The Spine Journal
Ian D. Coulter, Ph.D
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, as well as how these approaches compare to other therapies.
Purpose
To determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain.
Study Design/Setting
A systematic literature review and meta-analysis.
Outcome Measures
Self-reported pain, function, health-related quality of life, 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 and/or mobilization therapies to 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
51 trials were included in the systematic review. Nine trials (1176 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% CI, -0.47 to -0.09, P=0.004; I2=57% at post-treatment; within seven trials (923 patients) the reduction in disability was SMD= -0.33, 95% CI, -0.63 to -0.03, P=0.03; I2=78% for manipulation or mobilization as compared to other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared to other active comparators including exercise and physical therapy (SMD= -0.43, 95% CI, -0.86 to 0.00; P=0.05, I2=79%), (SMD= -0.86, 95% CI, -1.27 to -0.45; P<0.0001, I2=46%). Mobilization interventions, as compared to other active comparators including exercise regimens, significantly reduced pain (SMD= -0.20, 95% CI, -0.35 to -0.04; p=0.01; I2=0%) but not disability (SMD= -0.10, 95% CI, -0.28 to 0.07; p=0.25; I2=21%). Studies comparing manipulation or mobilization to 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 the 51 trials were multimodal studies and narratively described.
Conclusions
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.