Elsevier

The Spine Journal

Volume 10, Issue 10, October 2010, Pages 918-940
The Spine Journal

Review Article
NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain

https://doi.org/10.1016/j.spinee.2010.07.389Get rights and content

Abstract

Background context

Low back pain (LBP) continues to be a very prevalent, disabling, and costly spinal disorder. Numerous interventions are routinely used for symptoms of acute LBP. One of the most common approaches is spinal manipulation therapy (SMT).

Purpose

To assess the current scientific literature related to SMT for acute LBP.

Patient sample

Not applicable.

Outcome measures

Not applicable.

Design

Systematic review (SR).

Methods

Literature was identified by searching MEDLINE using indexed and free text terms. Studies were included if they were randomized controlled trials (RCTs) published in English, and SMT was administered to a group of patients with LBP of less than 3 months. RCTs included in two previous SRs were also screened, as were reference lists of included studies. Combined search results were screened for relevance by two reviewers. Data related to methods, risk of bias, harms, and results were abstracted independently by two reviewers.

Results

The MEDLINE search returned 699 studies, of which six were included; an additional eight studies were identified from two previous SRs. There were 2,027 participants in the 14 included RCTs, which combined SMT with education (n=5), mobilization (MOB) (n=4), exercise (n=3), modalities (n=3), or medication (n=2). The groups that received SMT were most commonly compared with those receiving physical modalities (n=7), education (n=6), medication (n=5), exercise (n=5), MOB (n=3), or sham SMT (n=2). The most common providers of SMT were chiropractors (n=5) and physical therapists (n=5). Most studies (n=6) administered 5 to 10 sessions of SMT over 2 to 4 weeks for acute LBP. Outcomes measured included pain (n=10), function (n=10), health-care utilization (n=6), and global effect (n=5). Studies had a follow-up of less than 1 month (n=7), 3 months (n=1), 6 months (n=3), 1 year (n=2), or 2 years (n=1). When compared with various control groups, results for improvement in pain in the SMT groups were superior in three RCTs and equivalent in three RCTs in the short term, equivalent in four RCTs in the intermediate term, and equivalent in two RCTs in the long term. For improvement in function, results from the SMT groups were superior in one RCT and equivalent in four RCTs in the short term, superior in one RCT and equivalent in one RCT in the intermediate term, and equivalent in one RCT and inferior in one RCT in the long term. No harms related to SMT were reported in these RCTs.

Conclusions

Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.

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.

References (71)

  • K.T. Hoiriis et al.

    A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain

    J Manipulative Physiol Ther

    (2004)
  • V. Santilli et al.

    Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations

    Spine J

    (2006)
  • T.W. Flynn et al.

    The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain

    J Manipulative Physiol Ther

    (2006)
  • J.M. Fritz et al.

    Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain

    Arch Phys Med Rehabil

    (2005)
  • 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)
  • E.L. Hurwitz et al.

    Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study

    J Manipulative Physiol Ther

    (2004)
  • K.A. Shearar et al.

    A randomized clinical trial of manual versus mechanical force manipulation in the treatment of sacroiliac joint syndrome

    J Manipulative Physiol Ther

    (2005)
  • G. Bronfort et al.

    Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis

    Spine J

    (2004)
  • P. Gallinaro et al.

    Three cases of lumbar disc rupture and one of cauda equina associated with spinal manipulation (chiropraxis)

    Lancet

    (1983)
  • J.S. Oppenheim et al.

    Nonvascular complications following spinal manipulation

    Spine J

    (2005)
  • X. Morandi et al.

    Caudal spinal cord ischemia after lumbar vertebral manipulation

    Joint Bone Spine

    (2004)
  • J.M. Whedon et al.

    Spinal epidural hematoma after spinal manipulative therapy in a patient undergoing anticoagulant therapy: a case report

    J Manipulative Physiol Ther

    (2006)
  • D. Oliphant

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

    J Manipulative Physiol Ther

    (2004)
  • R. Waxman et al.

    A prospective follow-up study of low back pain in the community

    Spine

    (2000)
  • J.D. Cassidy et al.

    Incidence and course of low back pain episodes in the general population

    Spine

    (2005)
  • P.L. Loney et al.

    The prevalence of low back pain in adults: a methodological review of the literature

    Phys Ther

    (1999)
  • B.F. Walker

    The prevalence of low back pain: a systematic review of the literature from 1966 to 1998

    J Spinal Disord

    (2000)
  • C.E. Dionne et al.

    A consensus approach toward the standardization of back pain definitions for use in prevalence studies

    Spine

    (2008)
  • A.D. Furlan et al.

    2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group

    Spine

    (2009)
  • G.B. Andersson et al.

    The intensity of work recovery in low back pain

    Spine

    (1983)
  • I. Atroshi et al.

    Primary care patients with musculoskeletal pain. Value of health-status and sense-of-coherence measures in predicting long-term work disability

    Scand J Rheumatol

    (2002)
  • M. Roland et al.

    A study of the natural history of low-back pain. Part II: development of guidelines for trials of treatment in primary care

    Spine

    (1983)
  • T.R. Stanton et al.

    After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought

    Spine

    (2008)
  • F.M. Kovacs et al.

    The transition from acute to subacute and chronic low back pain: a study based on determinants of quality of life and prediction of chronic disability

    Spine

    (2005)
  • N.J. Manek et al.

    Epidemiology of back disorders: prevalence, risk factors, and prognosis

    Curr Opin Rheumatol

    (2005)
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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).

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