Manipulation and Mobilization for Treating Chronic Low Back Pain: A Systematic Review and Meta-analysis
SOURCE: Spine J. 2018 (May); 18 (5): 866–879
Ian D. Coulter, PhD, Cindy Crawford, BA, Eric L. Hurwitz, DC, PhD, Howard Vernon, DC, PhD, Raheleh Khorsan, PhD, Marika Suttorp Booth, MS, Patricia M. Herman, ND, PhD
1776 Main St,
Santa Monica, CA 90407-2138, USA
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.
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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.
KEYWORDS: Chiropractic; Chronic low back pain; Manipulation; Meta-analysis; Mobilization; Systematic review
From the FULL TEXT Article:
Similar to conclusions reported most recently in BMJ , a recent review published in JAMA reported that among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, study results showed substantial heterogeneity.  The review did not address the efficacy of manipulation and mobilization for chronic low back pain. Given the current interest in non-pharmacological alternatives for the treatment of chronic pain, in particular non-opioid treatments , a systematic review of manipulation and mobilization for chronic low back pain is timely.
The lifetime prevalence of low back pain in the United States may be as high as 84%. The prevalence of chronic low back pain is about 23%; it disables 11%–12% of the population.  A recent systematic review of the clinical course of non-specific low back pain found that in the first 3 months, 33% of patients showed recovery, but 1 year after onset, 65% still reported pain.  The severity, length, or duration of pain for any one individual varies, and the transition from acute to chronic low back pain is difficult to determine. 
Pain management approaches vary greatly. Many physicians rely on non–steroidal anti–inflammatory drugs, opioid, and neurotropic medications, or steroid injections and surgery as their main tools.  Because of the potential or apparent risks associated with these tools , non–pharmacological approaches, thought to involve minimal adverse events, have become popular. In recent years, multiple studies have explored the evidence for treating chronic low back pain; options include spinal manipulation therapy, behavioral therapy, exercise therapy, transcutaneous electrical nerve stimulation, interferential currents, low–level laser therapy, and yoga.  Other therapies include massage, acupuncture, and superficial heat therapy (eg, therma heat wraps, hot water bottles, heated packs filled with grain, hot towels, and electric heating pads).  Manual modalities such as physiotherapy, massage, chiropractic, occupational, and osteopathic therapies, including spinal manipulation and mobilization, are often used together and alone to treat chronic non–specific low back pain. [11, 12]
Several systematic reviews have focused on manual therapies such as spinal manipulation and mobilization for treating back and neck pain. [13–16] Earlier work suggested that there is little or no evidence that spinal manipulative therapy was superior to other standard treatments for chronic low back pain [17, 18]; however, recent systematic reviews suggest that spinal manipulation and mobilization are “viable” options for pain treatment. [13, 19] However, the efficacy of manipulation and mobilization may vary depending on the duration of symptoms, how the intervention is administered (eg, whether there is additional exercise or general practitioner care, at what dosages, and follow–up periods), the comparator, and types of outcomes reported. Such variability could be considered inconsistent findings; however, the overall evidence suggests that manipulation and mobilization are effective treatment modalities compared with other therapies. [13, 19]
The purpose of the systematic review described here was to disentangle inconsistencies by evaluating the research according to different symptom durations across the spectrum of chronicity, the variations in treatment techniques, variations in comparators, and the impact on important patient–reported outcomes. Our goal was to better understand the effectiveness of mobilization and manipulation for chronic non–specific low back pain as compared and reported in randomized controlled trials (RCTs) since 2000. We would attempt meta–analysis when there were subsets of data similar enough to pool.
This systematic review is part of a larger project investigating the appropriateness of manipulation or mobilization for the treatment of chronic low back pain and cervical pain, funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912.