Spinal manipulation for chronic (long-term) low back pain


Overview

Chronic low back pain is localised or widespread pain in the lower back (often accompanied by a lack of flexibility in the back) that lasts for more than three months or longer than expected recovery times. Spinal manipulation involves the stretching, mobilising or manipulation of the spine, surrounding tissues and other joints in order to relieve back pain and improve mobility. This evidence summary is based on database searches of chiropractic literature. A total of eight systematic reviews published since 1999, and 150 clinical trials on the use of spinal manipulation for chronic low back pain were identified for this review. One recent systematic review summarized data from 38 clinical trials (involving about 5,000 patients), and found that spinal manipulation had no clear advantage over general practitioner care, pain relief medication, physiotherapy or exercises for the treatment of chronic back pain. However, spinal manipulation is a more effective treatment of chronic back pain, than bed rest, traction, topical gels, or no treatment. This review studied spinal manipulation delivered by a wide variety of health practitioners, including chiropractors. Results from the seven other systematic reviews (that included an additional 112 trials) were broadly consistent with these findings. Mild but reversible side effects (such as muscle and joint soreness) are reported by about 50% of people receiving spinal manipulation. Serious side effects can also occur (such as stroke or death), but are extremely rare.

Background

Chronic low back pain

Chronic low back pain is a common symptom that presents as localised or widespread pain in the lower back, often accompanied by a lack of flexibility and tenderness in the lower back. This condition is defined by activity intolerance due to lower back or leg symptoms (sciatica) lasting more than three months1. However, the key distinction between acute (less than three months duration) and chronic low back pain is not the duration of the pain, but the persistence of chronic pain beyond expected recovery times1. Chronic low back pain can be difficult to both diagnose and manage1. Back pain mainly affects adults of working age, particularly people aged between 40 and 60 years. Approximately 60-80% of the population will have experienced back pain at some point in time2. Back pain is sometimes referred to as mechanical back pain, idiopathic back pain, non-specific back pain, backache, or lumbago3. The main goal in treating and managing chronic low back pain is to control pain levels and prevent disability1.

Spinal manipulation

Spinal manipulation involves a range of manual (hands-on) manoeuvres that stretch, mobilise or manipulate the spine, surrounding tissues and other joints in order to relieve spinal pain and improve mobility4. Treatment sometimes involves a high velocity thrust, a technique in which the joints are adjusted rapidly4. Often these thrusts are accompanied by popping or snapping sounds4. The technique results in the brief stretching of joint capsules and is believed to reset the position of the spinal chord and nerves, allowing the nervous system to function at its best5.

Forms of spinal manipulation are practised by osteopaths, physiotherapists, chiropractors, and medical practitioners6. To practice as a chiropractor in New Zealand, a person must have an accepted qualification, hold a valid annual practicing certificate and be registered with the New Zealand Chiropractic Board7. This board administers the Chiropractic Act (1982), which provides for the registration and discipline of registered chiropractors in New Zealand7. Osteopathy is not currently regulated by statute in New Zealand, however, osteopaths who belong to the New Zealand Register of Osteopaths Incorporated are able to provide subsidised ACC treatment8. To practice as a physiotherapist in New Zealand, a person must have an accepted qualification, hold a valid annual practicing certificate and be registered with the Physiotherapy Board of New Zealand9. This board administers the Physiotherapy Act 1949, which provides for the registration and discipline of registered physiotherapists in New Zealand9. To practice as a medical practitioner in New Zealand, a doctor must have an accepted qualification, hold a valid annual practicing certificate and must be registered with the Medical Council of New Zealand10. This council and a separate Medical Practitioners Disciplinary Tribunal administer the Medical Practitioners Act 199510.

Chiropractic

Spinal manipulation involves a range of manual (hands-on) manoeuvres that stretch, mobilise or manipulate the spine, surrounding tissues and other joints in order to relieve spinal pain and improve mobility4. Treatment often involves a high velocity thrust, a technique in which the joints are adjusted rapidly4. Often these thrusts are accompanied by popping or snapping sounds4. The technique results in the brief stretching of joint capsules and is believed to reset the position of the spinal chord and nerves, allowing the nervous system to function at its best5.

Osteopathy

Osteopathy is an established system of diagnosis and treatment that places its main emphasis on the structural and functional integrity of the body11. The main focus of most osteopaths is the musculoskeletal system muscles, bones and joints, in that they are considered vital to the healthy functioning of the body as a whole11. Osteopathy is based on a set of unique biomechanical principles12. Treatment can consist of a wide range of manual therapies/techniques such as: massage and stretching, articulation techniques (passively moving joints through there range of motion), muscle energy techniques, counterstrain and functional techniques, manipulation, visceral techniques (used in the management of conditions affecting internal organs) and cranial osteopathy12.

Physiotherapy

Physiotherapy is a profession concerned with maximizing mobility and quality of life13. It uses physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status14. Physiotherapy extends from health promotion to: injury prevention, acute care, rehabilitation, maintenance of functional mobility, maintenance of the best achievable health in people with chronic illness, patient and carer education, and occupational health14. Treatment can consist of exercises to improve strength and fitness, massage, mobilization and manipulative techniques, use of electrotheraputic apparatus (such as ultrasound) to promote healing, and pool exercises15.
Evidence reviewed in this summary

Efficacy information

Systematic reviews: This evidence summary identified eight systematic reviews on chronic low back pain, published since 1999, from database searches of chiropractic literature16-23. These reviews ranged from meta-analyses with statistical pooling to narrative summaries. An additional report has recently been published by the Cochrane Collaboration (titled Spinal manipulative Therapy for Low Back Pain), however the full report is not currently accessible.

  • Clinical trials: The above systematic reviews identified 150 randomised controlled trials undertaken between the earliest database record and 2002. The authors of the most recently published meta-analysis identified 38 clinical trials, representing approximately 5,000 patients16. This review studied spinal manipulation delivered by a wide variety of health practitioners, including chiropractors. At least three clinical trials (involving between 480 and 1,350 people) of low back pain and spinal manipulation are currently underway (www.controlled-trials.gov).
  • Case-control studies/Cohort studies/Case studies: Given the extensive coverage of the above systematic reviews, no case-control, cohort studies or case studies were assessed for this evidence summary.
  • Safety information

  • Systematic reviews: Four systematic reviews published since 19965, 17, 21, 24 reported information on side effects associated with the use of spinal manipulation for chronic low back pain.
  • Other studies: Given the comprehensive information provided by the above studies, no further information on side effects was sought.

Evidence on efficacy

Current research evidence from a recent high-quality systematic review16, summarizing data from 38 clinical trials, generally found that:

  • Spinal manipulation had no clear advantage over general practitioner care, pain relief medication, physiotherapy, exercises or back school, for the treatment of chronic back pain.
  • Spinal manipulation is a more effective treatment of chronic back pain, than therapies judged to be ineffective or harmful, such as bed rest, traction, topical gels, or no treatment.
  • It remains unclear as to which people will benefit most from spinal manipulation or what the best spinal manipulative therapies are.

Results from three earlier, high-quality systematic reviews conducted since 1999 were broadly consistent with these findings17,18,23. Four further reviews found possible beneficial results for the use of spinal manipulative therapy to reduce chronic low back pain. However, the low quality of the trials included in these reviews would suggest that the results/conclusions were unreliable19-22.

Evidence on safety

Current research classifies side effects associated with spinal manipulation into three groups:21

  • Mild and reversible side effects: These effects include muscle and joint soreness and are reported by approximately 50% of patients21.
  • Serious, but reversible side effects. These effects include vertigo or dizziness of a few minutes duration, sternocostal cartilage separation, rib fracture, transient ischemic attacks caused by vertebral artery irritation, and progression of neurologic deficits because of cervical and lumbar disc herniation21. These side effects are reported to be rare. In a review of articles published prior to 1996, 295 side effects associated with spinal manipulations were reported5, 24, of which 56 complications such as dislocations and fractures were reported. Exact risk figures are not available.
  • Serious, irreversible side effects. These effects include arterial dissection, stroke, cauda equina syndrome or death24. The majority of these complications tend to be associated with forceful, rotational, upper spinal manipulation (also called rotational cervical manipulation. Risk estimates for the cauda equina syndrome are extremely low, ranging from about one case per 100 million manipulations to less than one per million manipulations17. The risk of a serious cerebrovascular complication is approximately one per million cervical (neck) manipulations21.
Cited references

To find out more about any of the references listed below go to the “About page” of this website and read the section titled “How can referenced articles be obtained.”

  1. Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone; 1998.
  2. Directorate of Information and Clinical Effectiveness (DICE). Topic of the month: acute and chronic low back pain. DICE; Available from: http://www.show.scot.nhs.uk/hhb/PUBLICAT/TOPIC%20OF%20MONTH/Dec%202001%20Low%20Back%20Pain/ACUTE%20&%20CHRONIC%20LOW%20BACK%20PAIN.pdf.
  3. Ernst E, Pilter M, Stevinson C, White A. The desktop guide to Complementary and Alternative Medicine: an evidence-based approach. London: Mosby; 2001.
  4. British Chiropractic Association. Chiropractic: a helping hand for you and your patients. Available from: http://www.chiropractic-uk.co.uk/ accessed on 18/04/03. Berkshire, UK: British Chiropractic Association; 2000.
  5. Stevinson C, Ernst E. Risks associated with spinal manipulation. American Journal of Medicine 2002;112(7):566-571.
  6. Ernst E. Does spinal manipulation have specific treatment effects? Family Practice 2000;17(6):554-556.
  7. New Zealand Chiropractic Board. New Zealand Chiropractic Board homepage. Available from: http://www.regboards.co.nz/chiropractic Accessed on 10 March 2004.
  8. Ministerial Advisory Committee on Complementary and Alternative Health. Public funding for CAM services: ACC subsidies. New Zealand Ministry of Health; Available from: http://www.newhealth.govt.nz/massah/publicfunding.htm Accessed on 10th March 2004.
  9. The Physiotherapy Board of New Zealand. Physiotherapists: registration.
  10. Medical Council of New Zealand. Medical Registration. Available from: http://www.mcnz.org.nz/registation Accessed on: 10th March 2004.
  11. The British School of Osteopathy. Osteopathy explained. Available from: http://www.bso.ac.uk/osteopathy.htm Accessed on 9th March 2004.
  12. Australian Osteopathic Association. Australian Osteopathic Association: about. Available from: http://www.osteopathic.com.au/about.htm Accessed on 9th March 2004.
  13. The Chartered Society of Physiotherapy. What is physiotherapy? Available from: http;//www.csp.org.uk/physiotherapy/whatisphysio.cfm. Accessed on: 10th March 2004.
  14. Australian Physiotherapy Association. What is physiotherapy? Available from: http://apa.advsol.com.au/ Accessed on 10th March 2004.
  15. School of Physiotherapy. What is a physiotherapist? University of Otago; Available from: http://physio.otago.ac.nz/becoming_a_physio/physios_are.asp Accessed on: 9th March 2004.
  16. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain – A meta-analysis of effectiveness relative to other therapies. Annals of Internal Medicine 2003;138(11):871-881.
  17. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine 2003;138(11):898-906.
  18. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Does spinal manipulative therapy help people with chronic low back pain? Australian Journal of Physiotherapy. 2002;48(4):277-284.
  19. Pengel HM, Maher CG, Refshauge KM. Systematic review of conservative interventions for subacute low back pain. Clinical Rehabilitation 2002;16(8):811-820.
  20. Ernst E, Harkness E. Spinal manipulation: A systematic review of sham-controlled, double-blind, randomized clinical trials. Journal of Pain & Symptom Management 2001;22(4):879-889.
  21. Bronfort G. Spinal manipulation: current state of research and its indications. Neurologic Clinics. 1999;17(1):91-111.
  22. Vernon H. Spinal manipulation for chronic low back pain: a review of the evidence. Topics in Clinical Chiropractic 1999;6(2):8-12.
  23. Mohseni-Bandpei MA, Stephenson R, Richardson B. Spinal manipulation in the treatment of low back pain: a review of the literature with particular emphasis on randomized controlled clinical trials [Review]. Physical Therapy Reviews 1998;3(4):185-194.
  24. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation: a comprehensive review of the literature. Journal of Family Practice. 1996;42(5):475-480.

Additional references:

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Glossary

Cauda equina syndrome
Cauda equina syndrome is characterised by dull pain in the lower back and upper buttock region, numbness in the buttocks, genitalia (or thigh) accompanied by a disturbance of bowel and bladder function.

Cerebrovascular
Cerebrovascular refers to the blood vessels of the cerebrum or brain.

Disk herniation
Disk herniation refers to a condition that results in the abnormal protrusion (bulging), herniation, or prolapse of a vertebral disk from its normal position in the vertebral column.

Sternocostal cartilage separation
Sternocostal cartilage separation is the separation of the cartilage in the breast-bone (sternum).

Transient ischaemic attack
Transient ischaemic attack (TIA) is a sudden focal loss of neurological function with complete recovery usually within 24 hours.

Vertebrobasilar accident
A vertebrobasilar accident results in vertebrobasilar insufficiency which is an obstruction or stenosis of the vertebral-basilar system manifested by disturbances of consciousness, vertigo, headache, hemi- or quadriplegia, dysarthria (imperfect articulation of speech due to disturbances of muscular control which result from damage to the central or peripheral nervous system), and facial paralysis.

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