A Review of Studies Assessing Efficacy and Safety of Spinal Manipulation and Mobilization in Treatment of Lower Back Pain
Spinal manipulation (SMT) to treat lower back pain (LBP) has been performed for generations, dating as far back as 2700 BC, it is thought. Since 1895, SMT has been primarily the domain of chiropractics, when it became a profession. With the increasing prevalence of lower back pain in the Western world, SMT and spinal mobilization (MOB) - similar to SMT but without the thrust - has become increasingly popular as a treatment.
Although there are different subtypes of SMT, the premise is the same, the most common is the application of a high-velocity, low-amplitude (HVLA) thrust to the spine with the practitioner's hand to distract spinal zygapophyseal joints.
Before any type of SMT, the patients must be thoroughly assessed to rule out any reasons why SMT should not be performed. These contraindications include presence of a malignancy, infection, spondyloarthritis, or neurological conditions that would not be appropriate for SMT. Other red flags include fever, unrelenting night pain or pain at rest, pain with below knee numbness or weakness, leg weakness, loss of bowel or bladder control, progressive neurologic deficit, direct trauma, unexplained weight loss, and history of cancer.
After evaluation of the patient, the practitioner positions the patients, with torso, hips, arms, and legs according to the type of treatment to be performed. The practitioner's treatment hand is placed over the super or inferior vertebra of the target spinal motion segment. A slow force is applied to preload the target spinal joints and then a HVLA thrust is administered. The procedure is considered to be a controlled medical act in many places, only to be performed by a licensed practitioner, such as doctors of chiropractic. Some doctors of osteopathy are qualified to perform the maneuver as well.
The authors of this article searched the literature for randomized controlled trials to assess the efficacy of SMT and MOB for management of chronic LBP. The authors noted that official guidelines for the management of LBP have been developed in several countries, however, they often become outdated quickly because of the number of on-going and new trials. In searching for study results of SMT, the authors found a systemic review that concluded SMT was not an effective intervention and it was not a recommended treatment. However, as the authors point out, the review was very limited because of "an incomplete quality assessment, lack of prespecified rules to evaluate the evidence, and several erroneous assumptions." They also pointed out the bias in the system against chiropractors.
In looking at other studies, findings indicated the following:
- moderate evidence for its effectiveness in chronic LBP, as well as that of MOB. For patient-related pain, SMT with exercise appeared to be similar in effect to prescription nonsteroidal anti-inflammatory drugs (NSAIDs) with exercise. As well, SMT and MOB appeared to be superior to usual medical care and placebo for very short-term pain and similar to usual medical care and placebo in the short term.
- moderate to strong evidence for predominantly chronic LBP
- strong evidence that SMT is similar in effect to medical care plus exercise or exercise instruction
- moderate evidence that SMT is superior to usual medical care alone
- moderate evidence that SMT is similar to Physical Therapy, both short term and long term
- moderate evidence that SMT/MOB is superior to Physical Therapy and to home exercise in the long term.
- limited evidence that SMT is superior to hospital outpatient care for pain and disability
- limited evidence that SMT is superior to SMT/MOB over short term to Physical Therapy, home back exercise, traction/exercise/corset, no treatment, and placebo
At the time of writing the article, there were three full-scale randomized controlled trials in progress, one comparing trunk exercise to SMT, investigating the effectiveness of SMT in the elderly, and one evaluating pretreatment prediction rules for positive outcomes.
When assessing adverse events, SMT was associated with mild localized soreness or pain (temporary). In one study of 1058 patients who underwent 4712 session total, 53 percent reported local discomfort, 12 percent headache, 11 percent fatigue, 10 percent radiating discomfort, and 5 percent dizziness. Most adverse effects occurred within 4 hours of the procedure and were mild to moderate in severity. There have been rare severe adverse events reported with SMT, including lumbar disc herniation and cauda equina syndrome.
In conclusion, the authors stated that there is evidence for efficacy of SMT and MOB in the treatment of chronic LBP and that future trials should "examine well-defined subgroups of LBP patients according to validated and reliable diagnostic classification criteria, establish the optimal number of treatment visits, and evaluate the cost effectiveness of care using appropriate methodology."
Gert Bronfort, DC, PhD, et al. Evidence-informed management of chronic low back pain with spinal manipulation an mobilization. In The Spine Journal. January/February 2008. Vol. 8. Issue 1. Pp. 213-225.