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  • JAMA: Spinal Manipulation Can Improve Acute LBP

    In brief:

    • Systematic review and meta-analysis studied 26 randomized clinical trials (1,711 individuals) involving the use of spinal manipulative therapy (SMT) for acute low back pain experienced for up to 6 weeks
    • Researchers found moderate but statistically significant decreases in pain and increases in function within 6 weeks after the intervention among individuals treated with SMT
    • Pain decrease was roughly equivalent to pain reduction associated with use of NSAIDs
    • Function improvement was more variable—1- to 2.5-point improvement on a 24-point scale
    • Lack of detail on SMT interventions used in the study, high heterogeneity of results, lack of large numbers of SMT studies make it difficult to identify what aspect of SMT is most strongly associated with improvements

    In a systematic review of 26 randomized clinical trials involving 1,711 individuals with acute low back pain (LBP), researchers have concluded that spinal manipulative therapy (SMT) produces moderate decreases in pain and increases in function for this group. Authors note that variability in individual study results—and the relatively small volume of SMT research available—make it difficult to pinpoint exactly what it is about SMT that makes it useful for the condition; still, the findings represent a positive endorsement of an intervention used by many physical therapists (PTs).

    The study, published in the Journal of the American Medical Association (abstract only available for free), reviewed studies of the use of SMT on adults with acute LBP lasting for 6 weeks or fewer, and that reported outcomes within 6 weeks of treatment. The SMT approaches varied between thrust and nonthrust techniques, and those that were used alone or in conjunction with a package of therapies. The interventions were administered by a range of clinicians, with 13 studies involving PTs, 7 studies involving chiropractors, 5 studies involving medical doctors, and 3 studies involving osteopathic physicians. Of the 26 studies, 4 compared SMT with a sham manipulative intervention.

    Researchers found that studies pointed to what they termed a "modest" yet statistically significant drop in pain among participants who received SMT—about a 10-point drop on a 100-point pain scale, a decrease they described as roughly equivalent to improvements associated with nonsteroidal anti-inflammatory drugs (NSAIDs). When it came to function, authors concluded that SMT resulted in an improvement of between 1 and 2.5 points on the 24-point scale used in the Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ).

    Authors noted several limitations to their review. First, of the studies included, more provided low-quality evidence that high-quality evidence (though better results for SMT were associated with the high-quality studies). Second, the studies tended to be foggy on the details of the SMT intervention, making it impossible to make precise conclusions related to application in practice. Third, researchers noted a high degree of heterogeneity in the results that couldn't be explained—partly because there haven't been enough studies like the ones reviewed. And fourth, no real consensus has been reached on what constitutes a minimum clinically important difference when it comes to outcome measures.

    Nevertheless, says Bill Boissonnault, PT, DHSc, FAPTA, executive vice president of professional affairs at APTA, the study adds important support for clinicians who use SMT in their practices.

    "The fact that the review had difficulty isolating 1 aspect of SMT that was most strongly tied to positive outcomes is consistent with something PTs have known about SMT for a long time," Boissonnault said. "SMT is an intervention whose benefits may arise from several areas—the actual manipulation, of course, but also the therapeutic elements of 'hands-on' work and the ways SMT is related to sense of trust between the patient and the PT."

    Boissonnault thinks that the study has an added upside. "The facts that so many studies involved physical therapists providing the SMT care, and that PTs authored several of the cited studies illustrate the important role PTs have had related to the evolution of SMT as an intervention," he said.

    In an editorial accompanying the study, author Richard Deyo, MD, MPH, describes the findings as "generally consistent" with recent clinical guidelines from the American College of Physicians, which shifted its recommendations to nonpharmacologic approaches as first-line treatment for acute, subacute, and chronic LBP.

    "The guidelines concluded that most patients with acute [LBP] improve with time, regardless of treatment," Deyo writes. "Thus, therapy is often directed simply at symptom relief while natural healing occurs. None of the trials in the study … suggested that SMT was less effective than conventional care."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • I have noticed in quite a few cases of acute LBP which are not older than 6 weeks responds very well with DN followed by SMT.

      Posted by Bibharthi Roy -> BJTa@K on 4/19/2017 4:44 AM

    • Bibharthi, research would say as long as you didn't provide a nocebo, and provided sound advice to stay active in a way that works for the individual and ruled out red flags, your DN and SMT may not have done much of anything. Your clinical experience has value of course in your hands, but avoiding cognitive bias is no easy feat. I tell my residents constantly that just because the patient got better didn't mean you did it.

      Posted by Kris Porter -> @FPc<I on 4/19/2017 3:45 PM

    • Mr Jones comes into my PT clinic. He has had, non radicular, right sided low back pain for 6 weeks. Right side bending is 60% limited with pain and extension is 40% limited. On evaluation, he appears to have a FRS left in the mid lumbar spine and a right on left sacral torsion. MET is used to correct these dysfunctions. Immediately post manipulation he has only 10% limitation with much less pain. I did it. He is given exercises to maintain his correction and come back in the next week and is almost pain free. I did it. This is my typical back patient. Do not discount the benefits of spinal manipulation.

      Posted by Brian Lambert on 4/21/2017 8:24 AM

    • I utilize muscle energy and spinal manipulation techniques and an MET and HVLAT manipulation are not the same interventions Brian Lambert.

      Posted by Donald Miller -> =FQ]=N on 4/25/2017 12:33 PM

    • My first revelation about the benefits of manual spinal therapy, of which there are many approaches, came when a new client came to the clinic in a wheelchair and could hardly move. After therapy using MET, which I consider a form of spinal manual therapy, he was able to roll off the table independently and walk out of the clinic. I recently saw a client with c/o neck & shoulder pain (for over a year) and "not feeling balanced" throughout her body who had recently seen a DPT for treatment. My client, an OTR who works in a NICU, stated that the previous PT was not helpful and that the DPT had only given her exercise therapy. Furthermore, the DPT told her she had a leg length discrepancy and needed an MRI to further assess this. Crazy! I treated with strain-counter-strain, Hesch Technique and MET for spinal, pelvic and rib dysfunctions with total pain resolution on the first visit. I assessed leg length because she appeared to have a scoliosis. Testing using techniques outlined in David J. Magee's Orthopedic Physical Assessment indicated a true leg length discrepancy. I am disappointed that a highly educated colleague was unable to help this fellow medical provider and furthermore offered misdirected guidance using an MRI to assess leg length discrepancy. I am a bachelor's level PT who graduated in 1985 and am highly trained in osteopathic manipulative therapies, MFR and other manual approaches as well as medical exercise therapy (Norwegian approach and SFMT). I have two points to make: 1. It's high time for physical therapists to recognize that spinal manipulative therapies are essential for restoration of functional movement and can help decrease overall treatment duration which is a bonus to both client and insurance companies. Let's quit bickering about which is better--exercise or manual therapies. They both go best together. 2. Blinded RCT's cannot effectively assess the results of spinal manual therapies because there are so many approaches (as pointed out by Brian Lambert), and a highly trained, skilled therapist combines approaches that are best for the client. This is a clinical decision based upon the unique presentation of the client. That's why "...the studies tended to be foggy on the details of the SMT intervention, making it impossible to make precise conclusions related to application in practice (PT in Motion News, April 14, 2017)." Even as our profession attempts to categorize clients based upon psycho-social evaluations, pain and functional questionnaires in order to deliver the "best" therapy approach, there is no one best spinal manual therapy approach. The best approach is a collaborative pursuit between the therapist, the client and the client's body to select and implement the optimal therapies to resolve pain, restore biomechanics and promote functional movement patterns.

      Posted by Karen Russo on 4/27/2017 11:08 PM

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