Low Back Pain - JOSPT

Low Back Pain: Clinical Practice Guidelines
Patients in the study by Childs et al 51 who received manipulation
and exercise demonstrated less risk of worsening disability
than those who received only exercise. 50 Patients who
received only exercise were 8 (95% CI: 1.1, 63.5) times more
likely to experience a worsening of disability. The number
needed to treat (NNT) with manipulation to prevent 1 additional
patient from experiencing a worsening in disability
was 9.9 (95% CI: 4.9, 65.3). 50
This rule has been further examined by Cleland et
al66 I with similar results for patients fitting the clinical
prediction rule treated with 2 different thrust
techniques, the previously utilized general lumbopelvic technique
and a sidelying rotational technique. The 2 groups receiving
thrust manipulation fared significantly better than a
group receiving nonthrust mobilization at 1 week, 4 weeks,
and 6 months.
The Cleland et al66 trial demonstrated that patient
outcomes are dependent on utilization of a thrust
manipulation, as those who received nonthrust
techniques did not have dramatic improvement. This had
previously been established by Hancock et al140 in a secondary
analysis of patients who fit the clinical prediction rule and
were treated primarily with nonthrust mobilization, where
no differences were found in a control group that received
placebo intervention. The findings of the Cleland et al66 and
Hancock et al140 I
papers demonstrate that rapid improvements
associated with patients fitting the clinical prediction
rule are specific to patients receiving thrust manipulation.
A secondary analysis by Fritz et al116 examined the
I relationship between judgments of passive accessory
mobility assessments and clinical outcomes
after 2 different interventions, stabilization exercise alone
or thrust manipulation followed by stabilization exercise.
The mean duration of symptoms for patients included in the
analysis was 27 days (range, 1-594). Patients who were assessed
to have lumbar hypomobility on physical examination
demonstrated more significant improvements with the thrust
manipulation and exercise intervention than with stabilization
alone. Seventy-four percent of patients with hypomobility
who received manipulation were deemed successful as
compared to 26% of patients with hypermobility who were
treated with manipulation. These findings may suggest that
assessment of hypomobility, in the absence of contraindications,
is sufficient to consider use of thrust manipulation as a
component of comprehensive treatment.
Beyond the success associated with the use of thrust
I manipulation in patients with acute low back pain
who fit the clinical prediction rule, there is evidence
for the use of thrust manipulation in other patients experi-
a32 | april 2012 | volume 42 | number 4 | journal of orthopaedic & sports physical therapy
encing low back pain. Aure and colleagues 13 demonstrated
superior reductions in pain and disability in patients with
chronic low back pain who received thrust manipulations
when compared to an exercise intervention. More recently,
Cecchi et al 45 conducted a randomized controlled trial (n =
210) in patients with subacute and chronic low back pain.
Subjects were randomized to receive thrust manipulation,
back school intervention, or individualized physiotherapy
intervention. Reductions in disability were significantly higher
for the manipulation group at discharge and 12 months.
Long-term pain relief, reoccurrences of low back pain, and
drug usage also favored the manipulation group.
Whitman et al316,317 demonstrated that, for patients
with clinical and imaging findings consistent with
lumbar central spinal stenosis, a comprehensive
treatment plan including thrust and nonthrust mobilization/
manipulation directed at the lumbopelvic region is effective
at improving patient recovery. In the randomized control trial,
58 patients were randomized to receive a comprehensive
manual therapy approach, abdominal retraining, and body
weight–supported treadmill training compared to lumbar
flexion exercises and traditional treadmill training. 316 Seventy-eight
percent of patients receiving manual treatments met
the threshold for success compared to 41% of the flexionbased
exercise group at 6 weeks. At long-term follow-up, all
outcomes favored the experimental group, although these
differences were not statistically significant. Manual therapy
was delivered in a pragmatic impairment-based approach;
specifically, 100% of patients received nonthrust mobilization
to the lumbar spine, 50% of patients received thrust manipulation
to the lumbar spine, and 31% of patients received
lumbopelvic manipulation. 14 Patients also received manual
therapy interventions to other regions of the lower quarter
and thoracic spine as deemed important by the treating therapists.
14 I
This study supports the use of a comprehensive treatment
program that includes manual therapy interventions
in the management of patients with lumbar spinal stenosis.
Murphy et al223 published a prospective cohort
study of 57 consecutive patients with central, lateral,
or combined central and lateral lumbar spinal
stenosis. Patients were treated with lumbar thrust manipulation,
nerve mobilization procedures, and exercise. The mean
improvement in disability, as measured by the Roland-Morris
Disability Questionnaire, was 5.1 points from baseline to discharge,
and 5.2 points from baseline to long-term follow-up,
satisfying the criteria for minimally clinical important difference.
Pain at worst was also reduced by a mean of 3.1 points.
Reiman et al, 252 III
in a recent systematic review, recommended
manual therapy techniques including thrust and nonthrust
mobilization/manipulation to the lumbopelvic region for patients
with lumbar spinal stenosis.