Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review

Interdisciplinary Fascia Therapy: A Proof-of-Concept Pilot Study for a New Myofascial Approach for Chronic Low Back Pain

Background/Objectives: Chronic low back pain (CLBP) is highly prevalent and relevant in all medical fields. This study evaluated the safety and effectiveness of interdisciplinary fascia therapy (IFT) for CLBP, focusing on its potential to reduce pain intensity, disability, and regulate autonomic nervous system (ANS) activity. Methods: Nine participants with CLBP each underwent nine sessions of IFT, twice weekly. The intervention involved a 12-grip manual sequence targeting deep paravertebral myofascial structures, complemented by heart rate variability (HRV) biofeedback training twice daily for 15 min. Pain and quality-of-life measures were assessed using the Brief Pain Inventory (BPI) questionnaire at baseline, mid-treatment (4th session), and post-treatment (9th session). HRV metrics were monitored with a 24 h ECG Holter device before and after the treatment period. Statistical analyses included paired t-tests, Wilcoxon signed-rank tests, and Cohen's d for effect size. Results: Significant reductions in pain levels were observed across all subjective BPI measures, including momentary, strongest, minimal, and average pain scores (p < 0.001), with 83% and 87% reductions in pain intensity and disability, respectively. Quality-of-life indicators such as mood, sleep, and enjoyment of life showed significant improvements (p < 0.001). While only one HRV metric (rMSSD) achieved statistical significance, other HRV measures indicated medium to large effect sizes, suggesting favorable trends in ANS regulation. Conclusions: IFT demonstrated significant effects on subjective BPI pain reduction and quality of life, alongside potential regulatory impacts on ANS activity in individuals with CLBP. These results support the use of IFT as an effective intervention for pain management in CLBP and ANS regulation, meriting further exploration.

Variability and repeatability of spinal manipulation force-time characteristics in thoracic spinal manipulation on a manikin

BACKGROUND

As part of multimodal therapy, spinal manipulation (SM) is a recommended and effective treatment for musculoskeletal pain. However, the underlying physiological mechanisms for pain relief are largely unknown. SM thrusts can be described and quantified using force-time characteristics (e.g. preload force, peak force, thrust speed, thrust duration, and thrust impulse). If these biomechanical parameters of SM are important for clinical outcomes, a large variability in the delivery of SM could lead to inconsistent responses and could thereby potentially mask a significant clinical effect. Our goal was to determine variability, and repeatability of thoracic spinal manipulation (SM) force-time profiles in a sample of Swiss chiropractors.

METHODS

All interventions were performed on a human analogue manikin. Participating chiropractors received three case scenarios with the following scenarios: 50-year-old male patient, 30-year-old male athlete, and a 70-year-old female patient, each presenting with uncomplicated musculoskeletal thoracic pain. Clinicians were asked to perform three consecutive thoracic SM thrusts for each of the scenarios and repeated the same interventions after 24-48 h.

RESULTS

Eighty-one chiropractors participated in the study, including 32 females (39.5%) with a mean age of 45.22 ± 12.96 years. The variability in SM force-time characteristics between clinicians was substantial, with preload forces ranging from 4.50 to 450.25 N and peak forces ranging from 146.08 to 1285.17 N. Significant differences between case scenarios were observed for peak force (p < 0.0001), maximum thrust speed (p = 0.0002), and thrust impulse (p = 0.0004). Except for thrust duration, repeatability within and between sessions was fair to excellent (ICCs between 0.578 and 0.957).

CONCLUSION

Substantial variability in application of SM was evident across clinicians and between case scenarios. Despite substantial clinician-dependent variability, the high repeatability of thoracic SM thrusts suggests a level of standardization in SM delivery, indicating that chiropractors might have 'their' individual force-time profile that they are capable to reproduce. Further research based on these findings should explore how to enhance the consistency, effectiveness, and safety of thoracic SM delivered clinically to humans.

Clinical Examination, Diagnosis, and Conservative Treatment of Chronic Low Back Pain: A Narrative Review

Chronic low back pain is one of the most frequent reasons for medical consultation. It is important to make the correct diagnosis to select the most appropriate treatment in a stepwise approach. In this narrative review, we focus on the clinical examination, the diagnosis, and the conservative treatment of chronic non-specific low back pain. Belgian guidelines for low back pain were used as a basis, followed by a snowball search starting from two articles. Besides that, the Cochrane database was consulted using the following research areas: "multidisciplinary biopsychosocial rehabilitation", "physical examination of lumbar spine", and "rehabilitation back pain". Lastly, we took information from three handbooks. The diagnosis of low back pain starts with a thorough history, including red, yellow, orange, black, and blue flags. Physical, neurological, sensory, and motor testing is performed and complemented with specific tests for low back pain. With a focus on the conservative treatment, pharmacological and non-pharmacological treatments are possible. For CNSLBP, conservative management is advised, starting with reassurance and clear patient education about the condition. While additional treatments, such as manipulation, massage, and acupuncture, can be considered, their effectiveness is not well supported by evidence. Our center emphasizes exercise within a multidisciplinary biopsychosocial rehabilitation program, and although evidence for this approach is limited, we have seen positive outcomes, including improved mobility, strength, and higher return-to-work rates, particularly with the David Spine Concept (DSC).

Mézières Method as a practice of embodiment in patients with low back pain: a mixed study

INTRODUCTION

The objectives of this study were to determine the effects of the Mézières Method (MM) on pain and disability related to low back pain (LBP), compared to a program of heat, massage and exercise, and to understand the meaning of the bodily experience with the MM.

PATIENTS AND METHODS

Mixed methods convergent parallel design, combining an equivalent randomized clinical trial with a qualitative phenomenological approach. Sixty-one participants aged 18-65 years with chronic non-specific LBP lasting more than 3 months. Patients were randomized into two groups: the MM group (n = 29) and the comparison group (CG) who received heat, massage plus flexibility and strengthening exercises (n = 31). MM and CG participants underwent 10 one-hour physical therapy sessions over a 5-week period and were evaluated three times: pre-intervention, post-intervention and follow-up at 6 weeks after the end of treatment.

RESULTS

Both groups reported positive effects on LBP . MM group showed superior effects in pain relief in the short term (Cohen's D 0.80; p = 0.004). Participants interpreted the interaction with the MM as a teaching-learning process that allowed body awareness.

CONCLUSION

Both treatment were similarly beneficial but MM had superior effects on pain in the short term. MM is perceived by the participants as a teaching-learning process focused on body awareness that facilitate effective management of LBP.

Role of non‑coding RNAs in cartilage endplate (Review)

Cartilage endplate (CEP) degeneration is considered one of the major causes of intervertebral disc degeneration (IDD), which causes non-specific neck and lower back pain. In addition, several non-coding RNAs (ncRNAs), including long ncRNAs, microRNAs and circular RNAs have been shown to be involved in the regulation of various diseases. However, the particular role of ncRNAs in CEP remains unclear. Identifying these ncRNAs and their interactions may prove to be is useful for the understanding of CEP health and disease. These RNA molecules regulate signaling pathways and biological processes that are critical for a healthy CEP. When dysregulated, they can contribute to the development disease. Herein, studies related to ncRNAs interactions and regulatory functions in CEP are reviewed. In addition, a summary of the current knowledge regarding the deregulation of ncRNAs in IDD in relation to their actions on CEP cell functions, including cell proliferation, apoptosis and extracellular matrix synthesis/degradation is presented. The present review provides novel insight into the pathogenesis of IDD and may shed light on future therapeutic approaches.

Cortical function and sensorimotor plasticity are prognostic factors associated with future low back pain after an acute episode: the Understanding persistent Pain Where it ResiDes prospective cohort study

ABSTRACT

Predicting the development of chronic low back pain (LBP) at the time of an acute episode remains challenging. The Understanding persistent Pain Where it ResiDes study aimed to identify neurobiological and psychological risk factors for chronic LBP. Individuals with acute LBP (N = 120) participated in a prospective cohort study with 6-month follow-up. Candidate predictors were selected from the neurobiological (eg, sensorimotor cortical excitability assessed by sensory and motor-evoked potentials and brain-derived neurotrophic factor genotype), psychological (eg, depression and anxiety), symptom-related (eg, LBP history), and demographic domains. Analyses involved multivariable linear regression models with pain intensity or disability degree as continuous variables. Secondary analyses involved a multivariable logistic model with the presence of LBP at 6 months (thresholding pain intensity and disability degree) as a dichotomous variable. Lower sensory cortex and corticomotor excitability, higher baseline pain intensity, higher depression, stress, and pain catastrophizing were the strongest predictors ( R2 = 0.47) of pain intensity at 6 months. Older age and higher pain catastrophizing were the strongest predictors ( R2 = 0.30) of disability at 6 months. When the LBP outcome was dichotomised, sensory cortex and corticomotor excitability, brain-derived neurotrophic factor genotype, depression and anxiety, LBP history and baseline pain intensity, discriminated between those who did and did not report LBP at 6 months (C-statistic 0.91). This study identifies novel risk factors for the development of future LBP. Neurobiological risk factors, when added to a multivariable linear regression model, explained a further 15% of the variance in the 6-month pain intensity.

Efficacy of Hip Strengthening on Pain Intensity, Disability, and Strength in Musculoskeletal Conditions of the Trunk and Lower Limbs: A Systematic Review with Meta-Analysis and Grade Recommendations

To investigate the efficacy of hip strengthening on pain, disability, and hip abductor strength in musculoskeletal conditions of the trunk and lower limbs, we searched eight databases for randomized controlled trials up to 8 March 2022 with no date or language restrictions. Random-effect models estimated mean differences (MDs) with 95% confidence intervals (CIs), and the quality of evidence was assessed using the GRADE approach. Very low quality evidence suggested short-term effects (≤3 months) of hip strengthening on pain intensity (MD of 4.1, 95% CI: 2.1 to 6.2; two trials, n = 48 participants) and on hip strength (MD = 3.9 N, 95% CI: 2.8 to 5.1; two trials, n = 48 participants) in patellofemoral pain when compared with no intervention. Uncertain evidence suggested that hip strengthening enhances the short-term effect of the other active interventions on pain intensity and disability in low back pain (MD = -0.6 points, 95% CI: 0.1 to 1.2; five trials, n = 349 participants; MD = 6.2 points, 95% CI: 2.6 to 9.8; six trials, n = 389 participants, respectively). Scarce evidence does not provide reliable evidence of the efficacy of hip strengthening in musculoskeletal conditions of the trunk and lower limbs.

Evidence (-based medicine) in manual medicine/manual therapy—a summary review

Objective

The aim of this summary review is to analyse the current state of evidence in manual medicine or manual therapy.

Methods

The literature search focussed on systematic reviews listed in PubMed referring to manual medicine treatment until the beginning of 2022, limited to publications in English or German. The search concentrates on (1) manipulation, (2) mobilization, (3) functional/musculoskeletal and (4) fascia. The CASP Checklist for Systematic Reviews was used to present the included reviews in a clear way.

Results

A total of 67 publications were included and herewith five categories: low back pain, neck pain, extremities, temporomandibular disorders and additional effects. The results were grouped in accordance with study questions.

Conclusion

Based on the current systematic reviews, a general evidence-based medicine level III is available, with individual studies reaching level II or Ib. This allows manual medicine treatment or manual therapy to be used in a valid manner.

Treatment-based classification for low back pain: systematic review with meta-analysis

OBJECTIVE

To systematically review the effects of treatment-based classification (TBC) in patients with specific and nonspecific acute, subacute and chronic low back pain.

METHODS

The following databases were searched: MEDLINE, EMBASE, PsycINFO, Global Health, CENTRAL, Web of Science, CINAHL, SPORTDiscus, PEDro and WHO from inception up to December 2021. We used the PEDro scale, the TIDieR checklist and the GRADE approach to evaluate the risk of bias, quality on reporting and the certainty of the evidence, respectively.

RESULTS

Twenty-three trials (pooled n = 2,649) met the inclusion criteria. We have identified a total of 22 comparisons and 134 estimates of treatment effects. There was a very large heterogeneity with regards to the comparison groups. Most of individual trials had low risk of bias with a mean score of 6.8 (SD = 1.3) on a 0-10 scale. The certainty of evidence for most comparisons was low, which indicates that more high quality and robust trials are needed. We were able to pool the data using a meta-analysis approach for only two comparisons (TBC versus mobility exercises in patients with acute low back pain and traction for patients with sciatica). In general, the TBC approach seems to be useful for patients with acute low back pain, sciatica and with spinal stenosis. We strongly suggest readers to carefully read our summary of findings table for further details on each comparison.

CONCLUSION

The TBC approach seems to be useful for patients with acute low back pain, sciatica and with spinal stenosis.

Asymmetric Biomechanical Properties of the Paravertebral Muscle in Elderly Patients With Unilateral Chronic Low Back Pain: A Preliminary Study

Background: Clinical incidences of chronic low back pain among the elderly are increasing. However, studies have not fully elucidated on changes in biomechanical properties of paravertebral muscles in patients with unilateral chronic low back pain. We evaluated the changes in biomechanical properties of painful and non-painful paravertebral muscles in elderly patients with unilateral chronic low back pain.

Methods: Biomechanical properties of paravertebral muscles, including muscle tone and stiffness, in elderly patients with unilateral chronic low back pain were measured using MyotonPRO. Lumbar Lordosis and Sacral Slope were measured by magnetic resonance imaging. Cross-sectional areas of paravertebral muscles were evaluated using ImageJ software version 1.53. Chronic low back pain severity was assessed by Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores. The correlations between VAS scores, ODI scores, Lumbar Lordosis, Sacral Slope, cross-sectional areas (painful side), disease duration, and biomechanical properties of paravertebral muscles in the painful side were analyzed.

Results: A total of 60 elderly patients with unilateral chronic low back pain were enrolled in this study. The muscle tone and stiffness of paravertebral muscles on the painful side were significantly higher than those on the non-painful side (p &lt; .05). Cross-sectional areas of paravertebral muscles on the painful side at the L3 level were smaller than those of the non-painful side (p &lt; .05). The VAS scores and ODI scores were significantly positively correlated with muscle tone and stiffness of paravertebral muscles on the painful side (p &lt; .05 and p &lt; .01, respectively). There were no significant correlations between disease duration, cross-sectional areas (painful side), Lumbar Lordosis, or Sacral Slope and muscle tone and stiffness of paravertebral muscles on the painful side (p &gt; .05).

Conclusion: In elderly patients with unilateral chronic low back pain, muscle tone and stiffness of paravertebral muscles on the painful side are higher than for those on the non-painful side. The asymmetry of biomechanical properties of paravertebral muscles is associated with severity of chronic low back pain.

Misconceptions of physical therapists and medical doctors regarding the impact of lifting a light load on low back pain

BACKGROUND

A common misconception about low back pain (LBP) is that the spine is weak and that lumbar flexion should be avoided. Because the beliefs of health-care professionals (HCPs) influence patients, it is important to understand the attitudes of health care professionals towards LBP and lifting.

OBJECTIVES

To assess and compare the perceptions of different categories of HCPs regarding the safety of specific movement strategies used to lift a light load, and their beliefs regarding back pain. The secondary aim was to determine whether certain factors influenced the beliefs of HCPs.

METHODS

Data were collected via an electronic survey. Student and qualified physical therapists (PTs), medical students, and general practitioner (GP) trainees were included. The questionnaire included eight photographs, depicting eight different strategies to lift a light load. Respondents were requested to select the strategy(s) they considered as "unsafe" to use for asymptomatic people with a previous history of LBP and people with chronic LBP. Beliefs and attitudes towards LBP were evaluated using the Back Pain Attitudes Questionnaire (Back-PAQ).

RESULTS

Questionnaires from 1005 participants were included. Seventy percent of qualified PTs considered none of the strategies as harmful (versus 32% of PT students, 9% of GP trainees and 1% of medical students). Qualified PTs had higher Back-PAQ scores (mean ± SD: 13.6 ± 5.5) than PT students (8.7 ± 5.7), GP trainees (5.9 ± 5.9) and medical students (4.1 ± 5.2), indicating less misconceptions regarding LBP. Having LBP negatively influenced beliefs while taking a pain education course positively influenced beliefs.

CONCLUSION

Misconceptions regarding LBP and the harmfulness of lifting a light load with a rounded back remain common among HCPs, particularly medical doctors.

Non-operative treatment for low back pain: A review of evidence and recommendations

Background Low back pain (LBP) is a healthcare problem with high global prevalence, with non-operative management being the first line of treatment in the majority of patients. This literature review summarizes the current evidence for various modalities of non-operative treatment for LBP. Methods We did a literature search to elicit high-quality evidence for non-operative treatment modalities for LBP, including Cochrane Database reviews and systematic reviews or meta-analysis of randomized controlled trials. Only when these were not available for a particular treatment modality, other level 1 studies were included. The quality of evidence was categorized in accordance with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method-a globally adopted tool for grading the quality of evidence and making treatment recommendations. Results The treatment modalities that were reviewed included: general measures, medications/pharmacotherapy, exercises, electromagnetic therapies, alternative treatment modalities and interventional therapies. We found that high-quality evidence is lacking for most non-operative treatment modalities for LBP. The majority of interventions have small benefits or are similar to placebo. Conclusion The current evidence for non-operative treatment modalities for LBP is insufficient to draw conclusions or make recommendations to clinicians. High-quality trials are required before widespread use of any treatment modality. Considering that non-operative treatment is usually the first line of therapy for most patients with LBP, it deserves to be the focus of future research in spinal disorders.

Computer Kinesiology: New Diagnostic and Therapeutic Tool for Lower Back Pain Treatment (Pilot Study)

The aim of this study was to demonstrate the effectiveness of the diagnostic and therapeutic medical information system Computer Kinesiology in physiotherapy in patients with low back pain who were not responding to conventional therapy. Computer Kinesiology is primarily intended for the diagnostics and therapy of functional disorders of the locomotor system. This pilot study population included 55 patients (Group 1) with acute and chronic back pain and 51 persons (Group 2) without back pain. The third group was a control group of 67 healthy volunteers with no evidence of musculoskeletal pathologies and no back pain. All 173 subjects were examined three times by the diagnostic part of the Computer Kinesiology method. Groups 1 and 2 were treated after every diagnostics. Group 3 was not treated. The effect was evaluated by H score. Improvements after therapy were defined by reducing the H score by at least 1 point. In Group 1, the H score decreased by at least 1 point in 87.3% (95% CI: 75.5-94.7) and in Group 2 in 78.4% (95% CI: 64.7-88.7). There was no change of distribution of H Score grade in Group 3. The improvement neither depended on gender, age, and BMI nor was it influenced by the length of the therapy. This study demonstrated a high therapeutic efficacy of the Computer Kinesiology system in patients with back pain (Group 1) and in persons without back pain (Group 2) who used the Computer Kinesiology system for primary and secondary prevention of back pain.

Directed vertebral manipulation is not better than generic vertebral manipulation in patients with chronic low back pain: a randomised trial

QUESTION

In people with chronic low back pain, what is the average effect of directing manipulation at the most painful lumbar level compared with generic manipulation of the spine?

DESIGN

Randomised controlled trial with concealed allocation, a blinded assessor and intention-to-treat analysis.

PARTICIPANTS

148 people with non-specific chronic low back pain with a minimum level of pain intensity of 3 points (measured from 0 to 10 on the Pain Numerical Rating Scale).

INTERVENTIONS

All participants received 10 spinal manipulation sessions over a 4-week period. The experimental group received treatment to the most painful segment of the lower back. The control group received treatment to the thoracic spine.

OUTCOME MEASURES

The primary outcome was pain intensity, measured at the end of the intervention (Week 4). Secondary outcomes were: pain intensity at Weeks 12 and 26; pressure pain threshold at Week 4; and global perceived change since onset and disability, both measured at Weeks 4, 12 and 26.

RESULTS

Each group was randomly allocated 74 participants. Data were collected at all time points for 71 participants (96%) in the experimental group and 72 (97%) in the control group. There were no clinically important between-group differences for pain intensity, disability or global perceived effect at any time point. The estimate of the effect of directing manipulation at the most painful lumbar level, as compared with generic manipulation, on pain intensity was too small to be considered clinically important: MD 0 (95% CI -0.9 to 0.9) at Week 4 and -0.1 (95% CI -1.0 to 0.8) at Week 26.

CONCLUSION

No clinically important differences were observed between directed manipulation and generic manipulation in people with chronic low back pain.

TRIAL REGISTRATION

NCT02883634.

Balance Ability in Low Back Pain Patients With Lumbosacral Radiculopathy Evaluated With Tetrax: A Matched Case-Control Study

Objective

To compare postural balance ability in patients with low back pain between groups with and without lumbosacral radiculopathy.

Methods

Patients who were referred for electromyography because of low back pain during the period from April 2017 through June 2018 were chosen as subjects. They were divided into groups with and without lumbosacral radiculopathy based on the results of electromyography. We used Tetrax (Sunlight Medical Ltd., Ramat Gan, Israel) to objectively evaluate postural balance ability, and to measure the fall risk, stability index, weight distribution index, and Fourier index.

Results

Patients in the lumbosacral radiculopathy group showed significantly higher fall risk (73.25 vs. 38.00; p<0.05), weight distribution index (8.57 vs. 5.00; p<0.05), and stability index (21.19 vs. 13.16; p<0.05) than those in the group without lumbosacral radiculopathy. The Fourier index at high-medium frequency was significantly increased in the lumbosacral radiculopathy group (8.27 vs. 5.56; p<0.05), whereas weight-bearing on the side of radiculopathy was significantly decreased.

Conclusion

Patients with lumbosacral radiculopathy have decreased postural balance compared with patients without this condition. Somatosensory disturbances in lumbosacral radiculopathy might cause postural balance impairment. Assessment and treatment plan not only for pain reduction but also for postural balance improvement should be considered in the management of patients with lumbosacral radiculopathy.

Osteopathy in the French-speaking part of Switzerland: Practitioners' profile and scope of back pain management

Background

Osteopathy is commonly used for spinal pain, but knowledge about back pain management by osteopaths is scarce.

Objective

The aim of this study was to survey osteopaths across the French-speaking part of Switzerland about the scope of their practice and their management of patients with back pain.

Design

This cross-sectional observational study was based on an online survey conducted from March to June 2017. Setting and participants: All registered osteopaths of the French-speaking part of Switzerland were asked to complete the survey. Outcome measures: In addition to descriptive statistics (practice characteristics, patients’ profiles, scope of treatment modalities, health promotion, research, and osteopathic practice), we explored variables associated with osteopaths’ practice, such as age and gender.

Results

A total of 241 osteopaths completed the questionnaire (response rate: 28.8%). Almost two thirds of osteopaths were female. Ages ranged from 25 to 72 years with an overall mean of 42.0 (SD 10.7) years. Male osteopaths reported more weekly working hours than female osteopaths did (38.2 [SD 11.0] vs 31.6 [SD 8.9], respectively, p<0.001). Almost a third (27.8%,) of osteopaths could arrange an appointment for acute conditions on the same day and 62.0% within a week. Acute or subacute spinal conditions, mainly low back and neck pain, were the most frequent conditions seen by our respondents. For 94.4% of osteopaths, one to three consultations were required for the management of such conditions.

Conclusion

Osteopaths play a role in the management of spinal conditions, especially for acute problems. These findings, combined with short waiting times for consultations for acute conditions, as well as prompt management capabilities for acute low back and acute neck pain, support the view that the osteopathic profession constitutes an added value to primary care.

Physical therapies for postural abnormalities in people with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is the most common life-threatening, inherited disease in white populations which causes several dysfunctions, including postural abnormalities. Physical therapy may help in some consequences of these postural abnormalities, such as pain, trunk deformity and quality of life.

OBJECTIVES

To determine the effects of a range of physical therapies for managing postural abnormalities in people with cystic fibrosis, specifically on quality of life, pain and trunk deformity.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches, hand-searched journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies. Date of the last search: 19 March 2020.

SELECTION CRITERIA

Randomised controlled trials examining any modality of physical therapy considered relevant for treating postural disorders compared with each other, no physical therapy, sham treatment or usual care in people with CF (of any age or disease severity).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted the data. We contacted trial authors to obtain missing or additional information. We assessed the quality of the evidence using the GRADE criteria.

MAIN RESULTS

Two trials, involving a total of 50 participants with CF and postural abnormalities, were included in this review. One was in people with stable disease (lasting three months) and one in hospital inpatients experiencing an exacerbation (20 days). Both trials compared manual therapy comprising mobilizations to the rib cage and thoracic spine, treatment of specific muscle dysfunction or tight muscle groups; and postural awareness and education versus medical usual care. The age of participants ranged from 17 years to 58 years. Both trials were conducted in the UK. The following outcomes were measured: change in quality of life, change in pain, change in trunk deformity and change in pulmonary function. Manual therapy may make little or no difference to the change in trunk deformity compared to usual care (low-quality evidence). No results could be analysed for quality of life (very low-quality evidence) and pain outcomes (very low-quality evidence) because of the high heterogeneity between trials. It is uncertain whether the intervention improves lung function: forced vital capacity (very low-quality evidence); forced expiratory volume in one second (very low-quality evidence); or Tiffeneau's index (ratio of forced expiratory volume at one second (FEV₁) and forced vital capacity (FVC)). Only one trial (15 participants) measured functional capacity, and the change in walked distance seemed to favour intervention over usual care, but with the possibility of no effect due to wide confidence intervals. The same trial also reported that six participants in the intervention group had positive comments about the intervention and no adverse events were mentioned.

AUTHORS' CONCLUSIONS

Due to methodological limitations in the included trials, and in addition to the very low to low quality of the current evidence, there is limited evidence about the benefits of physical therapies on postural abnormalities in people with CF. Therefore, further well-conducted trials with robust methodologies are required considering a prior inclusion criterion to identify the participants who have postural abnormalities.

Potential mechanisms for lumbar spinal stiffness change following spinal manipulative therapy: a scoping review

INTRODUCTION

In individuals having low back pain, the application of spinal manipulative therapy (SMT) has been shown to reduce spinal stiffness in those who report improvements in post-SMT disability. The underlying mechanism for this rapid change in stiffness is not understood presently. As clinicians and patients may benefit from a better understanding of this mechanism in terms of optimizing care delivery, the objective of this scoping review of current literature was to identify if potential mechanisms that explain this clinical response have been previously described or could be elucidated from existing data.

METHODS

Three literature databases were systematically searched (MEDLINE, CINAHL, and PubMed). Our search terms included subject headings and keywords relevant to SMT, spinal stiffness, lumbar spine, and mechanism. Inclusion criteria for candidate studies were publication in English, quantification of lumbar spinal stiffness before and after SMT, and publication between January 2000 and June 2019.

RESULTS

The search identified 1931 articles. Of these studies, 10 were included following the application of the inclusion criteria. From these articles, 7 themes were identified with respect to potential mechanisms described or derived from data: 1) change in muscle activity; 2) increase in mobility; 3) decrease in pain; 4) increase in pressure pain threshold; 5) change in spinal tissue behavior; 6) change in the central nervous system or reflex pathways; and 7) correction of a vertebral dysfunction.

CONCLUSIONS

This scoping review identified 7 themes put forward by authors to explain changes in spinal stiffness following SMT. Unfortunately, none of the studies provided data which would support the promotion of one theme over another. As a result, this review suggests a need to develop a theoretical framework to explain rapid biomechanical changes following SMT to guide and prioritize future investigations in this important clinical area.

[Diagnostics and therapy of back pain: what is advisable? What should be avoided and why is it still done?]

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

Effects of manual therapies on stability in people with musculoskeletal pain: a systematic review

Introduction

Chronic musculoskeletal pain is associated with reduced balance performance and falls risk. Manual therapies are commonly used interventions for musculoskeletal pain. There is emerging evidence that manual therapies may improve balance. The aim of this systematic review was to examine the effectiveness of manual therapies for musculoskeletal pain on measures of static and dynamic stability.

Methods

Six electronic databases were searched using pre-defined eligibility criteria and two independent reviewers assessed all identified records. Risk of bias was assessed using the 12-item Cochrane Risk of Bias assessment by two authors independently and any discrepancies resolved through consensus. Meta-analysis was conducted when three or more studies used the same outcome measures including gait speed, timed up and go test, step test and sit-to-stand test.

Results

Twenty-six studies were included in the analysis. Both spinal and extremity musculoskeletal pain conditions were represented. Manual therapies included manipulation, mobilisation and massage. The most common intervention compared to manual therapy was exercise. Outcome measures included both clinical and objective measures of stability. Overall the risk of bias was reported as generally low or unclear.

Conclusion

Improvement in stability measures were reported in studies comparing manual therapy in the short term, but not long-term follow-up. There was no clear association between significant pain reduction and measures of stability. Further prospective studies are recommended to investigate whether manual therapies should be part of an integrative healthcare plan for risk of falls management and when a transition from manual therapy to more active interventions should occur for long term management.

Effectiveness of spinal manipulation and myofascial release compared with spinal manipulation alone on health-related outcomes in individuals with non-specific low back pain: randomized controlled trial

OBJECTIVE

To investigate the effectiveness of spinal manipulation combined with myofascial release compared with spinal manipulation alone, in individuals with chronic non-specific low back pain (CNLBP).

DESIGN

Randomized controlled trial with three months follow-up.

SETTING

Rehabilitation clinic.

PARTICIPANTS

Seventy-two individuals (between 18 and 50 years of age; CNLBP ≥12 consecutive weeks) were enrolled and randomly allocated to one of two groups: (1) Spinal manipulation and myofascial release - SMMRG; n=36) or (2) Spinal manipulation alone (SMG; n=36).

INTERVENTIONS

Combined spinal manipulation (characterized by high velocity/low amplitude thrusts) of the sacroiliac and lumbar spine and myofascial release of lumbar and sacroiliac muscles vs manipulation of the sacroiliac and lumbar spine alone, twice a week, for three weeks.

MAIN OUTCOME MEASURES

Assessments were performed at baseline, three weeks post intervention and three months follow-up. Primary outcomes were pain intensity and disability. Secondary outcomes were quality of life, pressure pain-threshold and dynamic balance.

RESULTS

No significant differences were found between SMMRG vs SMG in pain intensity and disability post intervention and at follow-up. We found an overall significant difference between-groups for CNLBP disability (SMG-SMMRG: mean difference of 5.0; 95% confidence interval of difference 9.9; -0.1), though this effect was not clinically important and was not sustained at follow-up.

CONCLUSIONS

We demonstrated that spinal manipulation combined with myofascial release was not more effective compared to spinal manipulation alone for patients with CNLBP.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03113292.

Addition of MoodGYM to physical treatments for chronic low back pain: A randomized controlled trial

Background

Low back pain (LBP) is prevalent, costly and disabling. A biopsychosocial treatment approach involving physical and cognitive behavioural therapy (CBT) is recommended for those with chronic LBP. It is not known if online psychological coaching tools might have a role in the secondary prevention of LBP related disability. To assess the effectiveness of an internet-delivered psychological program (MoodGYM) in addition to standard physical treatment in patients with chronic non-specific LBP at medium risk of ongoing disability.

Methods

A multisite randomized controlled trial was conducted with 108 participants (aged mean 50.4 ± 13.6 years) with chronic LBP attending one of six private physiotherapy or chiropractic clinics. Disability (Roland Morris Disability Questionnaire) and self-efficacy (Patient Self-Efficacy Questionnaire), were assessed at baseline, post-treatment (8-weeks) with follow-up at six- and twelve-months. Participants were randomized into either the intervention group, MoodGYM plus physical treatments, or the control group which received physical treatments alone.

Results

No statistically significant between group differences were observed for either disability at post-treatment (Effect size (standardised mean difference) 95% CI) RMD - 0.06 (- 0.45,0.31), 6-months RMD 0.01 (- 0.38,0.39) and 12-months - 0.20 (- 0.62,0.17) or self-efficacy at post-treatment PSEQ 0.06 (- 0.31,0.45), 6-months 0.02 (- 0.36,0.41) and 12-months 0.21 (- 0.16,0.63).

Conclusion

There was no additional benefit of an internet-delivered CBT program (MoodGYM) to physical treatments in those with chronic non-specific LBP at medium risk of ongoing disability measured at post-treatment, or at 6 and 12 months.

Trial registration

This trial was prospectively registered with Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000269538.

The effectiveness of complex application of osteopathy and shock wave therapy in the rehabilitation treatment of myofascial pain syndrome

Background. Myofascial pain syndromes are the most frequent companions of acute and chronic lumbar pain, and the problem of eliminating pain syndrome should be considered in terms of developing an effective program for diagnosis, treatment, physical rehabilitation and its accessibility for all categories of the population. Аim. To evaluate the effectiveness of complex application of osteopathy and shock wave therapy in the rehabilitation treatment of patients with MPS. Materials and methods. 120 patients with myofascial pain syndrome (MPS), mean age 49.65±0.89 years, mean disease duration 2.29±0.18 years were examined. Results. With the combination of standard therapy, osteopathic treatments and extracorporeal shock wave therapy (ESWT), the severity of pain on the scale of visual analogue scale (VAS) after 12 months of observation decreased by an average of 77.1%, in the group of standard therapy in combination with ostepathic treatment, 62.2%, in group of standard therapy and ESWT by 52.8% and in the group of standard therapy by 30.9%. According to the 12-month prospective follow-up, the maximum positive effect on the severity of MPS and emotional disorders was noted in the combination of standard therapy, osteopathic treatments and ESWT. Conclusion. The combination of these methods of treatment can be considered as a method of choice in complex programs of rehabilitation treatment of patients with MPS.

The Effects Induced by Spinal Manipulative Therapy on the Immune and Endocrine Systems

Background and Objectives: Spinal manipulations are interventions widely used by different healthcare professionals for the management of musculoskeletal (MSK) disorders. While previous theoretical principles focused predominantly on biomechanical accounts, recent models propose that the observed pain modulatory effects of this form of manual therapy may be the result of more complex mechanisms. It has been suggested that other phenomena like neurophysiological responses and the activation of the immune-endocrine system may explain variability in pain inhibition after the administration of spinal manipulative therapy (SMT). The aim of this paper is to provide an overview of the available evidence supporting the biological plausibility of high-velocity, low-amplitude thrust (HVLAT) on the immune-endocrine system. Materials and Methods: Narrative critical review. An electronic search on MEDLINE, ProQUEST, and Google Scholar followed by a hand and "snowballing" search were conducted to find relevant articles. Studies were included if they evaluated the effects of HVLAT on participants' biomarkers Results: The electronic search retrieved 13 relevant articles and two themes of discussion were developed. Nine studies investigated the effects of SMT on cortisol levels and five of them were conducted on symptomatic populations. Four studies examined the effects of SMT on the immune system and all of them were conducted on healthy individuals. Conclusions: Although spinal manipulations seem to trigger the activation of the neuroimmunoendocrine system, the evidence supporting a biological account for the application of HVLAT in clinical practice is mixed and conflicting. Further research on subjects with spinal MSK conditions with larger sample sizes are needed to obtain more insights about the biological effects of spinal manipulative therapy.

Neurophysiological Effects of High Velocity and Low Amplitude Spinal Manipulation in Symptomatic and Asymptomatic Humans: A Systematic Literature Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To summarize the evidence of neurophysiological effects of spinal manipulative therapy (SMT) with a high velocity low amplitude thrust (HVLA-SMT) in asymptomatic and symptomatic humans.

SUMMARY OF BACKGROUND DATA

HVLA-SMT is effective in reducing back pain, but its mode of action is not fully understood.

METHODS

A systematic literature search (until July 2018) was conducted by a professional librarian in seven databases (Medline (OvidSP), Premedline (PubMed), EMBASE, Cochrane, CINAHL, PEDro, and Scopus). Two authors selected the studies according to the a priori described criteria and scored study quality. Only controlled studies of at least moderate quality were included. Effects of HVLA-SMT on a particular outcome measure were defined as more than one study showing a significantly greater effect of HVLA-SMT compared with the control intervention.

RESULTS

From the 18 studies included (932 participants in total), there was evidence only for an association between HVLA-SMT and changes in the autonomic nervous system, reflected in changes in heart rate variability and skin conductance. Most studies focused on healthy volunteers and none related neurophysiologic changes to pain reduction.

CONCLUSION

This systematic review points to HVLA-SMT affecting the autonomic nervous system. The effects seem to depend on the spinal level of HVLA-SMT application and might differ between healthy volunteers and pain patients. There is a need for high-quality studies that include patients, well characterized for pain duration and outcome measure baseline values, and address the relation between changes in neurophysiology and pain.

LEVEL OF EVIDENCE

2.

Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP)

Examination of a patient with chronic low back pain (LBP) is aimed at eliminating its specific cause and assessing the social and psychological factors of chronic pain. The diagnosis of chronic nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain, discogenic radiculopathy, and lumbar stenosis. It is advisable to identify possible pain sources: pathology of intervertebral disc pathology, facet joints, and sacroiliac joint and myofascial syndrome.

An integrated multidisciplinary approach (a high level of evidence), including therapeutic exercises, physical activity optimization, psychological treatments (cognitive behavioral therapy), an educational program (back pain school for patients), and manual therapy, is effective in treating chronic musculoskeletal LBP. For pain relief, one may use nonsteroidal anti-inflammatory drugs in minimally effective doses and in a short cycle, muscle relaxants, and a capsaicin patch, and, if there is depressive disorder, antidepressants (a medium level of evidence). Radiofrequency denervation or therapeutic blockages with anesthetics and glucocorticoids (damage to the facet joints, sacroiliac joint), back massage, and acupuncture (a low level of evidence) may be used in some patients.

Therapeutic exercises and an educational program (the prevention of excessive loads and prolonged static and uncomfortable postures and the use of correct methods for lifting weights, etc.) are recommended for preventive purposes. 

Power Point Therapy: An Effective and Simple Treatment for Subacute Back Pain - A Randomized Controlled Trial

OBJECTIVE

Subacute low back pain is a frequent problem with the danger of chronification. Conventional treatment options are not always effective. Power Point therapy (PPT) is a novel approach that uses reflexological insights and can be easily applied by practitioners and patients.

METHODS

Randomized, active controlled study comparing 10 units of PPT of 10 min each, with 10 units of standard physiotherapy of 30 min each. Outcomes were functional scores (Roland Morris Disability, Oswestry, McGill Pain Questionnaire, Linton-Halldén - primary outcome) and health-related quality of life (SF-36), as well as blinded assessments by clinicians (secondary outcome).

RESULTS

Eighty patients consented and were randomized, 41 to PPT, 39 to physiotherapy. Measurements were taken at baseline, after the first and after the last treatment (approximately 5 weeks after enrolment). Multivariate linear models of covariance showed significant effects of time and group (p < 0.001) and for the quality of life variables also a significant interaction of time by group (p < 0.001). Clinician-documented variables showed significant differences at follow-up (p = 0.05 to p < 0.0001).

DISCUSSION

Both physiotherapy and PPT improve subacute low back pain significantly. PPT is likely more effective and should be studied further.

Effect of spinal manipulative therapy on mechanical pain sensitivity in patients with chronic nonspecific low back pain: a pilot randomized, controlled trial

Objectives: The long-term goal of our study is to improve the understanding of the biological mechanisms associated with spinal manipulative therapy (SMT) in low back pain.Methods: This project involved a pilot randomized, blinded clinical trial (ClinicalTrials.gov registration number NCT03078114) of 3-week SMT in chronic nonspecific low back pain (CNSLBP) patients. We recruited 29 participants and randomly assigned them into either a SMT (n = 14) or sham SMT (n = 15) group. Pre- and postintervention, we quantified the effect of SMT on clinical outcomes (Numeric Pain Rating Scale and Oswestry Disability Index) and pressure pain threshold (PPT) at local (lumbar spine), regional (lower extremity), and remote (upper extremity) anatomical sites.Results: We observed a significant main effect for time signifying reduced hypersensitivity (increased PPT) at local (p = .015) and regional (p = .014) locations at 3 weeks. Furthermore, we found significant main effects of time indicating improvements in pain (p < .001) and disability (p = .02) from baseline among all participants regardless of intervention. However, no between-group differences were observed in PPT, clinical pain, or disability between the SMT and sham SMT groups over 3 weeks.Conclusions: After 3 weeks of SMT or sham SMT in CNSLBP patients, we found hypoalgesia at local and remote sites along with improved pain and low back-related disability.Level of Evidence: 1b.

Spinal manipulation plus laser therapy versus laser therapy alone in the treatment of chronic non-specific low back pain: a randomized controlled study

BACKGROUND

Low back pain (LBP) is a common musculoskeletal disorder causing pain and disability in most of the countries. In recent years, new approaches such as Spinal manipulation and laser therapy have been considered as an alternative to conventional exercise and also found contradicting results in terms of its effectiveness.

AIM

A study to compare the combined effects of spinal manipulation, Laser and exercise versus Laser and exercise alone in chronic non-specific low back pain (cnLBP).

DESIGN

Randomized control study.

SETTING

Subjects with cnLBP were treated with spinal manipulation, Laser and exercise in outpatient department for four weeks.

POPULATION

Three hundred and thirty subjects who fulfilled the selection criteria were randomized (1:1:1 ratio) into SM-LT-CE (N.=110), LT-CE (N.=110) and control group (N.=110).

METHODS

The outcome measurements were Visual Analog Scale (VAS), Modified Modified Schober Test (MMST) Roland and Morris Disability Questionnaire (RMDQ), Physical Health Questionnaire-9 (PHQ-9) and Health Related Quality of Life-4 (HRQOL-4). Baseline and follow-up measurements were measured at 4 weeks, 6 and 12 months by a blinded investigator.

RESULTS

Three hundred and twenty-six subjects completed the intervention and 304 completed the 12-month follow-up. Demographic variables show homogeneity between the groups and ANOVA analyses showed significant improvement (P<0.001) in pain reduction (VAS), flexion range of motion (MMST), functional disability (RMDQ), depression status (PHQ-9), and quality of life (HRQOL-4) in SM-LT-CE group compared to the other two groups at one-year follow-up.

CONCLUSIONS

Spinal manipulation combined with laser therapy and conventional exercise is more effective than laser therapy and conventional exercise alone in chronic non-specific low back pain.

CLINICAL REHABILITATION IMPACT

Spinal manipulation is an adjuvant intervention and it can be applied in every day clinical practice.

Complementary medicine use, views, and experiences: a national survey in England

Background

In 2005,12% of the English population visited a complementary and alternative medicine (CAM) practitioner.

Aim

To obtain up-to-date general population figures for practitioner-led CAM use in England, and to discover people's views and experiences regarding access.

Design & setting

A face-to-face questionnaire survey was commissioned. A nationally representative adult quota sample (aged ≥15 years) was used.

Method

Ten questions were included within Ipsos MORI’s weekly population-based survey. The questions explored 12-month practitioner-led CAM use, reasons for non-use, views on NHS-provided CAM, and willingness to pay.

Results

Of 4862 adults surveyed, 766 (16%) had seen a CAM practitioner. People most commonly visited CAM practitioners for manual therapies (massage, osteopathy, chiropractic) and acupuncture, as well as yoga, pilates, reflexology, and mindfulness or meditation. Women, people with higher socioeconomic status (SES) and those in south England were more likely to access CAM. Musculoskeletal conditions (mainly back pain) accounted for 68% of use, and mental health 12%. Most was through self-referral (70%) and self-financing. GPs (17%) or NHS professionals (4%) referred and/or recommended CAM to users. These CAM users were more often unemployed, with lower income and social grade, and receiving NHS-funded CAM. Responders were willing to pay varying amounts for CAM; 22% would not pay anything. Almost two in five responders felt NHS funding and GP referral and/or endorsement would increase their CAM use.

Conclusion

CAM use in England is common for musculoskeletal and mental health problems, but varies by sex, geography, and SES. It is mainly self-referred and self-financed; some is GP-endorsed and/or referred, especially for individuals of lower SES. Researchers, patients, and commissioners should collaborate to research the effectiveness and cost-effectiveness of CAM and consider its availability on the NHS.

Scoping review of systematic reviews of complementary medicine for musculoskeletal and mental health conditions

OBJECTIVE

To identify potentially effective complementary approaches for musculoskeletal (MSK)-mental health (MH) comorbidity, by synthesising evidence on effectiveness, cost-effectiveness and safety from systematic reviews (SRs).

DESIGN

Scoping review of SRs.

METHODS

We searched literature databases, registries and reference lists, and contacted key authors and professional organisations to identify SRs of randomised controlled trials for complementary medicine for MSK or MH. Inclusion criteria were: published after 2004, studying adults, in English and scoring >50% on Assessing the Methodological Quality of Systematic Reviews (AMSTAR); quality appraisal checklist). SRs were synthesised to identify research priorities, based on moderate/good quality evidence, sample size and indication of cost-effectiveness and safety.

RESULTS

We included 84 MSK SRs and 27 MH SRs. Only one focused on MSK-MH comorbidity. Meditative approaches and yoga may improve MH outcomes in MSK populations. Yoga and tai chi had moderate/good evidence for MSK and MH conditions. SRs reported moderate/good quality evidence (any comparator) in a moderate/large population for: low back pain (LBP) (yoga, acupuncture, spinal manipulation/mobilisation, osteopathy), osteoarthritis (OA) (acupuncture, tai chi), neck pain (acupuncture, manipulation/manual therapy), myofascial trigger point pain (acupuncture), depression (mindfulness-based stress reduction (MBSR), meditation, tai chi, relaxation), anxiety (meditation/MBSR, moving meditation, yoga), sleep disorders (meditative/mind-body movement) and stress/distress (mindfulness). The majority of these complementary approaches had some evidence of safety-only three had evidence of harm. There was some evidence of cost-effectiveness for spinal manipulation/mobilisation and acupuncture for LBP, and manual therapy/manipulation for neck pain, but few SRs reviewed cost-effectiveness and many found no data.

CONCLUSIONS

Only one SR studied MSK-MH comorbidity. Research priorities for complementary medicine for both MSK and MH (LBP, OA, depression, anxiety and sleep problems) are yoga, mindfulness and tai chi. Despite the large number of SRs and the prevalence of comorbidity, more high-quality, large randomised controlled trials in comorbid populations are needed.

The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain-A pragmatic randomized controlled trial

Background

For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP.

Method

This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18–65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model.

Results

Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded.

Conclusion

MC was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP but it resulted in a higher number of treatments. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.

Outcomes of Various Treatment Modalities for Lumbar Spinal Ailments in Elite Athletes: A Literature Review

Lumbar spinal injuries are common in elite athletes, who can present with a spectrum of ailments ranging from lumbar strain to prolapsed intervertebral discs. Sequelae can include neurological impairment and lumbar instability among other possible outcomes. This group of patients is unique in terms of their clinicoradiological presentation and treatment modalities. The primary goals of treatment are a rapid return to play and prevention of recurrence, thus prolonging the athlete’s professional career. Treatment modalities can range from activity restriction to nerve root blocks and surgery. A successful treatment outcome is based on timely diagnosis, treatment suiting the demands of the particular sport, and early rehabilitation. A multidisciplinary team approach involving the coach, rehabilitation specialist, pain management specialist, and spine surgeon helps in planning appropriate treatment. In this article, we review special considerations in the elite athletic population with lumbar spinal ailments as well as the outcomes of various treatment modalities.

Optimizing treatment protocols for spinal manipulative therapy: study protocol for a randomized trial

BACKGROUND

Low back pain is a common and costly condition. Spinal manipulative therapy (SMT) is a treatment supported in some guidelines, although most clinical trials examining SMT report small effect sizes. Enhancing the effects of SMT requires an understanding of underlying mechanisms and a systematic approach to leverage understanding of mechanisms to create more effective treatment protocols that are scalable in clinical practice. Prior work has identified effects on spinal stiffness and lumbar multifidus activation as possible mechanisms. This project represents a refinement phase study within the context of a multi-phase optimization strategy (MOST) framework. Our goal is to identify an optimized SMT treatment protocol by examining the impact of using co-intervention exercise strategies that are proposed to accentuate SMT mechanisms. The optimized protocol can then be evaluated in confirmation phase clinical trials and implementation studies.

METHODS

A phased, factorial randomized trial design will be used to evaluate the effects of three intervention components provided in eight combinations on mechanistic (spinal stiffness and multifidus muscle activation) and patient-reported outcomes (pain and disability). All participants will receive two sessions then will be randomly assigned to receive six additional sessions (or no additional treatment) over the next three weeks with factorial combinations of additional SMT and exercise co-interventions (spine mobilizing and multifidus activating). Outcome assessments occur at baseline, and one week, four weeks, and three months after enrollment. Pre-specified analyses will evaluate main effects for treatment components as well as interaction effects.

DISCUSSION

Building on preliminary findings identifying possible mechanisms of effects for SMT, this trial represents the next phase in a multiphase strategy towards the ultimate goal of developing an optimized protocol for providing SMT to patients with LBP. If successful, the results of this trial can be tested in future clinical trials in an effort to produce larger treatment benefits and improve patient-centered outcomes for individuals with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02868034 . Registered on 16 August 2016.

A randomized control trial to determine the effectiveness and physiological effects of spinal manipulation and spinal mobilization compared to each other and a sham condition in patients with chronic low back pain: Study protocol for The RELIEF Study

BACKGROUND

Low back pain (LBP) is one of the most common reasons for seeking medical care. Manipulative therapies are a common treatment for LBP. Few studies have compared the effectiveness of different types of manipulative therapies. Moreover, the physiologic mechanisms underlying these treatments are not fully understood. Herein, we present the study protocol for The Researching the Effectiveness of Lumbar Interventions for Enhancing Function Study (The RELIEF Study).

METHODS AND STUDY DESIGN

The RELIEF Study is a Phase II RCT with a nested mechanistic design. It is a single-blinded, sham-controlled study to test the mechanisms and effectiveness of two manual therapy techniques applied to individuals (n = 162; 18-45 years of age) with chronic LBP. The clinical outcome data from the mechanistic component will be pooled across experiments to permit an exploratory Phase II RCT investigating the effectiveness. Participants will be randomized into one of three separate experiments that constitute the mechanistic component to determine the muscular, spinal, and cortical effects of manual therapies. Within each of these experimental groups study participants will be randomly assigned to one of the three treatment arms: 1) spinal manipulation, 2) spinal mobilization, or 3) sham laser therapy. Treatments will be delivered twice per week for 3-weeks.

DISCUSSION

This data from this will shed light on the mechanisms underlying popular treatments for LBP. Additionally, the coupling of this basic science work in the context of a clinical trial will also permit examination of the clinical efficacy of two different types of manipulative therapies.

Osteopathic Manipulative Treatment Including Specific Diaphragm Techniques Improves Pain and Disability in Chronic Nonspecific Low Back Pain: A Randomized Trial

OBJECTIVE

To investigate the effects of an osteopathic manipulative treatment (OMT), which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic nonspecific low back pain (NS-CLBP).

DESIGN

Parallel group randomized controlled trial.

SETTING

Private and institutional health centers.

PARTICIPANTS

Participants (N=66) (18-60y) with a diagnosis of NS-CLBP lasting at least 3 months.

INTERVENTIONS

Participants were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks.

MAIN OUTCOME MEASURES

The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland-Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12.

RESULTS

A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12 (SF-MPQ [mean difference -6.2; 95% confidence interval, -8.6 to -3.8]; VAS [mean difference -2.7; 95% confidence interval, -3.6 to -1.8]; RMQ [mean difference -3.8; 95% confidence interval, -5.4 to -2.2]; ODI [mean difference -10.6; 95% confidence interval, -14.9 to 6.3]). Moreover, improvements in pain and disability were clinically relevant.

CONCLUSIONS

An OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.

A workforce survey of Australian osteopathy: analysis of a nationally-representative sample of osteopaths from the Osteopathy Research and Innovation Network (ORION) project

Background

Limited information is available regarding the profile and clinical practice characteristics of the osteopathy workforce in Australia. This paper reports such information by analysing data from a nationally-representative sample of Australian osteopaths.

Methods

Data was obtained from a workforce survey of Australian osteopathy, investigating the characteristics of the practitioner, their practice, clinical management features and perceptions regarding research. The survey questionnaire was distributed to all registered osteopaths across Australia in 2016 as part of the Osteopathy Research and Innovation Network (ORION) project.

Results

A total of 992 Australian osteopaths participated in this study representing a response rate of 49.1%. The average age of the participants was 38.0 years with 58.1% being female and the majority holding a Bachelor or higher degree qualification related to the osteopathy professional. Approximately 80.0% of the osteopaths were practicing in an urban area, with most osteopaths working in multi-practitioner locations, having referral relationships with a range of health care practitioners, managing patients a number of musculoskeletal disorders, and providing multi-model treatment options.

Conclusions

A total of 3.9 million patients were estimated to consult with osteopaths every year and an average of approximate 3.0 million hours were spent delivering osteopathy services per year. Further research is required to provide rich, in-depth examination regarding a range of osteopathy workforce issues which will help ensure safe, effective patient care to all receiving and providing treatments as part of the broader Australian health system.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3158-y) contains supplementary material, which is available to authorized users.

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

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.

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative

OBJECTIVE

The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

METHODS

The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

RESULTS

For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

CONCLUSIONS

A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Immediate Effects of Thoracic Spine Thrust Manipulation on Neurodynamic Mobility

OBJECTIVE

The purpose of this study was to investigate the immediate effects of thoracic spine thrust manipulation (TSM) on the upper limb provocation test (ULPT) and seated slump test (SST) in individuals with identified neurodynamic mobility impairments. A secondary aim was to determine if correlation existed between the perception of effect and improvements in neurodynamic mobility following a thrust manipulation compared with mobilization.

METHODS

A pretest-posttest experimental design randomized 48 adults into 2 groups: TSM or mobilization. Participants with identified neurodynamic mobility impairment as assessed with the ULPT or SST received a pre-assigned intervention (TSM, n = 64 limbs; mobilization, n = 66 limbs). Perception of effect was assessed to determine its influence on outcome. Repeated-measures analysis of variance was used to examine the effects of intervention, and Fisher's exact test and independent t tests were used to determine the influence of perception.

RESULTS

Both the ULPT (P < .001) and SST (P < .001) revealed improvements at posttest regardless of intervention. The ULPT effect sizes for TSM (d = 0.70) and mobilization (d = 0.69) groups were medium. For the SST, the effect size for the TSM group (d = 0.53) was medium, whereas that for the mobilization group (d = 0.26) was small. Participants in the mobilization group with positive perception had significantly greater (P < .05) mean neurodynamic mobility changes than those with a negative perception.

CONCLUSIONS

Neurodynamic mobility impairment improved regardless of intervention. The magnitude of change was greater in the ULPT than SST. Although both interventions appeared to yield similar outcomes, individuals who received mobilization and expressed a positive perception of effect exhibited significantly greater changes in neurodynamic mobility than those without a positive perception.

Introduction to Integrative Medicine in the Primary Care Setting

Integrative Medicine has been described as "healing oriented medicine that takes account of the whole person (body, mind, and spirit) including all aspects of lifestyle. It emphasizes therapeutic relationships and makes use of all appropriate therapies, both conventional and alternative." National surveys consistently report that approximately one-third of adults and 12% of children use complementary and integrative medicine approaches. Although there are barriers to primary care professionals engaging in discussions about lifestyle change and complementary and integrative medicine options, there is also great potential to impact patient well-being.

Prognostic factors of a favorable outcome following a supervised exercise program for soldiers with sub-acute and chronic low back pain

Background

Low back pain (LBP) encompasses heterogeneous patients unlikely to respond to a unique treatment. Identifying sub-groups of LBP may help to improve treatment outcomes. This is a hypothesis-setting study designed to create a clinical prediction rule (CPR) that will predict favorable outcomes in soldiers with sub-acute and chronic LBP participating in a multi-station exercise program.

Methods

Military members with LBP participated in a supervised program comprising 7 stations each consisting of exercises of increasing difficulty. Demographic, impairment and disability data were collected at baseline. The modified Oswestry Disability Index (ODI) was administered at baseline and following the 6-week program. An improvement of 50% in the initial ODI score was considered the reference standard to determine a favorable outcome. Univariate associations with favorable outcome were tested using chi-square or paired t-tests. Variables that showed between-group (favorable/unfavorable) differences were entered into a logistic regression after determining the sampling adequacy. Finally, continuous variables were dichotomized and the sensitivity, specificity and positive and negative likelihood ratios were determined for the model and for each variable.

Results

A sample of 85 participants was included in analyses. Five variables contributed to prediction of a favorable outcome: no pain in lying down (p = 0.017), no use of antidepressants (p = 0.061), FABQ work score < 22.5 (p = 0.061), fewer than 5 physiotherapy sessions before entering the program (p = 0.144) and less than 6 months’ work restriction (p = 0.161). This model yielded a sensitivity of 0.78, specificity of 0.80, LR+ of 3.88, and LR- of 0.28. A 77.5% probability of favorable outcome can be predicted by the presence of more than three of the five variables, while an 80% probability of unfavorable outcome can be expected if only three or fewer variables are present.

Conclusion

The use of prognostic factors may guide clinicians in identifying soldiers with LBP most likely to have a favorable outcome. Further validation studies are needed to determine if the variables identified in our study are treatment effect modifiers that can predict success following participation in the multi-station exercise program.

Trial registration

ClinicalTrials.gov Identifier: NCT03464877 registered retrospectively on 14 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2022-x) contains supplementary material, which is available to authorized users.

How frequent are non-evidence-based health care beliefs in chiropractic students and do they vary across the pre-professional educational years

Background

Evidence suggests that a students’ beliefs already prior to entering a program may be important as a determinant in sustaining unsuitable health care beliefs. Our objectives were to investigate the proportion of Australian chiropractic students who hold non-evidence-based beliefs in the first year of study and the extent to which they may be involved in non-musculoskeletal health conditions. Finally, to see if this proportion varies over the course of the chiropractic program.

Method

In 2016, students from two Australian chiropractic programs answered a questionnaire on how often they would give advice on five common health conditions in their future practices as well as their opinion on whether chiropractic spinal adjustments could prevent or help seven health-related conditions.

Results

From a possible 831 students, 444 responded (53%). Students were highly likely to offer advice (often/quite often) on a range of non-musculoskeletal conditions. The proportions were lowest in first year and highest the final year. Also, high numbers of students held non-evidence-based beliefs about ‘chiropractic spinal adjustments’ which tended to occur in gradually decreasing in numbers in sequential years, except for fifth year when a reversal of the pattern occurred.

Conclusions

New strategies are required for chiropractic educators if they are to produce graduates who understand and deliver evidence-based health care and able to be part of the mainstream health care system.

Electronic supplementary material

The online version of this article (10.1186/s12998-018-0178-y) contains supplementary material, which is available to authorized users.

[The role of extracorporeal shock wave therapy in the combined restorative treatment of the patients presenting with myofascial pain syndrome]

The myofascial pain syndromes (MPS) is ranked among the most frequent clinical manifestations of acute and chronic pain in the lumbar region. The authors of the article undertook the analysis of scientific publications from the Pubmed, Medline, and Scopus databases that appeared during the recent years. The analysis has demonstrate that extracorporeal shock wave therapy (ESWT) can be considered as a method of choice to be used in the framework of the complex programs of the treatment and rehabilitation of the condition of interest. The specific etiopathogenetic features of ESWT are considered in terms of the contemporary views with special reference to their influence on the choice of the treatment strategies and concrete methods for the treatment of the myofascial pain syndromes. It is shown that extracorporeal shock wave therapy makes it possible to enhance the blood flow and circulation and increase the permeability of cell membranes thereby facilitating the activation of the regenerative processes in the structural elements of the vertebral-motor segment undergoing the dystrophic changes. Moreover, ESWT produces the anti-inflammatory effects and causes muscle relaxation. There is strong evidence of the possibility to use such modern modalities of manual needs tlomethods of ESWT and manual therapy in patients with MFBS that requires further research. The expected effects of the combined application of extracorporeal shock wave therapy and manual therapy for the treatment of the patients presenting with myofascial pain syndrome remain to be verified in the further studies.