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

Primary tabs

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

The analysis discovers moderate – quality evidence regarding manipulation and mobilization therapies role in lessening pain and disability with complete safety.

Low back pain is counting among the diseases which cause most devastation in a person's life. About 23% of the population suffering from low back pain. Out of which, 11%–12% population exhibit disability due to severe pain. The management of low back pain involves various modalities; pharmacological as well as non-pharmacological. One section of doctors prefer pharmacological approaches like steroids, NSAIDs, neurotropic, opioid or surgery, While other choose non-pharmacological approaches as these associated with lesser adverse effects. 

ABSTRACT: 
Background: 

Low back pain is counting among the diseases which cause most devastation in a person's life. About 23% of the population suffering from low back pain. Out of which, 11%–12% population exhibit disability due to severe pain. The management of low back pain involves various modalities; pharmacological as well as non-pharmacological. One section of doctors prefer pharmacological approaches like steroids, NSAIDs, neurotropic, opioid or surgery, While other choose non-pharmacological approaches as these associated with lesser adverse effects. The non-pharmacological modalities explored for low back pain treatment are exercise, behavioural,manipulation, yoga,interferential currents, trans-cutaneous electrical nerve stimulation, physiotherapy, occupational,osteopathic, massage, chiropractic and physiotherapy. Out of these, several studies focused on spinal manipulation and mobilization to manage back and neck pain.

The effectiveness of spinal manipulation and mobilization depends upon various factors like the method, how therapy dispensed, symptoms duration, outcomes and controls. Therefore, Ian D. Coulter and colleagues conducted this systematic study to evaluate more evidence as earlier studies hardly show any pieces of evidence and to understand the treatment efficacy.

 

Rationale behind research

  • Previous studies unable to present proper evidence regarding  spinal manipulation and mobilization
  • Conducted Systematic analysis to evaluate efficacy as compared to data exhibited in RCTs since 2000 and meta-analysis to extract the common result.

Objective

  • To assess efficacy and safety of  several mobilizations and manipulation approaches
  • To determine effect size among mobilization and manipulation
Methods: 

 

Study outcomes:

  • Health-related quality of life (HRQoL), disability and pain measurements as primary and secondary outcomes after a specific time

Time period:

  • Primary outcome – 1 month after the treatment
  • Secondary outcome – 3, 6 and 12 months after the treatment
Results: 

 

Outcomes

  • Study characteristics

The data was extracted only from the year 2000 to 2014 as no study from 2015 to 2017 matched the eligibility criteria. RCTs involved either unimodal or multimodal approaches. In the unimodal approach, 60% studies exhibited 3 months,  12% of studies showed 6 months, 28% of studies showed more than one-year pain duration. In the multimodal approach, 30% studies exhibited 3 months,  19% of studies showed 6 months,  51% of studies showed more than one-year pain duration.
Out of 25 unimodal studies, 15 evaluated as mobilization, 7 as manipulation interventions and 3 as the combination (manipulation +  mobilization). Along with existing intervention, other prescribed modalities that used with combination to treat low back pain were exercises,  massage stretches, education, advice and ultrasound. The controls were present in about 84% of studies, and the remaining showed the comparison with sham treatment or no treatment.
The outcomes were measured via Short Form-36 (HRQoL), VAS/NPRS (pain) and ODI/Roland-Morris Disability Questionnaire (disability).

  • Methodological quality

No serious risk of bias noticed in either uni- or multimodal approaches. Out of 25 unimodal RCTs, 3 exhibited high-quality score, 18 medium quality and 4 low-quality scores. Further, out of 26 multimodal studies, 3 were of high quality, 20 were of medium quality, and 3 were of low quality. The multisite similarities,  pitfalls in reporting group differences and intention-to-treat analyses exhibited poor quality criteria. However, all categories showed satisfactory EVAT scores. Besides, only 23 studies described the places (hospitals, private clinics or university setting), facilities and staff involved in the treatment. Majority of studies included physicians,  naturopathic, osteopathic clinicians, chiropractors and physical therapists.

  • Adverse events

Out of 25 unimodal RCTs, 17 provide no information, 5 reported no adverse effects, 2 described minor, and one study showed severe adverse events. Although, no case was treatment-related. Out of multimodal studies, 10 provide no information, 10 reported no incidents and rested 6 reported minor adverse events like tiredness and soreness. The non-RCT studies hardly reported any adverse event.

  • Data Synthesis

The thrust or non-thrust comparable studies could not be pooled as the studies were diverse. Further, studies involved in the systematic review were also heterogeneous and therefore excluded from analysis. The studies which taken foe consideration were the studies involved thrust and non-thrust comparison with other modalities ( exercise, physical therapy or any other active therapy) through multiple sessions and the post-treatment evaluation was nearest to one month.            

  • Reduction in pain

The meta-analysis included nine trials with pain reduction at post-treatment closest to 1 month. As per the pooled analysis, thrust and non-thrust approaches showed significant pain reduction as compared to exercise or physical therapy. The thrust modalities exhibited better pain reduction scores than active approaches as per statistical subgroup analysis. Another 5 trials showed the significant reduction in the non-thrust group as compared to the active intervention group. According to VAS, thrust approaches showed  10.75 points and non-thrust showed the 5.0-point decrease on  0–100-mm scale in comparison to active approaches. Further, as compared to thrust, non-thrust expressed no significant change in pain improvement at 3 and 6- months follow up after treatment.

  • Reduction in disability

The meta-analysis included nine trials with pain reduction at post-treatment closest to 1 month. As per the pooled analysis, thrust and non-thrust approaches showed significant pain reduction as compared to exercise or physical therapy. The thrust modalities exhibited better pain reduction scores than active approaches as per statistical subgroup analysis. Another 5 trials showed the significant reduction in the non-thrust group as compared to the active intervention group. According to VAS, thrust approaches showed  10.75 points, and non-thrust showed the 5.0-point decrease on  0–100-mm scale in comparison to active approaches. Further, as compared to thrust, non-thrust expressed no significant change in pain improvement at 3 and 6- months follow up after treatment.

  • Improvement in health-related quality of time

In concern to health-related quality of time improvement, very few studies were present.

  • Confidence in the effect estimates

As per results, the risk of bias was not determined as the severe concern during the analysis. Significant statistical heterogeneity was noticed in pain and disability reduction. The subgroups analysis involved thrust interventions comparison with active modalities also showed considerable heterogeneity as the active modalities include various exercises and physical therapies. For the meta-analysis, very few studies were present. However, the results were accurate, and no bias was detected by  Begg or Egger test. On the whole, the confidence in given data was rated as the moderate level for pain and disability reduction.

Conclusion: 

The study provides moderate quality evidence regarding thrust interventions in pain and disability reduction among patients with low back pain as compared to active controls. However, more analysis is required to evaluate more strong evidence with regards to mobilization and manipulation role in low back pain treatment.

The methodological quality of mobilization and manipulation RCTs for low back is adequate in the overall period from 2000 to 2017, except the heterogeneity. The reason behind heterogeneity is diversity in dose, techniques, practitioner, controls and chronicity duration of patients. The approaches, mobilization and manipulation are safe. The manipulation approaches show moderate evidence in low back pain reduction which increases over 3 and 6 months of follow up after the treatment. As compared to manipulation,  mobilization does not exhibit strong evidence for chronic back pain management.

The spinal manipulation therapy, including mobilization, is the referral by European Workgroup guidelines. Similar recommendations were seen in US guidelines in favour of manipulation and mobilization therapies. Although, the recommendations regarding manipulation and mobilization therapies vary according to region or country. In one sector,  manipulation considered as therapeutic modality whereas in other is it not.

The strengths of the study involved transparent, explicit and systematic methodology; involvement of an internal steering committee and the external advisory committee on devised questions, interventions, populations, controls and outcomes. Further, the study also shows external and model validity, the risk of bias and meta-analysis as per patients report results; GRADE frames and independent methodology review along with addressing the complexity of chronic and non-specific low back pain condition and attempt to sort literature in predefined eligibility criteria, precisely and in possible homogeneous fashion.

Spine J. Author manuscript; available in PMC 2018 Jun 27
Therapeutic, Low back pain, Lower back, Systematic review, Meta-analysis, Efficacy, Safety, Short Form-36, VAS/NPRS and ODI/Roland-Morris Disability Questionnaire
Log in or register to post comments