Spinal manipulative therapy for acute low-back pain

136 Pages·2012·1.77 MB·English

Spinal manipulative therapy for acute low-back pain (Review)
Rubinstein SM, Terwee CB, AssendelftWJJ, de BoerMR, van Tulder MW
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2012,Issue12
http://www.thecochranelibrary.com
Spinalmanipulativetherapyforacutelow-backpain(Review)
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Figure6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 20
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Analysis1.1.Comparison1Spinalmanipulativetherapyversusinertinterventions,Outcome1Pain. . . . . . . 102
Analysis1.2.Comparison1Spinalmanipulativetherapyversusinertinterventions,Outcome2Functionalstatus. . 103
Analysis1.3.Comparison1Spinalmanipulativetherapyversusinertinterventions,Outcome3Recovery. . . . . 104
Analysis2.1.Comparison2SpinalmanipulativetherapyversusshamSMT,Outcome1Pain. . . . . . . . . 105
Analysis2.2.Comparison2SpinalmanipulativetherapyversusshamSMT,Outcome2Functionalstatus. . . . . 105
Analysis3.1.Comparison3Spinalmanipulativetherapyversusallothertherapies,Outcome1Pain. . . . . . . 106
Analysis3.2.Comparison3Spinalmanipulativetherapyversusallothertherapies,Outcome2Functionalstatus. . . 107
Analysis3.3.Comparison3Spinalmanipulativetherapyversusallothertherapies,Outcome3Recovery. . . . . 109
Analysis3.4.Comparison3Spinalmanipulativetherapyversusallothertherapies,Outcome4Return-to-work. . . 110
Analysis4.1.Comparison 4Spinalmanipulativetherapyplusanyinterventionversusthatsameinterventionalone,
Outcome1Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Analysis4.2.Comparison 4Spinalmanipulativetherapyplusanyinterventionversusthatsameinterventionalone,
Outcome2Functionalstatus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Analysis4.3.Comparison 4Spinalmanipulativetherapyplusanyinterventionversusthatsameinterventionalone,
Outcome3Recovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Analysis4.4.Comparison 4Spinalmanipulativetherapyplusanyinterventionversusthatsameinterventionalone,
Outcome4Return-to-work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Analysis5.1.Comparison5Spinalmanipulativetherapy(SMT)versusanotherSMTtechnique,Outcome1Pain. . 116
Analysis5.2.Comparison5Spinalmanipulativetherapy(SMT)versusanotherSMTtechnique,Outcome2Functional
status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Analysis5.3.Comparison5Spinalmanipulativetherapy(SMT)versusanotherSMTtechnique,Outcome3Recovery. 119
Analysis6.1.Comparison6SMTversusallcomparisons-forconstructionoffunnelplot,Outcome1Pain-Forfunnel
plot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Analysis6.2.Comparison6SMTversusallcomparisons-forconstructionoffunnelplot,Outcome2Functionalstatus-
Forfunnelplot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Spinalmanipulativetherapyforacutelow-backpain(Review) i
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 133
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Spinalmanipulativetherapyforacutelow-backpain(Review) ii
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Spinal manipulative therapy for acute low-back pain
SidneyMRubinstein1,CarolineBTerwee2,WillemJJAssendelft3,4,MichielRdeBoer5,MauritsWvanTulder5
1Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center,
Amsterdam,Netherlands.2DepartmentofEpidemiologyandBiostatistics,VUUniversityMedicalCenter,Amsterdam,Netherlands.
3DepartmentofPublicHealthandPrimaryCare,LeidenUniversityMedicalCenter,Leiden,Netherlands.4DepartmentofPrimary
andCommunityCare,RadboudUniversityMedicalCenter,Nijmegen,Netherlands.5DepartmentofHealthSciences,FacultyofEarth
andLifeSciences,VUUniversity,Amsterdam,Netherlands
Contactaddress:SidneyMRubinstein,DepartmentofEpidemiologyandBiostatistics,EMGOInstituteforHealthandCareResearch,
VUUniversityMedicalCenter,POBox7057,RoomD518,Amsterdam,1007MB,[email protected].
Editorialgroup:CochraneBackGroup.
Publicationstatusanddate:Edited(nochangetoconclusions),publishedinIssue12,2012.
Reviewcontentassessedasup-to-date: 4March2012.
Citation: RubinsteinSM,TerweeCB,AssendelftWJJ,deBoerMR,vanTulderMW.Spinalmanipulativetherapyforacutelow-back
pain.CochraneDatabaseofSystematicReviews2012,Issue9.Art.No.:CD008880.DOI:10.1002/14651858.CD008880.pub2.
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Manytherapiesexistforthetreatmentoflow-backpainincludingspinalmanipulativetherapy(SMT),whichisaworldwide,extensively
practisedintervention.ThisreportisanupdateoftheearlierCochranereview,firstpublishedinJanuary2004withthelastsearchfor
studiesuptoJanuary2000.
Objectives
ToexaminetheeffectsofSMTforacutelow-backpain,whichisdefinedaspainoflessthansixweeksduration.
Searchmethods
A comprehensive search was conducted on 31 March 2011 in the Cochrane Central Register of Controlled Trials (CENTRAL),
MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature. Other search strategies were employed for
completeness.Nolimitationswereplacedonlanguageorpublicationstatus.
Selectioncriteria
Randomizedcontrolledtrials(RCTs) whichexaminedtheeffectivenessofspinalmanipulation ormobilization inadultswithacute
low-backpainwereincluded.Inaddition,studieswereincludedifthepainwaspredominantlyinthelowerbackbutthestudyallowed
mixedpopulations,includingparticipantswithradiationofpainintothebuttocksandlegs.Studieswhichexclusivelyevaluatedsciatica
wereexcluded.Nootherrestrictionswereplacedonthesettingnorthetypeofpain.Theprimaryoutcomeswerebackpain,back-
painspecificfunctionalstatus,andperceivedrecovery.Secondaryoutcomeswerereturn-to-workandqualityoflife.SMTwasdefined
asanyhands-ontherapydirectedtowardsthespine,whichincludesbothmanipulationandmobilization, andincludesstudiesfrom
chiropractors,manualtherapists,andosteopaths.
Datacollectionandanalysis
Two review authors independently conducted the study selection and risk of bias (RoB) assessment. Data extraction was checked
bythesecondreviewauthor.Theeffectswereexaminedinthefollowingcomparisons: SMTversus1)inertinterventions, 2)sham
SMT,3)otherinterventions,and4)SMTasanadditionaltherapy.Inaddition,weexaminedtheeffectsofdifferentSMTtechniques
Spinalmanipulativetherapyforacutelow-backpain(Review) 1
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
comparedtooneanother.GRADEwasusedtoassessthequalityoftheevidence.Authorswerecontacted,wherepossible,formissing
oruncleardata.Outcomeswereevaluatedatthefollowingtimeintervals:short-term(oneweekandonemonth),intermediate(three
tosixmonths),andlong-term(12monthsorlonger).Clinicalrelevancewasdefinedas:1)small,meandifference(MD)<10%ofthe
scaleorstandardizedmeandifference(SMD)<0.4;2)medium,MD=10%to20%ofthescaleorSMD=0.41to0.7;and3)large,
MD>20%ofthescaleorSMD>0.7.
Mainresults
Weidentified20RCTs(totalnumberofparticipants=2674),12(60%)ofwhichwerenotincludedinthepreviousreview.Sample
sizesrangedfrom36to323(median(IQR)=108(61to189)).Intotal,sixtrials(30%ofallincludedstudies)hadalowRoB.Atmost,
threeRCTscouldbeidentifiedpercomparison,outcome,andtimeinterval;therefore,theamountofdatashouldnotbeconsidered
robust. Ingeneral, for theprimary outcomes, thereislow tovery lowquality evidence suggesting nodifference in effectfor SMT
whencompared toinertinterventions, shamSMT, or whenadded toanother intervention. There was varying quality of evidence
(fromverylowtomoderate)suggestingnodifferenceineffectforSMTwhencomparedwithotherinterventions,withtheexception
oflowqualityevidencefromonetrialdemonstratingasignificantandmoderatelyclinicallyrelevantshort-termeffectofSMTonpain
reliefwhencomparedtoinertinterventions, aswellaslowquality evidencedemonstrating asignificant short-termandmoderately
clinicallyrelevanteffectofSMTonfunctional statuswhenaddedtoanother intervention. Ingeneral,side-lyingandsupine thrust
SMTtechniquesdemonstrateashort-termsignificantdifferencewhencomparedtonon-thrustSMTtechniquesfortheoutcomesof
pain,functionalstatus,andrecovery.
Authors’conclusions
SMTisnomoreeffectiveinparticipantswithacutelow-backpainthaninertinterventions, shamSMT,orwhenaddedtoanother
intervention.SMTalsoappearstobenobetterthanotherrecommendedtherapies.Ourevaluationislimitedbythesmallnumberof
studiespercomparison,outcome,andtimeinterval.Therefore,futureresearchislikelytohaveanimportantimpactontheseestimates.
ThedecisiontoreferpatientsforSMTshouldbebaseduponcosts,preferencesofthepatientsandproviders,andrelativesafetyof
SMTcomparedtoothertreatmentoptions.FutureRCTsshouldexaminespecificsubgroupsandincludeaneconomicevaluation.
PLAIN LANGUAGE SUMMARY
Spinalmanipulativetherapyforacutelow-backpain
Low-backpainisacommonanddisablingdisorder,representingagreatburdenbothtotheindividualandsociety.Itoftenresultsin
reducedqualityoflife,timelostfromwork,andsubstantialmedicalexpense.Spinalmanipulativetherapy(SMT)iswidelypractised
byavarietyofhealthcareprofessionalsworldwideandisacommonchoiceforthetreatmentoflow-backpain.Theeffectivenessofthis
formoftherapyforthemanagementofacutelow-backpainis,however,notwithoutdispute.
For this review, acute low-back pain was defined as pain lasting less than six weeks. Only cases of low-back pain not caused by a
knownunderlyingcondition,forexample,infection,tumour,orfracture,wereincluded.Alsoincludedwerepatientswhosepainwas
predominantlyinthelowerbackbutmayalsohaveradiated(spread)intothebuttocksandlegs.
SMTisknownasa’hands-on’treatmentdirectedtowardsthespine,whichincludesbothmanipulationandmobilization.Thetherapist
appliesmanualmobilizationbypassivelymovingthespinaljointswithinthepatient’srangeofmotionusingslow,passivemovements,
beginningwithasmallrangeandgraduallyincreasingtoalargerrangeofmotion.Manipulationisapassivetechniquewherebythe
therapistappliesaspecificallydirectedmanualimpulse,orthrust,toajointatorneartheendofthepassive(orphysiological)rangeof
motion.Thisisoftenaccompaniedbyanaudible‘crack’.
In this review, a total of 20 randomized controlled trials (RCTs) (representing 2674 participants) assessing the effects of SMT in
patientswithacutelow-backpainwereidentified.Treatmentwasdeliveredbyavarietyofpractitioners,includingchiropractors,manual
therapists,andosteopaths.Approximatelyone-thirdofthetrialswereconsideredtobeofhighmethodologicalquality,meaningthese
studiesprovidedahighlevelofconfidenceintheoutcomeofSMT.
Overall,wefoundgenerallylowtoverylowqualityevidencesuggesting thatSMTisnomoreeffectiveinthetreatmentofpatients
withacutelow-backpainthaninertinterventions,sham(orfake)SMT,orwhenaddedtoanothertreatmentsuchasstandardmedical
care.SMTalsoappearstobenomoreeffectivethanotherrecommendedtherapies.SMTappearstobesafewhencomparedtoother
treatmentoptionsbutotherconsiderationsincludecostsofcare.
Spinalmanipulativetherapyforacutelow-backpain(Review) 2
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SUMMARYOFFINDINGSFORTHEMA Spinalmanipulativetherapycomparedtootherinterventionsforacutelow-b Patientorpopulation:Patientswithacutelow-backpainSettings:PrimaryortertiarycareIntervention:SpinalmanipulativetherapyComparison:Otherinterventions(e.g.physiotherapy,exercise,backschool) OutcomesIllustrativecomparativerisks*(95%CI) AssumedriskCorrespondingrisk OtherinterventionsSpinalmanipulativetherapy PainatoneweekThemeanpainatoneThemeanpainatone0(nopain)to10(worseweekrangedacrosscon-weekintheinterventiontrolgroupsfromgroupswaspain)2.6to3.5points0.1higher(0.5lowerto0.7higher) PainatonemonthThemeanpainatoneThemeanpainatone0(nopain)to10(worsemonthrangedacrossmonthintheinterventionpain)controlgroupsfromgroupswas0.5to2.3points0.2lower(0.5lowerto0.2higher) FunctionalstatusatoneThemeanfunctionalsta-Themeanfunctionalsta-weektusatoneweekinthetusatoneweekinthein-RolandMorrisDisabil-controlgroupswasterventiongroupswas7.2points0.1standarddeviationsityQuestionnaire.Scalehigherfrom:0(nodysfunction)to24(worsefunction)(0.2lowerto0.3higher)
Spinalmanipulativetherapyforacutelow-backpain(Review) 3
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Small,notclinically-rel-evanteffect.BasedonpooledSMD:-0.11(-0.426to0.05). Small,notclinically-rele-vanteffect. Total578participants.NoseriousadverseeventswereobservedintheSMTgroup stothedifferentlevelsof
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and ate.
⊕⊕⊕(cid:13)1moderate ⊕⊕(cid:13)(cid:13),15low wasfulfilled eestimate.getheestim
m than
681(3studies) 117(2studies) 2studies swerefulfilled(foreach,oneite⊕ estimateofeffectandmaychangeestimateofeffectandislikelytoch
FunctionalstatusatoneThemeanfunctionalsta-Themeanfunctionalsta-monthtusatonemonthinthetusatonemonthinthecontrolgroupswasinterventiongroupswasRolandMorrisDisabil-4.1points0.5pointslowerityQuestionnaire.Scale(1.2lowerto0.2higher)from:0(nodysfunction)to24(worsefunction) RecoveryatonemonthStudypopulationRR1.06(0.94to1.21)87per10092per100(81to100) SeriousadverseeventsStudypopulationNotestimable CI:RR:⊕⊕Confidenceinterval;Riskratio;=thesesymbolsindicatehowmanyoftheitem(cid:13)(cid:13)evidence) GRADEWorkingGroupgradesofevidenceHighquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.Moderatequality:FurtherresearchislikelytohaveanimportantimpactonourconfidenceintheLowquality:FurtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheVerylowquality:Weareveryuncertainabouttheestimate. 1HighRoB2N<400subjects.3Onlyonestudyreportedtheoutcome;therefore,dataareinconsistentandimprecise.4RMDQbaseduponCherkin1998.5N<300events.
Spinalmanipulativetherapyforacutelow-backpain(Review) 4
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
BACKGROUND
Descriptionoftheintervention
Low-backpainisacommonanddisablingdisorderinwesternsoci-
Inthisreview,SMTisconsideredtobeanyhands-ontreatment
etywhichrepresentsagreatsocietalandfinancialburden(Dagenais
that includes manipulation, mobilization, or both, directed to-
2008).Therefore,adequatetreatmentoflow-backpainisanim-
wards the spine. Mobilizations use low-grade velocity, small or
portantissueforpatients,clinicians,andhealthcarepolicymakers.
largeamplitudepassivemovementtechniqueswithinthepatient’s
Onewidelyusedinterventionforlow-backpainisspinalmanipu-
joint range of motion and control. Manipulation, on the other
lativetherapy(SMT),whichhasbeenexaminedinnumerousran-
hand,usesahighvelocityimpulseorthrustappliedtoasynovial
domizedcontrolledtrials(RCTs).Thesetrialshavebeensumma-
joint over a short amplitude at or near the end of the passive
rizedinrecentsystematicreviews(Bronfort2004a;Cherkin2003;
or physiologicrange ofmotion, whichisoftenaccompanied by
Brown2007)thathaveformedthebasisforrecommendationsin
anaudible ’crack’(Sandoz1969).Thecrackingsoundiscaused
clinicalguidelines(Chou2007;vanTulder2006).However,these
by cavitation of the joint, which is a termused to describe the
recommendations are largely based on an earlier version of this
formationandactivityofbubbleswithinthefluid(Evans2002;
Cochranereview(Assendelft2004),whichreportedthatSMTwas
Unsworth 1971).Variouspractitioners, including chiropractors,
superioronlytoshamtherapyortherapiesjudgedtobeineffective
manualtherapists(physiotherapiststrainedinmanipulativetech-
orevenharmful,andconcludedthattherewasnoevidencethat
niques),orthomanualtherapists(medicaldoctorstrainedinma-
SMT is superior to other standard treatments for patients with
nipulation),orosteopathsusethisintervention.However,thefo-
acutelow-backpain.Theeffectsizes,however,weresmallandar-
cusofthetreatment,education,diagnosticproceduresused,treat-
guablynotclinicallyrelevant.Furthermore,theseestimateswere
mentobjectives,techniques,aswellasthephilosophyofthevari-
basedmainlyonsmallstudieswithahighriskofbias.
ousprofessionsdiffer,oftenconsiderably.Forexample,thefocus
SMTis deliveredbyvarious professional groups, including chi- oforthomanualtherapyisoncorrectingabnormalpositionsofthe
ropractors,manualtherapists,andosteopaths,andisincludedin skeletonandestablishing symmetryinthespine through mobi-
manynationalguidelinesforthemanagementofacutelow-back lization. Manual therapyfocusesoncorrectingfunctional disor-
pain(Koes2001;vanTulder2004).Theserecommendationsvary ders of the musculoskeletal system through predominantly pas-
however.Inmostguidelines,SMTisconsideredtobeatherapeu- sivemobilization andsometimesusing high-velocitylow-ampli-
ticoptionintheacutephaseofalow-backpainepisode.TheUSA, tude(HVLA)techniques.Chiropractors,ontheotherhand,focus
UK,NewZealand,andDanishguidelinesconsiderSMTauseful oncorrectingdisordersoftheneuromusculoskeletalsystembyus-
treatment,whereastheDutch, Australian, andIsraeliguidelines ingpredominantlyHVLAmanipulativetechniques(vandeVeen
donotrecommendSMTfortheacutephase(vanTulder2006). 2005).
ThisreportisanupdateofthepreviousCochranereviewandfol-
lowsthemostrecentguidelinesdevelopedbyTheCochraneCol-
laborationingeneral(Higgins2011)andbytheCochraneBack Howtheinterventionmightwork
Review Group (Furlan 2009) in particular. The current review
Many hypotheses exist regarding the mechanism of action for
wassplitintotwopartsaccordingtodurationofthecomplaint,
spinal manipulation and mobilization (Bronfort 2008; Khalsa
namelyacuteandchroniclow-backpain.Thereviewonchronic
2006;Pickar2002),whichtosomeextentisduetothedifference
low-backpainhassincebeenpublished(Rubinstein2011).The
inopinionsbetweenthevariousprofessionalgroups.Somehave
presentreviewfocusesontheeffectivenessofSMTforacutelow-
postulatedthatmobilizationandmanipulationshouldbeassessed
backpain(Rubinstein2010)andfollowsthesamemethodology
asseparateentitiesgiventheirtheoreticallydifferentmechanisms
asthereviewforchroniclow-backpain.
of action (Evans 2002).The modesof action mightbe roughly
dividedintomechanicalandneurophysiologic.Themechanistic
approach suggests that SMT acts on a manipulable lesion (of-
Descriptionofthecondition
ten calledthe functional spinal lesion or subluxation) and pro-
Low-backpainisdefinedaspainanddiscomfortthatislocalised posesthatforcestoreduceinternalmechanicalstressesresultinre-
belowthecostalmarginandabovetheinferiorglutealfolds,with ducedsymptoms(Triano2001).Theneurophysiologicapproach
or without referred leg pain. Acute low-back pain is defined as suggests that SMT impacts the primary afferent neurons from
thedurationofanepisodepersistingfornolongerthansixweeks. paraspinal tissues, the motor control system, and pain process-
Thiscondition isconsideredtobetypicallyself-limiting,witha ing(Pickar2002).Inconclusion,itwouldappearthattheactual
recoveryrateof90%withinsixweeksoftheinitialepisode,while mechanismremainsdebatable(Evans2002;Khalsa2006).
2%to7%developchroniclow-backpain(vanTulder2006).Non-
specificlow-back pain isoperationally definedaslow-back pain
notattributedtoarecognisable, specificpathology(forexample
Whyitisimportanttodothisreview
infection,tumor,orfracture).
Spinalmanipulativetherapyforacutelow-backpain(Review) 5
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
SMTisaworldwide,extensivelypractisedintervention;however, Exclusioncriteria
itseffectivenessforacutelow-backpainisnotwithoutdispute.Al-
Participantswith:
thoughnumeroussystematicreviewshaveexaminedtheeffective- • post-partumlow-backpainorpelvicpainduetopregnancy,
nessofSMTforlow-backpain(Airaksinen2006;Chou2007), • painnotrelatedtothelow-back,e.g.coccydynia,
veryfewhaveconductedameta-analysis,especiallyforacutelow- • post-operativestudiesorparticipantswith’failed-back
backpain.ThepreviousCochranereview(Assendelft2004)last
syndrome’;
searchedfor studiesupto January 2000. NumerousRCTs have
beenidentifiedsincethen.Inaddition,themethodologyforcon- orstudieswhich:
ducting systematic reviews, including the criteria for evaluating • examined’maintenancecare’orprevention,
theriskofbiasandtheGRADEsystemforevaluatingthestrength • exclusivelyexaminedspecificpathologies,including
of the evidence, have been substantially revised; therefore, this sciatica.Ofnote:Studiesofsciaticawereexcludedbecauseitisa
updateisthoughttoshedamorereliableoverviewonthisissue prognosticfactorassociatedwithworsepain,disability,orboth
(Higgins2011). (Bronfort2004;Bouter1998),especiallywithSMT(Axen2005;
Malmqvist2008).Itisthoughttorepresentapathologydifferent
thannon-specificlow-backpain.
Typesofinterventions
OBJECTIVES
Theobjective of thisreviewwas toexamine theeffectivenessof
SMT on primary (that is pain, functional status, and recovery) Experimentalintervention
andsecondaryoutcomes(thatisreturn-to-work,qualityoflife)as Theexperimentalinterventionsexaminedinthisreviewincluded
comparedtoinertinterventions, sham,andallothertreatments both spinal manipulation andmobilization of thespine. Unless
foradultswithacutelow-backpain.Theeffectswereexaminedfor otherwiseindicated,SMTreferstobothmodesof’hands-on’treat-
short-term(closesttoonemonth),intermediate(closesttothree mentofthespine.
tosixmonths),andlong-termfollow-up(closestto12months).
Typesofcomparisons
Studieswereincludedforconsideration ifthestudydesignused
METHODS
indicatedthattheobserveddifferenceswereduetotheuniquecon-
tributionofSMT.Thisexcludesstudieswithamulti-modaltreat-
mentasoneoftheinterventions(forexamplestandardphysician
Criteriaforconsideringstudiesforthisreview care+spinalmanipulation+exercisetherapy)andeitheradiffer-
enttypeofinterventionoronlyoneinterventionfromthemulti-
modaltherapyasthecomparison(forexamplestandardphysician
care alone) since this would make itimpossible todecipher the
Typesofstudies
actualeffectofSMT.
Allrandomized controlledtrials(RCTs) wereincludedwith the Comparison therapies were combined into the following main
exceptionofthosethatusedinappropriaterandomizationproce- clusters:
dures(forexamplealternateallocation,birthdates).Inaddition, 1)SMTversusinertinterventions;
studieswithfollow-upoflessthanonedaywereexcluded. 2)SMTversusshamSMT;
3)SMTversusallothertherapies;
4)SMTplusanyinterventionversusthatsameinterventionalone
Typesofparticipants
(i.e.SMTasanadjuncttherapy);
5) SMT versus another SMT technique (e.g. side-lying thrust
SMTversusnon-thrustside-lyingtechnique,supinethrustSMT
Inclusioncriteria versusside-lyingthrustSMT).
• Adultparticipants(>18yearsofage)withameanduration Inertinterventionsincludedetuneddiathermyanddetunedultra-
oflow-backpain<sixweeks sound.ShamSMTwasdefinedasanymanipulationormobiliza-
• Participantswithorwithoutradiatingpain tiontechniquethatwasostensiblyindistinguishableforthepatient
fromthetruetechnique,meaningthepatientdidnotknowifhe
Nolimitswereplacedonthesetting(thatiswhetherfromprimary, orshewasreceivingthereal’(oractivecomponent)ortheplacebo
secondary,ortertiarycare). or’fake’therapy.ShamSMTwasconsideredacceptableifthiswas
Spinalmanipulativetherapyforacutelow-backpain(Review) 6
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
queriedamongtheparticipantspost-treatmentandtheblinding Searchingotherresources
appearedtobesuccessful.
Wealsoscreenedthereferencelistsofallincludedstudiesand(sys-
tematic)reviewspertinenttothistopic.Wereviewedgreylitera-
turethatisavailableelectronicallyfromclinicaltrialsregistersand
Typesofoutcomemeasures
thewebsitesrecommendedbytheChiropracticLibraryCollabo-
Onlypatient-reportedoutcomemeasureswereevaluated.Physio-
ration.WesearchedforregisteredtrialsintheUSClinicalTrials
logicalmeasures,suchasspinalflexibilityordegreesachievedwith
databaseandtheWorldHealthOrganizationInternationalClin-
astraightlegraisetest(thatisLasegue’stest),werenotconsidered
icalTrialsRegistryPlatform(ICTRP).Selectedresearchersfamil-
clinically-relevantoutcomesandwerenotincludedintheanalyses.
iarwiththisliteraturewerealsoapproachedinordertoconfirm
whetherourselectionofstudieswascomplete.
Primaryoutcomes
• Pain,measuredbyavisualanalogueorotherpainscale(e.g.
visualanaloguescale(VAS),numericalratingscale(NRS), Datacollectionandanalysis
McGillpainscore)
Two review authors(SMR, CBT)independently conducted the
• Back-painspecificfunctionalstatus,measuredbyaback-
selection of studies and performed the risk of bias assessment.
painspecificscale(e.g.Roland-MorrisDisabilityQuestionnaire
Bothqualitativeandquantitativedatawereextractedbyonereview
(RMDQ),OswestryDisabilityIndex(ODI))
authorandcheckedforaccuracyagainsttheoriginalpaperbythe
• Globalimprovementorperceivedrecovery,measuredbyan
second review author. All disagreements were resolved through
ordinalordichotomousscale(definedasthenumberofpatients
consensusanditwasnotnecessarytoconsultathirdreviewauthor
reportedtoberecoveredornearlyrecovered)
(MWvT).
Secondaryoutcomes
Selectionofstudies
• Perceivedhealthstatusorqualityoflife(e.g.subscalefrom
Wescreenedtitlesandabstractsfromthesearchresults.Potentially
theSF-36,theEuroQolthermometer)
relevantstudieswereobtainedinfulltextandindependentlyas-
• Return-to-work
sessedforinclusion.Disagreementswereresolvedthroughdiscus-
sion.Onlyfullpaperswereevaluated.Abstractsandproceedings
fromcongressesoranyother’greyliterature’wereexcluded.No
Searchmethodsforidentificationofstudies languagerestrictionswereimposed.
Dataextractionandmanagement
Electronicsearches
Astandardizedformwasusedtoextractthequalitativedata.The
RCTs and systematic reviews were identified by electronically
followingwereextracted:studycharacteristics(forexamplecoun-
searchingthefollowingdatabases(searchdate:31March2011).
trywherethestudywasconducted,recruitmentmodality,sourceof
The search was limited to studies published since 2000. Stud-
funding,riskofbias),patientcharacteristics(forexamplenumber
ies published prior to this date were included in the previous
ofparticipants,age,gender),descriptionoftheexperimentaland
Cochrane review and were also considered for inclusion in this
control interventions, duration of follow-up, typesof outcomes
updatedreview.
assessed, and theauthors’ resultsandconclusions. Datarelating
• CochraneCentralRegisterofControlledTrials
totheprimaryoutcomeswereassessedforinclusioninthemeta-
(CENTRAL)(Appendix1).
analyses.Datawerenotextractedfromthosestudiesthoughtto
• MEDLINE(Appendix2).
• EMBASE(Appendix3). haveafatalflaw,whichwasdefinedas:1)adrop-outrategreater
• CINAHL(Appendix4). than50%atthefirstandsubsequentfollow-upmeasurements;or
2) statistically and clinically-relevant, important baseline differ-
• PEDro.
encesforoneormoreprimaryoutcomes(thatispain,functional
• IndextoChiropracticLiterature.
status)indicatingunsuccessfulrandomization. Finalvaluescores
The search strategy developed by the Cochrane Back Group wereusedforthemeta-analysesonly,meaningdatawereestimated
wasfollowedusingfreetextwordsandmedicalsubjectheadings when change scores were presented. Outcomes were assessed at
(MeSH).Thesearchwasconductedbyaclinicallibrarianwithex- oneweekaswellasatone,threeand12monthsandwerecate-
perienceinsearchingforarticlesforsystematicreviews.Thesearch gorizedaccording tothetimeclosesttotheseintervals.Insome
wasupdatedonJuly18,2012. casesoutcomedatawerenotavailableforthethreemonthinterval
Spinalmanipulativetherapyforacutelow-backpain(Review) 7
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.