Low Back Pain

Manipulation and Mobilization for Treating Chronic Low Back Pain: A Systematic Review and Meta-analysis

The Chiro.Org Blog

SOURCE:   Spine J. 2018 (May); 18 (5): 866–879

Ian D. Coulter, PhD, Cindy Crawford, BA, Eric L. Hurwitz, DC, PhD, Howard Vernon, DC, PhD, Raheleh Khorsan, PhD, Marika Suttorp Booth, MS, Patricia M. Herman, ND, PhD

RAND Corporation,
1776 Main St,
Santa Monica, CA 90407-2138, USA

BACKGROUND CONTEXT:   Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies.

PURPOSE:   The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain.

STUDY DESIGN/SETTING:   This is a systematic literature review and meta-analysis.

OUTCOME MEASURES:   The present study measures self-reported pain, function, health-related quality of life, and adverse events.

METHODS:   We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912.

RESULTS:   Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=–0.28, 95% confidence interval (CI) –0.47 to –0.09, p=.004; I²=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=–0.33, 95% CI –0.63 to –0.03, p=.03; I²=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=–0.43, 95% CI –0.86 to 0.00; p=.05, I²=79%; SMD=–0.86, 95% CI –1.27 to –0.45; p<.0001, I²=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=–0.20, 95% CI –0.35 to –0.04; p=.01; I²=0%) but not disability (SMD=–0.10, 95% CI –0.28 to 0.07; p=.25; I²=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described.

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What Low Back Pain Is and Why We Need to Pay Attention

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SOURCE:   Lancet. 2018 (Mar 20) [Epub]

Prof Jan Hartvigsen, PhD, Mark J Hancock, PhD, Alice Kongsted, PhD, Prof Quinette Louw, PhD, Manuela L Ferreira, PhD, Stéphane Genevay, MD, Damian Hoy, PhD, Prof Jaro Karppinen, PhD, Glenn Pransky, MD, Prof Joachim Sieper, MD, Prof Rob J Smeets, PhD, Prof Martin Underwood, MD

Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark,
Odense, Denmark;
Nordic Institute of Chiropractic and Clinical Biomechanics,
Odense, Denmark.

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide.

This is just one article from a series of 4:

The Lancet 2018 Series on Low Back Pain

For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause – eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling.

Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect.

Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

From the FULL TEXT Article:

Introduction

Low back pain is an extremely common symptom experienced by people of all ages. [1–3] In 2015, the global point prevalence of activity-limiting low back pain was 7.3%, implying that 540 million people were affected at any one time. Low back pain is now the number one cause of disability globally. [4] The largest increases in disability caused by low back pain in the past few decades have occurred in low-income and middle-income countries, including in Asia, Africa, and the Middle East, [5] where health and social systems are poorly equipped to deal with this growing burden in addition to other priorities such as infectious diseases.

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Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions

The Chiro.Org Blog

SOURCE:   Lancet. 2018 (Mar 20) [Epub]

Nadine E Foster, Johannes R Anema, Dan Cherkin, Roger Chou, Steven P Cohen, Douglas P Gross, Paulo H Ferreira, Julie M Fritz, Bart W Koes, Wilco Peul, Judith A Turner, Chris G Maher, on behalf of the Lancet Low Back Pain Series Working Group

Arthritis Research UK Primary Care Centre,
Research Institute for Primary Care and Health Sciences,
Keele University,
Staffordshire, UK.

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences.

This is just one article from a series of 4:

The Lancet 2018 Series on Low Back Pain

The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation.

These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

From the FULL TEXT Article:

Introduction

Despite the plethora of treatments and health-care resources devoted to low back pain, back-related disability and population burden have increased. [1, 2] The first paper [3] in this Series describes the global burden and effect of low back pain and provides an overview of the causes and course of low back pain. In this Series paper, we summarise the evidence for effectiveness of interventions for the prevention and treatment of low back pain and the recommendations from best practice guidelines. Despite generally consistent guideline recommendations around the world, clear evidence exists of substantial gaps between evidence and practice that are pervasive in low-income, middle-income, and high-income countries. Different response strategies are needed that prevent and minimise disability and promote participation in physical and social activities. Here we highlight examples of effective, promising, or emerging solutions from around the world and make recommendations to strengthen the vidence base for them.

Prevention

Table 1

By contrast with the large number of trials that assess treatments for low back pain, evidence about prevention, particularly primary prevention, is inadequate (table 1). Most of the widely promoted interventions to prevent low back pain (eg, work-place education, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices) do not have a firm evidence base. A 2016 systematic review [4] identified only 21 trials with 30,850 adults (one in a low-middle-income country [Thailand]), and a 2014 systematic review [5] analysed only 11 randomised controlled trials with 2,700 children (one in a low-middle income country [Brazil]).

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