Back pain is one of the most common health complaints, affecting 8 out of 10 people at some point during their lives. The lower back is the area most often affected.
Spinal manipulation may be used by chiropractors, osteopathic physicians, naturopathic physicians, physical therapists, and some medical doctors with a goal of relieving low-back pain and improving physical functioning. These health professionals perform spinal manipulation by using their hands or a device to apply a controlled force to a joint of the spine.
Most often they also recommend self-care practices. Most acute low-back pain gets better quickly with self-care practices, such as applying heat, using a firm mattress, doing back exercises, or taking pain medications. Privacy Policy Terms of Use. Access your subscriptions. Free access to newly published articles. Purchase access. Rent article Rent this article from DeepDyve.
Access to free article PDF downloads. Save your search. Customize your interests. Create a personal account or sign in to:. In a subsequent trial, the same authors investigated if the specific SMT technique selected influenced treatment effectiveness. The authors found no difference between the therapist-selected technique and a randomly selected low-velocity mobilization technique The level the treatment is directed to therefore seems important; however, the type of technique chosen does not.
While ambiguity about the optimal technique exists, it is important for therapists to closely reassess a patient's response to any single SMT technique and either continue or change the selected technique based on the individual patient's response to treatment.
As response to SMT can be very rapid, reassessment during and immediately after provision of a technique is highly recommended Provision of SMT at the most appropriate level requires an adequately reliable method of identifying the appropriate level. Much has been written about the reliability of manual assessment of the spine Attempts have been made to improve the reliability of manual stiffness judgements by providing specific feedback to students during training of stiffness judgement skills 24 , 25 , and by getting students to reference their judgement to a spring of known stiffness While referencing judgements to a spring improves reliability, training seems ineffective.
Interestingly, the poor reliability of manual stiffness judgements may have little influence on treatment. Chiradejnant et al 20 found that the treatment effect is better when the therapist-selected level most symptomatic or dysfunctional level is treated rather than a randomly selected level. It is unclear how therapists select the most appropriate level but it is likely that a patient's pain response to the application of posterior-anterior PA force would be weighted heavily.
There has been no investigation into the importance of treating the most hypomobile level; however, the existence of at least one hypomobile level is one of the five items that must be positive for inclusion on the SMT CPR developed by Flynn et al Fascinatingly, there is little evidence to support the existence of a relationship between LBP and lumbar posteroanterior stiffness, or that SMT changes lumbar posteroanterior stiffness Only one early study has demonstrated that posteroanterior lumbar stiffness, measured using a mechanical device, is increased in patients with LBP compared to when they have little or no pain A recent MRI study found no relationship between lumbar segmental motion and pain response to a PA mobilization SMT is sometimes divided into high-velocity manipulative techniques and low-velocity mobilization techniques.
While some believe the efficacy of one type is superior to the other, a systematic review of all available trials did not find evidence to support this view While it may seem that evidence on this issue could be obtained from a comparison of the results of mobilization trials to those of manipulation trials, this approach has major problems.
It is likely that trials differ in other ways, e. The only adequate design to compare the relative efficacy of these two approaches to SMT is a head-to-head comparison within the same trial.
Currently, there is no quality evidence suggesting superiority of either approach 16 , Future quality trials in this area would be informative, and the protocol for a trial that should help address this question specifically in patients who meet the CPR of Childs et al 18 has been published Like many physical therapy interventions for LBP, the search for a potential subgroup of responders to SMT has been widely reported as a key to improving the effectiveness of SMT.
The premise is that LBP is a heterogeneous disorder, and it is not reasonable for one treatment to be effective for all patients. The randomized trial by Childs et al 18 found that a CPR was able to identify a group of patients who responded better to SMT compared to control than patients who were not positive to the rule.
The CPR required patients to meet at least 4 of 5 criteria. The promising results of this trial were published in a high-profile journal and have been very highly cited. A recently published secondary analysis of the Hancock et al 33 trial provides some reason for caution regarding the generalizability of the CPR for identifying subgroups of responders to SMT.
Hancock et al 33 investigated whether the CPR used by Childs et al 18 could be generalized and identify responders to SMT, but they found that this was not the case. In the Hancock et al 33 study, patients who were positive on the rule did not respond better to SMT compared to control than patients who were negative on the rule There are several differences between the Childs et al 18 study and that of Hancock et al 33 that could explain these different findings.
Hancock et al 33 allowed clinicians to use a variety of SMT techniques with most therapists choosing to use low-velocity mobilization techniques, while in the Childs et al 18 study, all clinicians used the same high-velocity technique.
It is possible that the difference in the way the treatment was applied explains the different findings and that the CPR may not generalize to low-velocity techniques. There is a need to investigate if the CPR generalizes to high-velocity techniques other than the one used in the original Childs et al 18 study. It is also possible that the lack of generalization of the CPR is not due to the differences in the type of SMT used but other differences between the trials such as the co-interventions, setting, or patients.
Further research is required to determine in what patients and settings, and for what techniques the CPR for SMT does generalize. While the CPR currently provides the best evidence for identifying patients likely to respond to SMT, clinicians using the rule need to consider that the rule may not generalize to their particular patient or setting.
Until further research is available to clarify how generalizable the CPR is, we would recommend that therapists regularly re-assess their individual patient's response to SMT to ensure that the response is positive and if not, to change management approach regardless of status on the CPR. The treatment algorithm investigated by Brennan et al 34 provides some guidance to clinicians on which patients are likely to respond best for a range of different treatment approaches including SMT.
This approach helps clinicians identify patients likely to respond to one of three broad approaches: manipulation, specific exercise directional preference exercises 35 , or stabilization exercises. In a well-designed randomized controlled trial, those authors found that patients who received treatment matched to their classification did better than patients who did not receive matched treatment Identification of patients likely to respond to SMT was based on a modification of the criteria used by Childs et al The algorithm used by Brennan et al 34 forced all patients into one treatment group and it is unclear what proportion of patients belonged to more than one of these treatment groups or did not truly fit any of the groups.
It is likely some patients who were classified using the algorithm into a group other than the manipulation group, such as the specific exercise group, might also meet the criteria for the manipulation group as developed by Childs et al Whether these patients would benefit more or less from SMT compared to the treatment identified using the algorithm is unclear.
It is also possible that they might benefit most from a combination of both treatment approaches. It seems reasonable to start a patient with the treatment approach according to his or her classification on the algorithm and then for those patients who also meet the criteria for the manipulation group, to add a single treatment of manipulation and closely monitor the effect of this additional intervention.
In any health condition, the need for different degrees of intervention should be informed by knowledge of the likely prognosis of the condition without intervention. There is no doubt from the literature on prognosis of LBP that a proportion of patients with acute LBP recover quickly with either no intervention or simple treatments such as regular analgesics and advice. The ability to accurately identify those patients who will recover quickly without the need for more complex and expensive treatments such as SMT is clearly important.
It is difficult for SMT to provide worthwhile benefits in patients who will recover rapidly anyway, and inclusion of these patients in clinical trials is one possible reason for the small effects reported.
A significant amount of research has identified those patients at high risk of becoming chronic and not recovering 36 — 38 , but little investigation has been performed into identifying those patients likely to recover quickly regardless of treatment. We recently published a study that found that patients meeting three criteria had a highly favorable prognosis regardless of treatment The results of this study need to be shown to generalize to new settings and patients.
While the existing research literature provides some assistance to clinicians regarding the application of SMT, there are many unanswered questions. Research aimed at answering the most important questions is urgently needed.
The CPR of Childs et al 18 clearly justifies further investigation. It is vital to determine in what settings and for what techniques the rule generalizes.
Establishing the relative efficacy of different techniques, especially low-velocity and high-velocity techniques, is clearly important. With cheap simple treatments such as advice and simple analgesics widely recommended, it is important to investigate the efficacy of SMT in addition to these interventions.
While not all authors agree, we believe a greater understanding of the source of LBP and the mechanisms by which SMT works is essential to determining the optimal delivery of SMT, including which patients respond best and which techniques are most effective for different patients.
National Center for Biotechnology Information , U. J Man Manip Ther. Mark J. Hancock , PhD, a Christopher G.
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