Efficacy of spinal manipulative therapy for low back pain of less than three months' duration

A Comparative Electromyographic Analysis of Flying Squirrel and 3-Point Quadripod Exercise for Lumbar Multifidus Muscle Activations among Healthy Female Subjects

Physical therapists employ several exercises to alleviate low back pain (LBP). Electromyography (EMG) examination of exercises can monitor muscle activation to help clinicians determine the exercise’s effect on stabilisation, endurance, or strength. This study evaluated surface EMG activity comparison for Flying Squirrel Exercise (FSE) and the novel 3-Point Quadripod Exercise (3-PQE) to find the most effective exercise for stimulating the lumbar multifidus (LM) muscle. The study recruited 64 healthy young females (19–24 years). Raw data were normalized and are expressed as the percentage of maximum voluntary isometric contraction (%MVIC). The test–retest reliability of the EMG recordings was estimated using intraclass correlation coefficient (ICC3,1). One-way ANOVA was used to statistically analyse and compare the EMG amplitudes during the two exercises. The ICCs for 3-PQE and FSE were 0.94 (SEM, 21.7% MVIC) and 0.87 (SEM, 19.05% MVIC), respectively. The 3-PQE (69 ± 26% MVIC) demonstrated significantly higher activity than did FSE (30 ± 18% MVIC) (F = 15.573, p = 0.001). Thus, 3-PQE might be a feasible strategy for the prevention and rehabilitation of LBP in females.

Effects of exercise therapy in patients with acute low back pain: a systematic review of systematic reviews

BACKGROUND

Acute low back pain is associated with pain and disability, but symptoms are often self-healing. The effectiveness of exercise therapy for acute low back pain remains uncertain with conflicting evidence from systematic reviews. The aim of this systematic review of systematic reviews was to assess the overall certainty of evidence for the effects of exercise therapy, compared with other interventions, on pain, disability, recurrence, and adverse effects in adult patients with acute low back pain.

METHODS

PubMed, the Cochrane library, CINAHL, PEDro, Open Grey, Web of Science, and PROSPERO were searched for systematic reviews of randomized controlled trials. Methodological quality was assessed independently by two authors using AMSTAR. Meta-analyses were performed if possible, using data from the original studies. Data for pain, disability, recurrence, and adverse effects were analyzed. Certainty of evidence was assessed using GRADE.

RESULTS

The searches retrieved 2602 records, of which 134 publications were selected for full-text screening. Twenty-four reviews were included, in which 21 randomized controlled trials (n = 2685) presented data for an acute population, related to 69 comparisons. Overlap was high, 76%, with a corrected covered area of 0.14. Methodological quality varied from low to high. Exercise therapy was categorized into general exercise therapy, stabilization exercise, and McKenzie therapy. No important difference in pain or disability was evident when exercise therapy was compared with sham ultrasound, nor for the comparators usual care, spinal manipulative therapy, advice to stay active, and educational booklet. Neither McKenzie therapy nor stabilization exercise yielded any important difference in effects compared with other types of exercise therapy. Certainty of evidence varied from very low to moderate.

CONCLUSIONS

The findings suggest very low to moderate certainty of evidence that exercise therapy may result in little or no important difference in pain or disability, compared with other interventions, in adult patients with acute low back pain. A limitation of this systematic review is that some included reviews were of low quality. When implementing findings of this systematic review in clinical practice, patients' preferences and the clinician's expertise also should be considered, to determine if and when exercise therapy should be the intervention of choice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD46146, available at: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=46146 .

Efficacy of Caudal Epidural Steroid Injection with Targeted Indwelling Catheter and Manipulation in Managing Patients with Lumbar Disk Herniation and Radiculopathy: A Prospective, Randomized, Single-Blind Controlled Trial

BACKGROUND

Lumbar disk herniation (LDH) is considered a common cause of lumbosacral radiculopathy. Epidural steroid injection is a common method to treat inflammation associated with low back-related leg pain. Spinal manipulations are widely used, and systematic reviews have also shown that these manipulations are more effective than placebos.

OBJECTIVE

Due to the absence of clinical evidence, we designed a prospective, randomized, single-blind controlled trial in patients with LDH with radiculopathy, aiming to detect the safety and clinical efficacy of targeted indwelling catheter combined with "4-step" manipulative therapy in patients with LDH.

METHODS

Patient visits were performed at baseline and days 1, 3, 7, and 28 after treatment. Clinical outcomes were measured using visual analog scale for back and leg pain, Oswestry Disability Index (ODI), and clinical symptom scores of the Japanese Orthopedic Association (JAO).

RESULTS

The study included 85 eligible patients. They were categorized with a randomization schedule into a Catheter Group (N = 43) and No-Catheter Group (N = 42). Between the measurement points, there was a statistically significant difference in the visual analog scale (back) at days 1, 3, and 7 of follow-up after treatment between the 2 groups. The change was statistically different at days 1 and 3, and a higher change was observed in the Catheter Group compared with the No-Catheter Group. There was a statistically significant difference in change of JOA and ODI scores at day 1 of follow-up after treatment between the 2 groups, and a greater change was seen in the Catheter Group at days 1 and 3 compared with the No-Catheter Group.

LIMITATIONS

The small sample size was small, and the follow-up time was short. The study also lacked documents of adjuvant therapies, like individual patient exercise routines and analgesic drug therapy.

CONCLUSION

Both methods were effective in reducing pain intensity and functional disability compared with pretreatment. The Catheter Group showed a more significant decrease in visual analog scale and greater changes in JOA and ODI scores of short/term follow-up, compared with the No-Catheter Group. The therapy project was safe.

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis

IMPORTANCE

Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT.

OBJECTIVE

To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain.

DATA SOURCES

Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms.

DATA EXTRACTION AND SYNTHESIS

Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

MAIN OUTCOMES AND MEASURES

Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks.

FINDINGS

Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.

CONCLUSIONS AND RELEVANCE

Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

The Chiropractic Hospital-Based Interventions Research Outcomes Study: Consistency of Outcomes Between Doctors of Chiropractic Treating Patients With Acute Lower Back Pain

OBJECTIVE

The aim of this study was to determine if effectiveness differs between community-based doctors of chiropractic administering standardized evidence-based care that includes high-velocity low-amplitude spinal manipulative therapy (SMT) for acute low back pain (LBP).

METHODS

A secondary analysis of randomized controlled trial and observational pilot study data was performed with nonrandom allocation to 4 DCs. Patients included those with Quebec Task Force categories less than or equal to 2 and acute LBP of 2 to 4 weeks' duration. The intervention provided was clinical practice guidelines-based care including high-velocity low-amplitude SMT. Primary outcomes included changes from baseline in modified Roland Disability Questionnaire (RDQ) at 24 weeks. Comparisons of simple main effects at 24 weeks and of marginal main effects in repeated-measures analyses were performed.

RESULTS

Between groups, adjusted point-specific differences in RDQ change were minimally clinically important but not statistically significant at 24 weeks (largest pairwise difference, -3.1; 95% confidence interval, -6.3 to 0.1; overall P = .10). However, in optimal analyses that considered the repeated nature of the measurements for each outcome, significant differences in marginal mean RDQ changes were found between groups (largest pairwise difference, -3.8; 95% confidence interval, -4.9 to 2.6; overall P = .03).

CONCLUSIONS

Overall, DCs differed modestly in their effectiveness in improving LBP-specific disability. The point estimates mirrored typically reported effect sizes from recent systematic reviews of SMT; however, confidence limits did not exclude clinically negligible effects.

Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain

OBJECTIVE

Recent research suggests that sleep quality and pain intensity are intimately linked. Although sleep problems are common in patients with low back pain, the effect of sleep quality on the levels of pain intensity is currently unknown. The aim of this study was to investigate the effect of sleep quality on subsequent pain intensity in patients with recent-onset low back pain.

METHODS

Data on 1,246 patients with acute low back pain were included in the analysis. Sleep quality was assessed using the sleep quality item of the Pittsburgh Sleep Quality Index, scored on a 0-3-point scale, where 0 = very good sleep quality and 3 = very bad sleep quality. Pain intensity was assessed on a numerical rating scale (range 0-10). A generalized estimating equation (GEE) analysis modeled with an exchangeable correlation structure was used to examine the relationship between sleep quality and pain intensity. The model further controlled for symptoms of depression and prognostic factors for low back pain.

RESULTS

The GEE analysis demonstrated a large effect of poor sleep on subsequent pain intensity, such that for every 1-point decrease in sleep quality (based on a 0-3-point scale), pain intensity (based on a 0-10-point scale) increased by 2.08 points (95% confidence interval 1.99-2.16). This effect was independent of depression and common prognostic factors for low back pain.

CONCLUSION

Sleep quality is strongly related to subsequent pain intensity in patients with acute low back pain. Future research is needed to determine whether targeting sleep improvement contributes to pain reduction.

Neural responses of posterior to anterior movement on lumbar vertebrae: a functional magnetic resonance imaging study

OBJECTIVE

The purpose of this study was to develop and test a clinically relevant method to mechanically stimulate lumbar functional spinal units while recording brain activity by means of functional magnetic resonance imaging (MRI).

METHODS

Subjects were investigated in the prone position with their face lying on a modified stabilization pillow. To minimize head motion, the pillow was fixed to the MRI headrest, and supporting straps were attached around the shoulders. An experienced manual therapist applied controlled, nonpainful pressure stimuli to 10 healthy subjects at 3 different lumbar vertebrae (L1, L3, and L5). Pressure applied to the thumb was used as a control. The stimulation consisted of posterior to anterior (PA) pressure movement. The therapist followed a randomized stimulation protocol projected onto a screen in the MRI room. Blood oxygenation level-dependent responses were analyzed in relation to the lumbar and the thumb stimulations. The study was conducted by the Chiropractic Department, Faculty of Medicine, University of Zürich, Switzerland.

RESULTS

No participant reported any discomfort due to the prone-lying position or use of the pillow. Importantly, PA-induced pressure produced only minimal head movements. Stimulation of the lumbar spinous processes revealed bilateral neural responses in medial parts of the postcentral gyrus (S1). Additional activity was observed in the secondary somatosensory cortex (S2), posterior parts of the insular cortex, different parts of the cingulate cortex, and the cerebellum. Thumb stimulations revealed activation only in lateral parts of the contralateral S1.

CONCLUSION

The current study demonstrates the feasibility of the application of PA pressure on lumbar spinous processes in an MRI environment. This approach may serve as a promising tool for further investigations regarding neuroplastic changes in chronic low back pain subjects.

Stratified models of care

Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase health-care efficiency by offering the right treatment to the right patient at the right time. From being called the 'Holy Grail' of back pain research over a decade ago, stratified care is becoming the zeitgeist in research and clinical practice. In this chapter, we introduce and evaluate the quality and underpinning evidence for three examples of stratified care for back pain to highlight their general principles, research design issues and clinical practice implications. We include consideration of their merits for implementation in practice. We conclude with a set of remaining, key research questions.

The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain

BACKGROUND

The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of patients with chronic low back pain (LBP) has not been previously investigated.

OBJECTIVE

The purpose of this study was to investigate whether the therapeutic alliance between physical therapists and patients with chronic LBP predicts clinical outcomes.

DESIGN

This was a retrospective observational study nested within a randomized controlled trial.

METHODS

One hundred eighty-two patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate whether the alliance was a predictor of outcome or moderated the effect of treatment.

RESULTS

The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for 2 of 3 treatment contrasts (general exercise versus motor control exercise, spinal manipulative therapy versus motor control exercise). There was no treatment effect modification when outcome was measured with function, pain, and disability measures.

LIMITATIONS

Therapeutic alliance was measured at the second treatment session, which might have biased the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks.

CONCLUSIONS

Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.

Predictors of improvement in patients with acute and chronic low back pain undergoing chiropractic treatment

OBJECTIVES

The purpose of this study was to investigate outcomes and prognostic factors in patients with acute or chronic low back pain (LBP) undergoing chiropractic treatment.

METHODS

This was a prognostic cohort study with medium-term outcomes. Adult patients with LBP of any duration who had not received chiropractic or manual therapy in the prior 3 months were recruited from multiple chiropractic practices in Switzerland. Participating doctors of chiropractic were allowed to use their typical treatment methods (such as chiropractic manipulation, soft tissue mobilization, or other methods) because the purpose of the study was to evaluate outcomes from routine chiropractic practice. Patients completed a numerical pain rating scale and Oswestry disability questionnaire immediately before treatment and at 1 week, 1 month, and 3 months after the start of treatment, together with self-reported improvement using the Patient Global Impression of Change.

RESULTS

Patients with acute (<4 weeks; n = 523) and chronic (>3 months; n = 293) LBP were included. Baseline mean pain and disability scores were significantly (P < .001) higher in patients with acute LBP. In both groups of patients, there were significant (P < .0001) improvements in mean scores of pain and disability at 1 week, 1 month, and 3 months, although these change scores were significantly greater in the acute group. Similarly, a greater proportion of patients in the acute group reported improvement at each follow-up. The most consistent predictor was self-reported improvement at 1 week, which was independently associated with improvement at 1 month (adjusted odds ratio [OR], 2.4 [95% confidence interval, 1.3-4.5] and 5.0 [2.4-10.6]) and at 3 months (2.9 [1.3-6.6] and 3.3 [1.3-8.7]) in patients with acute and chronic pain, respectively. The presence of radiculopathy at baseline was not a predictor of outcome.

CONCLUSIONS

Patients with chronic and acute pain reporting that they were "much better" or "better" on the Patient Global Impression of Change scale at 1 week after the first chiropractic visit were 4 to 5 times more likely to be improved at both 1 and 3 months compared with patients who were not improved at 1 week. Patients with acute pain reported more severe pain and disability initially but recovered faster. Patients with chronic and acute back pain both reported good outcomes, and most patients with radiculopathy also improved.

The effectiveness of sub-group specific manual therapy for low back pain: a systematic review

BACKGROUND

Manual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond.

OBJECTIVES

To determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy.

DATA SOURCES

A systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL). TRIAL ELIGIBILITY CRITERIA: RCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included. TRIAL APPRAISAL AND SYNTHESIS METHODS: Identified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity.

RESULTS

Seven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low.

CONCLUSIONS

This review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required.

Strain-Counterstrain therapy combined with exercise is not more effective than exercise alone on pain and disability in people with acute low back pain: a randomised trial

QUESTION

Is Strain-Counterstrain treatment combined with exercise therapy more effective than exercise alone in reducing levels of pain and disability in people with acute low back pain?

DESIGN

Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

89 (55 female) participants between 18 and 55 years experiencing acute low back pain were randomised to experimental (n = 44) and control (n = 45) groups.

INTERVENTION

Participants attended four treatments in two weeks. The experimental group received Strain-Counterstrain treatment and review of standardised exercises (abdominal bracing, knee to chest, and lumbar rotation). The control group performed the standardised exercises under supervision. Following the intervention period, all participants received exercise progression, manual therapy, and advice.

OUTCOME MEASURES

The primary outcome was the modified Oswestry low back pain disability questionnaire, measured at 2 weeks (ie, end of treatment), 6 weeks, and 28 weeks. Secondary outcome measures included the SF-36, visual analogue scale pain ratings, and a 7-point global rating of change.

RESULTS

The experimental intervention was not more effective than exercise alone in reducing levels of pain and disability. Mean between-group differences in change from baseline for the Oswestry Disability Index were 0 (95% CI -6 to 7) after treatment, -1 (95% CI -7 to 6) at 6 weeks, and 2 (95% CI -4 to 8) at 28 weeks. Other outcomes did not differ significantly between groups.

CONCLUSION

There is no advantage in providing Strain- Counterstrain treatment to patients with acute low back pain, although further studies could examine whether a subset of these patients can benefit from the treatment.

TRIAL REGISTRATION

ACTRN 12609000084280.

Spinal manipulative therapy for acute low back pain: a clinical perspective

Low back pain (LBP) is an extremely common cause of pain and disability. While many treatments for acute LBP exist, one of the most widely used, but also most controversial, is spinal manipulative therapy (SMT). This therapy includes both high-velocity manipulative techniques and low-velocity mobilization techniques. The literature regarding the use of SMT is often conflicting, which explains the difference in recommendations regarding SMT in international LBP guidelines. The lack of a clear tissue diagnosis in the majority of patients with LBP combined with the unknown mechanism of action of SMT adds to the difficulty for clinicians in providing SMT in a logical and effective manner. Despite these limitations, the existing literature does provide some assistance to clinicians on when to provide SMT and how to provide it in an optimal way. This review aims to summarize the key research literature investigating SMT in LBP in order to help clinicians make informed decisions about the use of SMT for their patients with acute LBP.

Implications and limitations of appropriateness studies for chiropractic

OBJECTIVE

The appropriate role for chiropractic in US health care has not been established, but third-party payors and public policy makers must make decisions about the appropriate role for chiropractors in health care systems and for the services that chiropractors provide. Appropriateness studies for chiropractic may inform those decisions. The purpose of this article is to discuss the implications and limitations of appropriateness studies for chiropractic.

DISCUSSION

We reviewed the general context for assessment of the appropriateness and the application of appropriateness studies to chiropractic in particular. We evaluated the implications and limitations for chiropractic of methods of small area analysis and the RAND-UCLA Appropriateness Method. The RAND-UCLA Appropriateness Method has been applied to the evaluation of spinal manipulation. Regional variations in chiropractic utilization have yet to be described through small area analysis, but these methods appear to hold some potential for assessing the appropriateness of chiropractic care. Both small area analysis and the RAND-UCLA method offer limited possibilities for the assessment of chiropractic appropriateness.

CONCLUSION

Future assessment of the appropriate role for chiropractic in US health care will raise issues beyond the scope of previous appropriateness studies. Studying the appropriate role for chiropractic will require consideration of the clinical discipline in its entirety, rather than individual consideration of specific interventions. A fair assessment of chiropractic appropriateness will require new evidence and perhaps new research methodologies.

Integrative medicine approach to chronic pain

Chronic pain can be a frustrating condition for patient and clinician. The integrative medicine approach to pain can offer hope, adding safe complementary and alternative medical (CAM) therapies to mitigate pain and suffering. Such CAM therapies include nutrition, supplements and herbs, manual medicine, acupuncture, yoga, and mind-body approaches. The evidence is heterogeneous regarding these approaches, but some evidence suggests efficacy and confirms safety. The integrative medicine approach can be beneficial in a patient with chronic pain.

Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review

STUDY DESIGN

A systematic review of randomized controlled trials.

OBJECTIVE

To determine the efficacy and adverse effects of conservative treatments for people who have lumbar disc herniation with associated radiculopathy (LDHR).

SUMMARY OF BACKGROUND DATA

Although conservative management is commonly used for people who have LDHR, the efficacy and adverse effects of conservative treatments for this condition are unclear.

METHODS

We searched 10 computer databases for trials published in English between 1971 and 2008. Trials focusing on people with referred leg symptoms and radiologic confirmation of a lumbar disc herniation were included if at least 1 group received a conservative and noninjection treatment.

RESULTS

Eighteen trials involving 1671 participants were included. Seven (39%) trials were considered of high quality. Meta-analysis on 2 high-quality trials revealed that advice is less effective than microdiscectomy surgery at short-term follow-up, but equally effective at long-term follow-up. Individual high-quality trials provided moderate evidence that stabilization exercises are more effective than no treatment, that manipulation is more effective than sham manipulation for people with acute symptoms and an intact anulus, and that no difference exists among traction, laser, and ultrasound. One trial showed some additional benefit from adding mechanical traction to medication and electrotherapy methods. Adverse events were associated with traction (pain, anxiety, lower limb weakness, and fainting) and ibuprofen (gastrointestinal events).

CONCLUSION

Advice is less effective than microdiscectomy in the short term but equally effective in the long term for people who have LDHR. Moderate evidence favors stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound. Adverse events were associated with traction and ibuprofen. Additional high-quality trials would allow firmer conclusions regarding adverse effects and efficacy.

Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review

BACKGROUND

A central element in the current debate about best practice management of non-specific low back pain (NSLBP) is the efficacy of targeted versus generic (non-targeted) treatment. Many clinicians and researchers believe that tailoring treatment to NSLBP subgroups positively impacts on patient outcomes. Despite this, there are no systematic reviews comparing the efficacy of targeted versus non-targeted manual therapy and/or exercise. This systematic review was undertaken in order to determine the efficacy of such targeted treatment in adults with NSLBP.

METHOD

MEDLINE, EMBASE, Current Contents, AMED and the Cochrane Central Register of Controlled Trials were electronically searched, reference lists were examined and citation tracking performed. Inclusion criteria were randomized controlled trials of targeted manual therapy and/or exercise for NSLPB that used trial designs capable of providing robust information on targeted treatment (treatment effect modification) for the outcomes of activity limitation and pain. Included trials needed to be hypothesis-testing studies published in English, Danish or Norwegian. Method quality was assessed using the criteria recommended by the Cochrane Back Review Group.

RESULTS

Four high-quality randomized controlled trials of targeted manual therapy and/or exercise for NSLBP met the inclusion criteria. One study showed statistically significant effects for short-term outcomes using McKenzie directional preference-based exercise. Research into subgroups requires much larger sample sizes than traditional two-group trials and other included studies showed effects that might be clinically important in size but were not statistically significant with their samples sizes.

CONCLUSIONS

The clinical implications of these results are that they provide very cautious evidence supporting the notion that treatment targeted to subgroups of patients with NSLBP may improve patient outcomes. The results of the studies included in this review are too patchy, inconsistent and the samples investigated are too small for any recommendation of any treatment in routine clinical practice to be based on these findings. The research shows that adequately powered controlled trials using designs capable of providing robust information on treatment effect modification are uncommon. Considering how central the notion of targeted treatment is to manual therapy principles, further studies using this research method should be a priority for the clinical and research communities.

Factors defining care-seeking in low back pain--a meta-analysis of population based surveys

Little is known about factors determining health care-seeking behavior in low back pain. While a number of studies have described general characteristics of health care utilization, only a few have aimed at appropriately assessing determinants of care-seeking in back pain, by comparing seekers and non-seekers. The objective of this systematic review was to identify determinants of health care-seeking in studies with well-defined groups of care-seekers and non-seekers with non-specific low back pain. A search was conducted in Medline, AMED, Cinahl, Web of Science, PsycINFO, National Research Register, Cochrane Library and LILACS looking for population- based surveys of non-specific low back pain patients older than 18 years, published since 1966. To be included in the review, studies needed to report on characteristics of well-defined groups of care-seekers and non-seekers. Methodological quality was assessed using a criteria list based on sampling, response rate, data reproducibility, power calculation and external validity. Risk estimates were expressed as odd ratios (95% confidence intervals). When possible, meta-analyses were performed, using a random effects model. Eleven studies were included in the review. Pooled results show that women are slightly more likely to seek care for their back pain as are patients with a previous history of back pain. Pain intensity was only slightly associated with care-seeking, whereas patients with high levels of disability were nearly eight times more likely to seek care than patients with lower levels of disability.

An overview of CAM: components and clinical uses

Complementary and alternative medicine (CAM), more recently known as integrative health or integrative medicine, is a diverse field comprising numerous treatments and practitioners of various levels of training. This review defines several of the main CAM modalities and reviews some of the research relevant to their clinical application. The goal is to provide healthcare providers with a basic understanding of CAM to start the incorporation of proven treatments into their clinical practice as well as guide them to working with CAM providers; ultimately, such knowledge is a fundamental part of a collaborative approach to optimal patient health and wellness.

Manipulative Therapy and Clinical Prediction Criteria in Treatment of Acute Nonspecific Low Back Pain

Manipulative therapy as part of a multidimensional approach may be more effective than standard physical therapy in treating Acute Nonspecific Low Back Pain. 64 participants, 29 women and 35 men, with Acute Nonspecific Low Back Pain and a mean age of 40 yr. (SD = 9.6) were randomly assigned to two groups: an experimental group (manipulative therapy plus physical therapy) and a control group (only physical therapy). A multicentre, nonblinded, randomised clinical trial was conducted. Pain relief was the main performance criteria measured together with secondary criteria which included functional status and mobility of the lower back. Fritz, Childs, and Flynn's clinical prediction rule—a duration of symptoms less than 16 days, no pain distal of the knee—was used to analyse the results. In combination with an age > 35 years, results showed a statistical significant effect for disability, but no statistically significant benefit of additional manipulative therapy over physical therapy found for pain and mobility within 4 treatments. Controlled for the applied clinical prediction rule, there were statistically significant interaction effects with low effect size for disability and sex, but no significant effects were found for pain of mobility.

Can we predict poor recovery from recent-onset nonspecific low back pain? A systematic review

This systematic review of prospective cohort studies investigated the evidence for prognostic factors for poor recovery in recent-onset nonspecific low back pain (NSLBP). Medline, Cinahl, Embase, PsychINFO, and AMED databases were searched and citation tracking was performed. Fifty studies met the inclusion criteria. Bivariate and multivariable prognostic factor/outcome associations were extracted. Two reviewers independently performed data extraction and method quality assessment. Where data were available, odds ratios for bivariate associations were calculated and meta-analysis was performed on comparable prognostic factor/outcome associations. Despite the number of studies that have investigated these prognostic factors, uncertainty remains regarding which factors are associated with particular outcomes, the strength of those associations and the extent of confounding between prognostic factors. This uncertainty is the result of the disparate methods that have been used in these investigations, incomplete and contradictory findings, and an inverse relationship between study quality and the reported strength of these associations. The clinical implication is that the formation of clinically useful predictive models remains dependent on further high-quality research. The research implications are that subsequent studies can use the findings of this review to inform prognostic factor selection, and that prognostic studies would ideally be designed to enhance the capacity for findings to be pooled with those of other studies.

Inconsistent Grading of Evidence Across Countries: A Review of Low Back Pain Guidelines

OBJECTIVE

The aim of this study was to report clinical treatment recommendations for low back pain (LBP) based on 5 international guidelines and best evidence from the Cochrane database of systematic reviews.

METHODS

Five LBP guidelines available in English language were appraised, including 4 studies published since the seminal work by Koes et al (Spine 2001;26:2504-5213). The guidelines were examined for treatment recommendations concerning nonspecific LBP and guideline quality with application of the Appraisal of Guidelines for Research and Evaluation instrument. Secondly, a systematic literature search for reviews and randomized controlled trials was conducted using a modified version of the search strategy recommended by the Cochrane Back Review Group. Two systematic reviews were identified.

RESULTS

According to best evidence from review of the Cochrane database of systematic reviews, there remains a lack of consensus regarding reported efficacy of spinal manipulative therapy for the treatment of nonspecific LBP. Furthermore, the guidelines reviewed in the present study have not changed significantly with respect to treatment recommendations for nonspecific LBP since the original review, and there is inconsistency between the guidelines regarding optimal time to introduce spinal manipulation to treat nonspecific LBP.

CONCLUSION

Treatment recommendations for nonspecific LBP, particularly spinal manipulation, remain inconclusive. Guideline developers need to consider guidelines in neighboring countries and reach consensus on how evidence is graded and incorporated into guidelines. Guidelines should continue to be regularly updated to incorporate new evidence and methods of grading the evidence.

Review conclusions by Ernst and Canter regarding spinal manipulation refuted

In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter authored a review of the most recent systematic reviews on the effectiveness of spinal manipulation for any condition. The authors concluded that, except for back pain, spinal manipulation is not an effective intervention for any condition and, because of potential side effects, cannot be recommended for use at all in clinical practice. Based on a critical appraisal of their review, the authors of this commentary seriously challenge the conclusions by Ernst and Canter, who did not adhere to standard systematic review methodology, thus threatening the validity of their conclusions. There was no systematic assessment of the literature pertaining to the hazards of manipulation, including comparison to other therapies. Hence, their claim that the risks of manipulation outweigh the benefits, and thus spinal manipulation cannot be recommended as treatment for any condition, was not supported by the data analyzed. Their conclusions are misleading and not based on evidence that allow discrediting of a large body of professionals using spinal manipulation.

Specific stabilisation exercise for spinal and pelvic pain: A systematic review

The aim of this study was to conduct a systematic review of the efficacy of specific stabilisation exercise for spinal and pelvic pain. Randomised clinical trials evaluating specific stabilisation exercise were identified and retrieved. Outcomes were disability, pain, return to work, number of episodes, global perceived effect, or health-related quality of life. A single trial reported that specific stabilisation exercise was more effective than no treatment but not more effective than spinal manipulative therapy for the management of cervicogenic headache and associated neck pain. Single trials reported that specific stabilisation exercise was effective for pelvic pain and for prevention of recurrence after an acute episode of low back pain but not to reduce pain or disability associated with acute low back pain. Pooled analyses revealed that, for chronic low back pain, specific stabilisation exercise was superior to usual medical care and education but not to manipulative therapy, and no additional effect was found when specific stabilisation exercise was added to a conventional physiotherapy program. A single trial reported that specific stabilisation exercise and a surgical procedure to reduce pain and disability in chronic low back pain were equally effective. The available evidence suggests that specific stabilisation exercise is effective in reducing pain and disability in chronic but not acute low back pain. Single trials indicate that specific stabilisation exercise can be helpful in the treatment of cervicogenic headache and associated neck pain, pelvic pain, and in reducing recurrence after acute low back pain.

Selecting an appropriate placebo for a trial of spinal manipulative therapy

Selecting an appropriate control group or placebo for randomised controlled trials of spinal manipulative therapy is essential to the final interpretation and usefulness of these studies. Prior to starting a randomised controlled trial of spinal manipulative therapy for acute low back pain we wanted to ensure that the placebo selected would be considered appropriate by experts in the field thereby making the results more likely to be accepted and more likely to influence clinical practice. We developed ten placebo techniques that aimed to mimic spinal manipulative therapy as closely as possible which, while not including the active component of spinal manipulative therapy, were still credible. This list of placebo techniques with detailed descriptions was sent to 25 experts in the field from Australia and New Zealand including both clinicians and academics. We asked the experts to rate whether they believed each technique was appropriate for use as a placebo in a trial of spinal manipulative therapy. Sixteen (64%) of the experts responded. There were extremely low levels of agreement between the experts on which placebos were appropriate (kappa = 0.05, 95% CI 0.01 to 0.10). For nine of the ten placebos at least one expert considered the placebo to include the active component of spinal manipulative therapy while at least one other expert believed the same placebo was not only not active but also not credible. The results of this study demonstrate the different views of experts on what constitutes an appropriate placebo for trials of spinal manipulative therapy. Different beliefs about what is the active component of spinal manipulative therapy appear to be responsible for much of the disagreement.

Manipulative therapy and/or NSAIDs for acute low back pain: design of a randomized controlled trial [ACTRN012605000036617]

Background

Acute low back pain is a common condition resulting in pain and disability. Current national and international guidelines advocate general practitioner care including advice and paracetamol (4 g daily in otherwise well adults) as the first line of care for people with acute low back pain. Non-steroidal anti-inflammatory drugs (NSAIDs) and spinal manipulative therapy (SMT) are advocated in many guidelines as second line management options for patients with acute low back pain who are not recovering. No studies have explored the role of NSAIDs and/or SMT in addition to first line management for acute low back pain. The primary aim of this study is to investigate if NSAIDs and/or SMT in addition to general practitioner advice and paracetamol results in shorter recovery times for patients with acute low back pain. The secondary aims of the study are to evaluate whether the addition of SMT and/or NSAIDs influences pain, disability and global perceived effect at 1, 2, 4 and 12 weeks after onset of therapy for patients with significant acute low back pain.

Methods/design

This paper presents the rationale and design of a randomised controlled trial examining the addition of NSAIDs and/or SMT in 240 people who present to their general practitioner with significant acute low back pain.

Les manipulations vertébrales : enquête concernant la pratique des médecins formés dans le cadre du diplôme inter-universitaire de Strasbourg

INTRODUCTION

The use of spinal manipulation (SM) is widespread, particularly in English-speaking countries, where many studies are published showing its popularity. However, no study exists of the demography and activity of the French medical profession. Our objective was to investigate the use of SM by French doctors in their daily practice.

MATERIALS AND METHODS

We questioned 234 doctors, general practitioners and specialists who obtained the Inter-Academy of Manual Medicine and Osteopathy Diploma from Strasbourg University between 1985 and 2002.

RESULTS

We obtained a response from 140 physicians: 110 (79%) practiced SM in their daily practice. They considered the technique efficient and used it as a first intention. Approximately one quarter of cases resulted in adverse effects on the back. Most of the doctors (77%) continued their education during their career.

CONCLUSION

This first assessment of the practice of physicians trained in a university in manual medicine allows for confirming the respect of good medical practice with regular actualization of knowledge and reasonable outpatient care.

Evidence-Based Medicine and the Challenge of Low Back Pain: Where Are We Now?

Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.

Does Clinician Treatment Choice Improve the Outcomes of Manual Therapy for Nonspecific Low Back Pain? A Metaanalysis

OBJECTIVE

The purpose of this study is to quantitatively compare outcomes for trials when treating clinicians did, or did not, have the discretion to decide on treatment technique.

METHODS

CINAHL, EMBASE, MEDLINE, the Physiotherapy Evidence Database, the Cochrane Controlled Trials register, reference list searching, and citation tracking were investigated. Ten randomized controlled trials (RCTs) of mobilization and manipulation for nonspecific low back pain (NSLBP) met the inclusion criteria. The effectiveness of manual therapy with and without clinician technique choice was assessed using descriptive statistics and metaanalysis for the outcomes of pain and activity limitation.

RESULTS

In approximately two thirds of the included RCTs, clinicians had choice of treatment technique. There were no systematic differences favoring results for RCTs that did allow clinician choice of treatment technique.

CONCLUSIONS

Few quality studies are available, and conclusions on the basis of these data need to be interpreted with caution. However, allowing clinicians to choose from a number of treatment techniques does not appear to have improved the outcomes of these RCTs that have investigated the effect of manual therapy for NSLBP. If tailoring manual therapy treatment to NSLBP patients does positively impact on patient outcomes, this is not yet systematically apparent.

Physiotherapy management of low back pain: does practice match the Dutch guidelines?

The purpose of this study is to explore adherence by Dutch physiotherapists to the physiotherapists' guideline for non-specific low back pain. For this study data from the National Information Service for Allied Health Care were used. This is a registration network that continuously collects information about physiotherapy patients and their treatment episodes. Within this network, adherence to the low back pain guideline was assessed by three criteria based on the guideline. These criteria concerned the number of sessions, the treatment goals, and the interventions. Data from patients with 'non-specific low back pain' as the reason for referral and a completed treatment episode were selected (n = 1254); 90 therapists in 40 practices treated these patients. The criterion concerning the number of sessions applied only for patients with acute complaints and was met in 17% of these patients. In about half of the patients the criterion for the treatment goals as well as the criterion relating to the interventions was met. Treatment goals are aimed mainly at improving mobility functions and changing body position. In more than three-quarters of the treatment episodes manual interventions (massage or manual manipulation) and exercise therapy were used frequently. As considerable variation in guideline adherence was shown to exist among therapists, there is clearly room for improvement in the quality of the care.