Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis

Abstract

BACKGROUND CONTEXT Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies. PURPOSE The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain. STUDY DESIGN/SETTING This is a systematic literature review and meta-analysis. OUTCOME MEASURES The present study measures self-reported pain, function, health-related quality of life, and adverse events. METHODS We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912. RESULTS Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=−0.28, 95% confidence interval (CI) −0.47 to −0.09, p=.004; I2=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=−0.33, 95% CI −0.63 to −0.03, p=.03; I2=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=−0.43, 95% CI −0.86 to 0.00; p=.05, I2=79%; SMD=−0.86, 95% CI −1.27 to −0.45; p<.0001, I2=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=−0.20, 95% CI −0.35 to −0.04; p=.01; I2=0%) but not disability (SMD=−0.10, 95% CI −0.28 to 0.07; p=.25; I2=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described. CONCLUSION There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.

Lifestyle and Chronic Pain across the Lifespan: An Inconvenient Truth?

“…Ultimately, this should decrease the psychological and socioeconomic burden of chronic pain. This view is supported by evidence indicating that multimodal interventions are more effective than single modal interventions in, among others, children having chronic pain, adults with chronic nonspecific neck pain, chronic tension‐type headache, low back pain, fibromyalgia, pain following cancer, and osteoarthritis …”

Sacroiliac Joint Hypermobility Biomechanics and What it Means for Health Care Providers and Patients

“…We did not find a recent systematic review or CPG specific to sacroiliac hypermobility only; however, several recent guidelines on the management of acute and chronic low back pain including sacroiliac joint pain, recommend conservative management including manual therapies . The 2008 European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain did not identify any randomized controlled trials (RCTs) on manipulation and joint mobilization for pelvic girdle pain .…”

“…Manual therapies for nonspecific LBP is well‐studied and the CPGs on management of LBP generally recognize manual therapy (manipulation, mobilization) as safe and effective for short‐term pain relief and disability reduction . A recent summary of the CPGs recommends spinal manipulation as an intervention for management of acute and chronic LBP .…”

“…We did not find a recent systematic review or CPG specific to sacroiliac hypermobility only; however, several recent guidelines on the management of acute and chronic low back pain including sacroiliac joint pain, recommend conservative management including manual therapies. [38][39][40][41] The 2008 European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain did not identify any randomized controlled trials (RCTs) on manipulation and joint mobilization for pelvic girdle pain. 5 A recent RCT reported that both manipulation and stability exercises resulted in improvement in pain and disability in patients with subacute and chronic LBP, although no differences were observed between the groups.…”

“…44 Manual therapies for nonspecific LBP is well-studied and the CPGs on management of LBP generally recognize manual therapy (manipulation, mobilization) as safe and effective for short-term pain relief and disability reduction. 40 A recent summary of the CPGs recommends spinal manipulation as an intervention for management of acute and chronic LBP. 41 Like other therapies for LBP (eg, exercise, physical therapy), the literature is unclear on which mode of manual therapy or specific technique (eg, manipulation, mobilization) is superior for subgroups of patients.…”