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At Issue: Chronic low back pain
What is the role of spinal manipulation and mobilization in the treatment of chronic low back pain lasting at least 6 months?
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A study in The Spine Journal recently looked at spinal manipulation and mobilization to manage chronic low back pain and its findings were met with mixed reactions. Orthopedics Today invited spine specialists to discuss the study and similar issues raised in a Forbes article published about the same time.
Consensus unclear on use of spinal manipulation, mobilization therapies
Chronic low back pain is a prevalent health problem, with those affected experiencing major detriments to quality of life and financial burdens. A variety of conservative therapeutic approaches have been made available for use that range from NSAIDs and narcotics to steroid injections. However, the exploration of noninvasive techniques, such as spinal manipulation and mobilization, has demonstrated a recent increase in popularity. Manipulation, or thrust intervention, is the application of high-velocity, low-amplitude force to spinal joints, whereas mobilization, or non-thrust intervention, applies passive force to maximize range of motion in the joints. Currently, the idea of implementing these alternatives as treatment standards remains controversial.
Studies demonstrate some benefits
Manipulation and mobilization therapies have some benefits according to recent studies. Shum and colleagues described that posteroanterior mobilization maneuvers applied to the L4 level measurably reduced pain and stiffness in the short-term. Similarly, Bialosky and colleagues and Penza and colleagues demonstrated that manual maneuvers to the lumbar spine can provide post-procedure hypoalgesia to painful stimuli. Using functional MRI, Gay and colleagues established that manipulation and mobilization have an immediate effect on brain regions that process and modulate information from pain receptors. Hence, these noninvasive therapies have established physiological effects that appear to have positive clinical outcomes.
A subset of health care providers is advocating manipulation and mobilization as an alternative therapy to reduce the risk of complications secondary to pharmaceutical or surgical options. A meta-analysis provided by Rubenstein and colleagues details that serious complications from spinal manipulation, such as cauda equina syndrome, paraplegia or death, have only been reported in select case studies, which suggests these procedures are relatively safe in practice. It is estimated that adverse events for manual therapies occur in less than one case per million.
In their systematic review and meta-analysis, Coulter and colleagues focused attention on determining the safety and efficacy of manipulation and mobilization therapies for chronic low back pain (LBP). The authors determined manipulation produces a small to moderate reduction in lumbar pain intensity when compared to exercise or other active comparisons, while mobilization has minimal benefit. However, these investigators suggest that more expansive, long-term studies are needed for drawing conclusions about improving disability and quality of life since the studies included as part of this systematic review only provided 1-month post-intervention outcomes. Similarly, Rubenstein and colleagues insinuated that more evidence is needed to show improvement in costs of care and return to work after manipulation and mobilization.
Techniques are variable
The limitations of the Coulter analysis demonstrate the hardships in studies investigating manipulation and mobilization in chronic LBP. First, chronic back pain is difficult to evaluate due to non-specific symptoms and multiple pathologies with similar clinical manifestations. Previous studies have suggested chronic LBP is multi-factorial in nature with various work-related and non-work-related psychosocial influences. In addition, the specific techniques and duration of manipulation and mobilization treatments are highly variable between providers, which makes it difficult to compare studies exploring effects of manual maneuvers on LBP.
There remains no clear consensus regarding the use of spinal manipulation and mobilization therapies in place of pharmaceutical and surgical options when treating chronic LBP. It is still debated that even though manipulations and mobilization may have statistically significant short-term effects on pain relief, the effect is relatively small and may not translate to clinically significant, long-term improvements. Therefore, the use of manipulation or mobilization therapies should be based on provider or patient preference, cost of care and relative safety of treatments.
- References:
- Assendelft WJ, et al. Cochrane Database Syst Rev. 2004;doi:10.1002/14651858.CD000447.pub2.
- Bialosky JE, et al. Phys Ther. 2009;doi:10.2522/ptj.20090058.
- Bronfort G, et al. Spine J. 2004;doi:10.1016/j.spinee.2003.06.002.
- Clays E, et al. Spine (Phila Pa 1976). 2007;doi:10.1097/01.brs.0000251884.94821.c0.
- Coulter ID, et al. Spine J. 2018;doi:10.1016/j.spinee.2018.01.013.
- Gay CW, et al. J Manipulative Physiol Ther. 2014;doi:10.1016/j.jmpt.2014.09.001.
- Penza CW, et al. J Pain. 2017;doi:10.1016/j.jpain.2017.07.007.
- Powers CM, et al. Phys Ther. 2008;doi:10.2522/ptj.20070069.
- Rubinstein SM, et al. Spine (Phila Pa 1976). 2011;doi:10.1097/BRS.0b013e3182197fe1.
- Shum GL, et al. Arch Phys Med Rehabil. 2013;doi:10.1016/j.apmr.2012.11.020.
- For more information:
- Benjamin Khechen, BA; Dil V. Patel, BS; and Kern Singh, MD, can be reached at department of orthopaedic surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; Khechen’s email: singh.research@rushortho.com; Patel’s email: singh.research2@rushortho.com; Singh’s email: kern.singh@rushortho.com.
Disclosures: Khechen, Patel and Singh report no relevant financial disclosures.
Manipulation inclusion in best practice guidelines for safe and effective treatments
Chronic LBP is a common and often disabling condition affecting individuals worldwide. The estimated global point prevalence of chronic LBP in 2010 was 9.4% and it is the leading cause of disability and years lived with disability worldwide. As global health care improves and life expectancy increases, the population shifts toward an older population. The accompanying increase in non-fatal conditions and related increase in years lived with disability represents a significant economic burden and strain on health care resources.
Evidence-based care for chronic LBP
LBP can be a challenging diagnosis, in part due to its heterogeneous etiology, and it is equally difficult to treat. Investigations into the often-idiopathic nature of chronic LBP have produced numerous studies and recommendations for care with varying degrees of quality. This heterogeneity in some clinical trials may dilute treatment effects and influence generalizability of the results. Recent studies, however, have provided stronger evidence for manipulation as a treatment for LBP than previously reported. The 2018 systematic review and meta-analysis of manipulation and mobilization for chronic LBP by Coulter and colleagues provides the latest examination of this topic.
This systematic review examined efficacy, effectiveness, and safety of manipulation and mobilization for chronic LBP. Moderate quality evidence was reported for thrust-type manipulation, producing small to moderate reductions in pain compared with other active interventions, such as exercise. A subgroup analysis demonstrated manipulation significantly reduced pain and disability compared with other comparators, including exercise and physical therapy. These treatment effects appear to increase over time at 3- and 6-month follow-ups. There was moderate quality evidence that non-thrust mobilization has minimal effect on pain and disability compared to active therapies. Additional research on promising multimodal treatment protocols is warranted to further assess efficacy and safety.
Recent guidelines
Clinical practice guidelines serve to balance risks and benefits with the quality of existing evidence and patient applicability. Recent recommendations for noninvasive treatments for acute and chronic LBP have been adopted by several leading organizations. Systematic reviews and clinical guidelines from Agency for Healthcare Research and Quality, American College of Physicians (ACP), The Institute of Medicine and others recommend conservative care measures as primary therapies for acute and chronic LBP. Recent positive reviews of the treatment risks and therapeutic benefits of manipulation for improved pain and function recommend this as an option for the treatment of non-radicular chronic LBP. The systematic review of current evidence on risks and therapeutic benefits of manipulation for LBP published by the ACP in 2017 recommends conservative care over pharmacological or surgical approaches. This update of previous guidelines strongly recommends manipulation and other conservative therapies as a primary treatment for acute, subacute or chronic LBP.
Manipulation vs usual care
There is clear evidence that pharmacological approaches are not effective for the care of patients with LBP and carry risks not associated with conservative therapies. A study of 1,643 patients with LBP by Lin and colleagues demonstrated an association between paracetamol use and higher levels of disability, longer symptom duration and increased health care costs. Several studies that compared spinal manipulation with pharmacological treatments, primarily NSAIDs or opioids, showed evidence that favored manipulation as a conservative option with low risks and good benefits. These studies report moderate improvements in pain and disability with manipulation without drug-related risks.
In a randomized, double-blinded, placebo-controlled, parallel trial, participants who received spinal manipulation reported significant improvements compared to a group who received NSAIDs (diclofenac) and were clinically superior to a placebo group. A retrospective cohort analysis of the data for 13,384 patients with non-cancer-related LBP by Whedon and colleagues showed opioid analgesic use was 55% lower for patients who received chiropractic care compared to those who did not receive such care. With the number of office visits, the health care costs were significantly lower during a 2-year period.
An editorial by Salzburg in Forbes reported several common misnomers concerning manipulation. Although research continues to improve clinical decision-making tools, the concerns about safety, efficacy and cost effectiveness have been adequately addressed in many peer-reviewed publications.
VA health system
The Veterans Administration (VA) hospital system has included chiropractors into many VA sites. Many studies have tested the addition of chiropractic care into their service lines. A pragmatic comparative effectiveness clinical trial of 750 patients conducted at several large military medical centers by Goertz and colleagues demonstrated the inclusion of chiropractic care, including spinal manipulation, in usual medical care for veterans with chronic LBP resulted in statistically significant improvements in pain and disability scores.
The identification of potential risk factors and the development of subgroup classifications for LBP as a definitive etiology, as well as manipulation responder profiles, will further increase our understanding of the treatment protocol. The recent trends toward pragmatic study designs have yielded interesting results and provided attritional evidence for practitioners. Additional studies will improve the existing best practice guidelines for safe and effective treatments.
- References:
- Chou R, et al. Ann Intern Med. 2017;doi:10.7326/M16-2458.
- Chou R, et al. Ann Intern Med. 2017; doi:10.7326/M16-2459.
- Chou R, et al. Noninvasive treatments for low back pain. Comparative Effectiveness Review no. 169. Available at: https://effectivehealthcare.ahrq.gov/topics/back-pain-treatment/research/. Accessed: July 16, 2018.
- Goertz C M, et al. JAMA Network Open. 2018;doi:10.1001/jamanetworkopen.2018.0105.
- Haldeman S, et al. Spine J. 2008;doi:10.1016/j.spinee.2007.10.009.
- Lin CC, et al. Eur Spine J. 2018;doi:10.1007/s00586-016-4781-0.
- Paige N M, et al. JAMA. 2017;doi: 10.1001/jama.2017.3086.
- Phillips FM, et al. Spine (Phila Pa 1976). 2013;doi:10.1097/BRS.0b013e3182877f11.
- Qaseem A, et al. Ann Intern Med. 2017;doi:10.7326/M16-2367.
- von Heymann WJ, et al. Spine. 2013;doi:10.1097/BRS.0b013e318275d09c.
- Vos T, et al. Lancet. 2017;doi:10.1016/S0140-6736(17)32154-2.
- Whedon JM, et al. J Altern Complement Med. 2018;doi:10.1089/acm.2017.0131.
- For more information:
- Dennis E. Enix, DC, MBA, is a professor of chiropractic science at Logan University. He can be reached at 1851 Schoettler Road, Chesterfield, MO 63017; email: dennis.enix@logan.edu.
Disclosure: Enix reports he is a member of the North American Spine Society Evidence-Based Guideline Committee, which pays his travel expenses for committee work.
Patients should evaluate manipulative, mobilization treatment options
The authors of the recent meta-analysis looking at spinal manipulation for chronic LBP should be commended in their efforts to evaluate the treatment’s efficacy with rigorous scientific methodology. They defined their target population well as chronic, non-specific LBP and collected data from 8,748 patients in multiple studies. The authors concluded the pooled evidence provide some support that spinal manipulation allows for decreased pain and improved function.
However, their study has significant limitations – primarily related to the severe heterogeneity in treatment dosing, types and duration among the various pooled randomized trials. The authors mentioned this: “Studies comparing thrust or non-thrust with a sham or no treatment control were heterogeneous and could not be pooled for analysis in any meaningful way.”
Given the severe heterogeneity and inability to blind patients to their treatments, it is difficult to conclude there is strong or even moderate evidence to support the authors’ conclusions.
However, chronic pain does present significant challenges for scientific study as it is multifactorial in nature and many questions regarding its origin and treatment are still poorly understood.
Although we believe spinal manipulation and mobilization has a place in the treatment of chronic LBP, we do feel that all treatments must be tailored individually to a patient’s preferences.
We routinely counsel patients that there are typically six treatment options for most back pathologies: 1) doing nothing and living with the issue; 2) oral medications including anti-inflammatories, muscle relaxants and neuromodulators; 3) pain management treatments including epidural steroid injections, pain pumps and facet blocks/RFA; 4) formal physical therapy mobilization programs with modalities; 5) alternative treatments, including chiropractic manipulation, acupuncture, inversion tables, cognitive behavioral therapy, etc.; and 6) surgical intervention.
When discussing these treatment options, we always counsel patients that alternative treatment options are generally safe, especially in the low back, without significant side effects. However, there is a lack of high-quality medical evidence to support their routine use and utilizing them is up to the patient. We also emphasize surgical intervention should only be a last resort option. We only offer surgery in the setting of chronic LBP if there is a discrete anatomic pathology identified on imaging that correlates to the patient’s symptoms and is amenable to surgical treatment (such as sagittal imbalance, spondylosis, spondylolisthesis or spinal stenosis) and the patient has exhausted all the above mentioned non-surgical treatment options.
For patients with chronic LBP who do not have obvious anatomic pathology in the lumbar spine, we certainly believe a multimodal approach that combines the above is the most appropriate treatment option and that spinal mobilization and potentially manipulation may play a role for some patients. It is certainly better than narcotics as a long-term solution, especially considering the growing narcotic crisis.
However, we wish to remind all physicians that while LBP typically has a benign origin and is usually a degenerative musculoskeletal problem, careful history and physical examination must be performed to rule out the dreaded “red-flag” signs that may portend a more serious diagnosis (ie, infection, tumor, cauda equina syndrome or fracture) as the cause of chronic LBP.
It is our opinion patients should evaluate manipulative and mobilization spine treatments on an individual basis as a treatment option for their chronic LBP. As physicians, we found there is not enough data despite more recent publications to either adamantly recommend or discourage the use of these treatments.
- For more information:
- Nickul Jain MD, clinical instructor, and John C. Liu, MD, professor of neurosurgery at University of Southern California and co-director of University of Southern California Spine Center, can be reached at University of Southern California, DEI 2101, Los Angeles, CA 90089; Jain’s email: nickjain@gmail.com; Liu’s email: john.liu@med.usc.edu.
Disclosures: Liu reports he is a consultant for Viseon Inc. Jain reports no relevant financial disclosures.
Focus should be on who has chronic LBP and why
Results of a recent systematic review and meta-analysis of manipulation and mobilization for the treatment of chronic LBP published in The Spine Journal may catch some health care providers by surprise and others might think: “That’s what I thought.” Why such differing conclusions?
Manual medicine, which can involve mobilization and manipulation, has been utilized as an effective tool by U.S. health care providers for several hundred years. Though training is different by various professions (physical therapy, chiropractic medicine, osteopathic physicians and allopathic physicians who train and even teach manual medicine), the overarching goal of assisting tissue movement to a more symmetrical pattern of loading or moving is the underlying common theme. Physical therapists commonly use a mobilization technique to assist tissue motion that then allows improved neuromotor control and ultimately joint motion. A common example is mobilization of the posterior capsule of the glenohumeral joint in a patient with post-surgical stiffness. This is considered standard of care. A mobilization that passes the physiological barrier of motion is considered a manipulation technique. Some of these techniques involve the patient completing isometric contractions in an optimal posture or joint position. This type of technique does not require a “thrust” maneuver. Others require optimal passive joint positioning with movement through the physiological barrier.
This systematic review and meta-analysis of both mobilization and manipulations used in treatment of patients with chronic LBP found 51 separate trials of high quality with nine of the trials (involving 1,176 patients) with similar measurements to perform a meta-analysis. Those data show moderate evidence that manipulation and mobilization improve pain and function for patients with chronic LBP. Both interventions were found to be safe and, when were used as part of a multimodality intervention, promising.
Mobilization and manipulation treatments require education and experience to perform. An important part of the education piece is patient selection. The literature regarding this question needs help, especially regarding the chronic LBP population. We have several systems to choose from for subgrouping patients with LBP. Childs and colleagues published a clinical prediction rule for classifying patients with LBP and were able to accurately predict which patients would respond to spinal manipulation. This group of researchers has continued to publish data regarding therapeutic classification responses of which manipulation is one technique. Better agreement in how to assess patients will enable us to better apply treatments.
As chronic LBP is a symptom without a well-defined, holistic, medical community-endorsed means of assessment to direct management, this systematic review of mobilization and manipulation cannot answer the question we as health care providers really need answered. Who are the patients who benefit from these interventions? The more we can learn about why people have chronic LBP, the better we will be able to answer this question.
- References:
- Childs JD, et al. Ann Intern Med. 2004;141:920-928.
- Cleland JA, et al. Spine (Phila Pa 1976). 2009;doi:10.1097/BRS.0b013e3181b48809.
- Fritz JM, et al. J Orthop Sports Phys Ther. 2007;doi:10.2519/jospt.2007.2498.
- Fritz, JM, et al. Spine (Phila Pa 1976). 2003;doi:10.1097/01.BRS.0000067115.61673.FF.
- For more information:
- Heidi Prather, DO, is vice chair, department of orthopaedic surgery division chief, physical medicine and rehabilitation departments of orthopaedic surgery and neurology, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8233, St. Louis, MO 63110; email: pratherh@wustl.edu.
Disclosure: Prather reports no relevant financial disclosures.