comparative efficacy of different forms of SMT or MOB;
Outcomes: patient-reported pain reduction and functional improvement (primary outcomes), as well as global effect,
Search
The MEDLINE search resulted in 699 citations, of which eight were deemed potentially relevant [26], [27], [28], [29], [30], [31], [32], [33], and 11 were of uncertain relevance [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44]. After screening full-text articles for those 19 studies, only six were deemed eligible [26], [28], [29], [31], [32], [33]. Reasons for excluding full-text articles included duplicate reports (n=8) [34], [35], [36], [37], [38], [40], [41], [42], less than
Improvements in pain and function
Spinal manipulation therapy appears to be effective for pain reduction in the short, intermediate, and long term. Only 1 to 2 weeks after initiating care with SMT, pain reduction was substantial (62%), though it was almost as large for the control groups against which it was compared. Pain reduction tended to peak within 3 to 4 weeks of beginning SMT (80%) and tapered slightly after 2 to 3 months (67%) and 6 months (65% SMT) but remained higher than that achieved after 1 to 2 weeks. Pain
Conclusion
Based on the RCTs reviewed, SMT appears to be effective for pain reduction in the short, intermediate, and long terms. One-third of the studies included in this SR demonstrated more pain reduction with SMT than for control groups at one or more time points, whereas two-thirds showed no difference between SMT and the control groups. No study found SMT to be inferior to other treatments in regard to pain reduction at any time. There is no evidence to suggest that a higher number of treatment
Acknowledgments
The authors would like to thank all members of the NASS Complementary Medicine Task force for their advice and work on this project (in alphabetical order): Thiru M. Annaswamy, MD; Jay E. Bowen, DO; Simon Dagenais, DC, PhD; Michael D. Freeman, PhD, DC, MPH; Mark R. Foster, MD, PhD; Kim J. Garges, MD, DC; Ralph E. Gay, MD, DC; John M. Mayer, PhD, DC; Steven A. Schopler, MD. The authors would also like to thank their NASS staff liaison, Karen James, for her efforts on this project.
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For the Contemporary Concepts on Manipulation, Mobilization, and Massage Task Force of the North American Spine Society.
This Contemporary Concepts in Spine Care review is part of a series of referenced reviews of contemporary issues in spine care produced by the North American Spine Society (NASS). Each review represents the current state of knowledge on a particular topic. Before entering the review process for The Spine Journal, the authors were assisted by members of the NASS Committee on Contemporary Concepts: Daniel Brodke, MD, Chair; Christopher Bono, MD; Robert Dawe, MD; and Mitchell B. Harris, MD.
FDA device/drug status: not applicable.
Author disclosures: SD (salary, Palladian Health; stock ownership, including options and warrants, Palladian Health; training grant, NCMIC Foundation; speaking and/or teaching arrangements, NCMIC Foundation); REG (consulting, Mainstay Medical); ACT (consulting, Palladian Health); JMM (consulting, Palladian Health; scientific advisory board, Palladian Health; other office, US Spine & Sport Foundation; research support: investigator salary and staff and/or materials, Johnson and Johnson; grant, Johnson and Johnson).