Evidence Review

Physical Therapies

Manipulation

Back exercises

Physical Agents and Modalities

Traction

Transcutaneous Electrical Nerve Stimulation (TENS)

Shoe Insoles and Shoe Lifts

Lumbar Corsets and Supports

Trigger Point and Ligamentous Injections

Acupuncture

Epidural Steroid Injections

Facet Joint Injections

Biofeedback

Group education: back school

Manipulation

There are now 36 RCTs of manipulation for low back pain, though many have low methodological scores. Overall, 19 report ‘positive’ results and a further 5 report ‘positive’ results in one or more sub-groups. There are also even more systematic reviews of these trials, but the reviews sometimes reach conflicting conclusions. There is very little evidence available on manipulation in patients with nerve root pain.

	In acute and sub-acute back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared.
	However, there is no firm evidence that it is possible to select which patients will respond or what kind of manipulation is most effective. The optimum timing for this intervention is unclear. Lewis 1995, Koes et al 1996b, Shekelle et al 1995.
	The risks of manipulation for low back pain are very low, provided patients are selected and assessed properly and it is carried out by a trained therapist or practitioner. Manipulation should not be used in patients with severe or progressive neurological deficit in view of the rare but serious risk of neurological complication. Haldeman & Rubinstein 1992