Spinal manipulation for acute (short-term) low back pain


Overview

Acute low back pain is a sharp or widespread pain in the lower back (often accompanied by a lack of flexibility in the back) that lasts for less than three months. 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 ten systematic reviews published since 1992, and 213 clinical trials on the use of spinal manipulation for acute low back pain were identified. One recent systematic review summarized data from 38 clinical trials (involving about 5,000 people), and found that spinal manipulation can be beneficial for acute low back pain in the first 4-6 weeks. This review studied spinal manipulation delivered by a wide variety of health practitioners, including chiropractors. Results from the nine other systematic reviews (that included an additional 175 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

Acute low back pain

Acute low back pain is a common condition that presents as sharp or widespread pain in the lower back, and is 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 less than three months1. 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 acute low back pain is to decrease pain levels and allow people with the condition to resume their normal activities4.

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 mobility5. Treatment sometimes involves a high velocity thrust, a technique in which the joints are adjusted rapidly5. Often these thrusts are accompanied by popping or snapping sounds5. 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 best6.

Forms of spinal manipulation are practised by chiropractors, osteopaths, physiotherapists, and medical practitioners7. 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 Board8. This board administers the Chiropractic Act (1982), which provides for the registration and discipline of registered chiropractors in New Zealand8. 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 treatment9. 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 Zealand10. This board administers the Physiotherapy Act 1949, which provides for the registration and discipline of registered physiotherapists in New Zealand10. 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 Zealand11. This council and a separate Medical Practitioners Disciplinary Tribunal administer the Medical Practitioners Act 199511.

Chiropractic

Chiropractic is a profession which specialises in the diagnosis, treatment and overall management of conditions which are due to mechanical dysfunction of the joints, (particularly those of the spine) and their effects on the nervous system5. Chiropractic specialises in manual therapy, especially spinal manipulation. Treatment consists of a wide range of manipulative techniques designed to improve the function of joints, thereby relieving pain and muscle spasm. Manipulation is very specific and directed at individual joints in order to reduce strains and improve mobility in one area without upsetting another5.

Osteopathy

Osteopathy is an established system of diagnosis and treatment that places its main emphasis on the structural and functional integrity of the body12. 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 whole12. Osteopathy is based on a set of unique biomechanical principles13. 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 osteopathy13.

Physiotherapy

Physiotherapy is a profession concerned with maximizing mobility and quality of life14. It uses physical approaches to promote, maintain and restore physical, psychological and social well-being, taking account of variations in health status15. 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 health15. 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 exercises16.

Evidence reviewed in this summary
Efficacy information


  • Systematic reviews: This evidence summary identified ten systematic reviews on this topic, published since 1992, from database searches of chiropractic literature17-26. 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 213 randomised controlled trials undertaken between 1952 and 2002. The authors of the most recently published meta-analysis identified 38 clinical trials, representing approximately 5,000 patients17. 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.
  • Guidelines: This evidence summary identified three clinical guidelines related to this topic1, 2, 27.

Safety information


  • Systematic reviews: Four systematic reviews published since 19966, 18-19, 21 reported information on side effects associated with the use of spinal manipulation for acute 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

Spinal manipulation is recommended in the New Zealand Clinical Guidelines as a beneficial treatment for acute low back pain1. Current evidence from a recent, high-quality systematic review17 summarizing data from 38 clinical trials generally found that:

  • Spinal manipulation had a beneficial effect on the symptoms of acute low back pain (pain and reduced mobility) in the first 4-6 weeks.
  • Spinal manipulation appears to be as effective as other treatments for acute low back pain, such as physiotherapy and pain relief medication.
  • It remains unclear as to which people will benefit most from spinal manipulation or what the best spinal manipulative therapies are.

Results from the other nine systematic reviews conducted since 1992 were broadly consistent with these findings18-26.

Evidence on safety

Current research classifies side effects associated with spinal manipulation into three groups:19

  • Mild and reversible side effects: These effects include muscle and joint soreness and are reported by approximately 50% of patients19.
  • 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 herniation19. 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 reported6, 21, 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 death21. The majority of these complications tend to be associated with forceful, rotational, upper spinal manipulation (also called rotational cervical manipulation)6, 21. 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 manipulations18. The risk of a serious cerebrovascular complication is approximately one per million cervical (neck) manipulations19.

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. Acute Low Back Pain Guideline Team. New Zealand acute low back pain guide. New Zealand Guidelines Group; Available from: http://nzgg.org.nz/library/gl_complete/backpain1/index.cfm#contents Accessed on 3.11.03.
  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. Anonymous. Summaries for patients: the effectiveness of spinal manipulation relative to other therapies for low back pain. Annals of Internal Medicine 2003;138(11):33I.
  5. 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.
  6. Stevinson C, Ernst E. Risks associated with spinal manipulation. American Journal of Medicine 2002;112(7):566-571.
  7. Ernst E. Does spinal manipulation have specific treatment effects? Family Practice 2000;17(6):554-556.
  8. New Zealand Chiropractic Board. New Zealand Chiropractic Board homepage. Available from: http://www.regboards.co.nz/chiropractic Accessed on 10 March 2004.
  9. 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/maccah/publicfunding.htm Accessed on 10th March 2004.
  10. The Physiotherapy Board of New Zealand. Physiotherapists: registration.
  11. Medical Council of New Zealand. Medical Registration. Available from: http://www.mcnz.org.nz/registation Accessed on: 10th March 2004.
  12. The British School of Osteopathy. Osteopathy explained. Available from: http://www.bso.ac.uk/osteopathy.htm Accessed on 9th March 2004.
  13. Australian Osteopathic Association. Australian Osteopathic Association: about. Available from: http://www.osteopathic.com.au/about.htm Accessed on 9th March 2004.
  14. The Chartered Society of Physiotherapy. What is physiotherapy? Available from: http://www.csp.org.uk/physiotherapy/whatisphysio.cfm Accessed on: 10th March 2004.
  15. Australian Physiotherapy Association. What is physiotherapy? Available from: http://apa.advsol.com.au/ Accessed on 10th March 2004.
  16. 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.
  17. 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.
  18. 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.
  19. Bronfort G. Spinal manipulation: current state of research and its indications. Neurologic Clinics. 1999;17(1):91-111.
  20. 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.
  21. 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.
  22. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Spine. 1996;21(24):2860-2871; discussion 2872-2873.
  23. Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A. A meta-analysis of clinical trials of spinal manipulation. Journal of Manipulative & Physiological Therapeutics 1992;15(3):181-194.
  24. Assendelft WJJ, Koes BW, Van der Heijden G, Bouter LM. The efficacy of chiropractic manipulation for back pain: Blinded review of relevant randomized clinical trials. Journal of Manipulative & Physiological Therapeutics 1992;15(8):487-494.
  25. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain.[comment]. Annals of Internal Medicine. 1992;117(7):590-598.
  26. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991;303(6813):1298-1303.
  27. Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain. London: Royal College of General Practitioners; 2001.

Additional references:

A list of additional references on this topic can be seen by clicking here
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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