Evidence-informed Management of Chronic Low Back Pain with Spinal Manipulation and Mobilization
SOURCE: Spine J. 2008 (Jan); 8 (1): 213–225
Gert Bronfort, DC, PhDa, Mitch Haas, DC, MA, Roni Evans, DC, MS, Greg Kawchuk, DC, PhD, Simon Dagenais, DC, PhD
Northwestern Health Sciences University,
2501 W 84th St,
Bloomington, MN 55431, USA.
The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery.
Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.
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KEYWORDS: Chronic low back pain; Spinal manipulative therapy (SMT); Spinal mobilization (MOB); Low back pain,
manipulation, spinal; Meta-analysis
From the FULL TEXT Article:
For the purpose of this review, spinal manipulative therapy (SMT) is defined as the application of high-velocity, low-amplitude manual thrusts to the spinal joints slightly beyond the passive range of joint motion.  Spinal mobilization (MOB) is defined as the application of manual force to the spinal joints within the passive range of joint motion that does not involve a thrust.
Although the practice of spinal manipulation is now frequently associated with chiropractic – which began as a profession in 1895 – it predates any modern health profession and dates back thousands of years. Spinal manipulation is believed to have been practiced in China as far back as 2700 BC.  In India, spinal manipulation was historically practiced as an act of hygiene and related techniques were considered a component of surgery.  Hippocrates, in his book On Joints, was the first to give a formal definitio to the technique of manipulation; his belief in the spine as the epicenter of holistic bodily health is well known.  As a testament to its long history of use, there are now more randomized controlled trials (RCTs) examining SMT for low back pain (LBP) than any other intervention for that indication. 
There are many subtypes of SMT currently in use, including several named technique systems combining patient assessment and management. The most common type of SMT technique has been termed “diversified’’ because it incorporates many of the aspects taught in these different systems. It consists of the application of a high-velocity, low-amplitude (HVLA) thrust to the spine with the practitioner’s hand to distract spinal zygapophyseal joints slightly beyond their passive range of joint motion into the paraphysiologic space.  There are many specific HLVA techniques available to practitioners of SMT that can be modified according to patient need. This type of SMT has also been termed short-lever SMT, because the thrust is applied directly to the spine. It is distinguished from long-lever SMT, originally from the osteopathic tradition, in which force is not provided to the spine directly, but from rotation of the patient’s thigh and leg.