1. Common Therapies for Back Pain:
Manual Therapies
EMGO Instituut - Common Mental Disorders

2. Manual Therapies
Encompasses a broad array of treatments provided by several different professional disciplines.
manual therapy: the use of hands-on techniques to evaluate, treat, and improve the status of neuro- musculoskeletal conditions
Soft Tissue Techniques
Joint Techniques

3. What Do Patients with Back Pain Think About Manual Therapies?
Sherman et al, Spine 2004

4. What Do Patients with Back Pain Think About Manual Therapies?
Data from 371 patients with back pain receiving physical therapy

5. Manipulation - Definitions
NIH/NCCAM
Manipulation = “The application of a controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems.”

6. Manipulation - Definitions
Guide to Physical Therapy Practice-
Mobilization/Manipulation = “A manual therapy technique comprised of a continuum of skilled passive movements to joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement”

7. What is the Evidence for Manipulation for Low Back Pain?
Practice Guideline
Acute LBP
Chronic LBP
American College Physicians (2007)
Recommended
American College of Occupational and Environmental Medicine (2010)
“Manipulation or mobilization for select acute LBP based on Clinical Prediction Rule”
“Manipulation or mobilization for sub-acute LBP
Not Recommended
Regular or routine manip-ulation or mobilization (several times a month for years)

8. What is the Evidence for Massage for Low Back Pain?
Practice Guideline
Acute LBP
Chronic LBP
American College Physicians (2007)
Not recommended
“Evidence is insufficient”
Recommended
American College of Occupational and Environmental Medicine (2010)
“Time limited use as adjunct to conditioning program”

9. Recommended as an Option
Practice Guideline
Acute LBP
Chronic LBP
MIXED RESULTS
“Some studies show these measures relieve acute low back pain and some do not.”
Recommended
(first 4-6 weeks only)
(with low evidence)
Recommended as part of a activating strategy for patients with acute or chronic low back pain
Recommended as a treatment option taking into account patient preferences - Treatment may be provided by a range of health professionals including chiropractors, osteopaths, manipulative physiotherapists or doctors who have had specialist training
Recommended as an Option
Consider (referral for) spinal manip-ulation for patients who are failing to return to normal activities
Consider a short course of spinal manipulation /mobilisation as a treatment option for CLBP.

10. Spinal Manipulative Therapy for Chronic Low Back Pain High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. (2011) Spinal Manipulative Therapy for Acute Low Back Pain SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation. (2013)

11. 2012
Six economic evaluations were included which evaluated the cost-effectiveness of SMT compared to other treatment options for people with neck and back pain.
Regardless of the perspective employed or the region of pain, SMT appears to be a cost-effective treatment when used alone or in combination with GP care or advice and exercise compared to GP care alone, exercise or any combination of these.

12. Massage for Low Back Pain Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.(2009)

13. Some Observations on the Evidence
Findings from primary research studies and guidelines/reviews offer conflicting recommendations.
Systematic reviews often focus on isolated comparisons of manipulation to alternative treatments
Practice guidelines focus on more comprehensive management decisions including considerations of:
costs
patient preferences/expectations
alternatives

14. “The limited data available do not provide support for a hypothesis that RCTs of manual therapy for NSLBP show a greater therapeutic effect when participating clinicians have discretion regarding treatment selection.”

15. Some Observations on the Evidence
Manipulation and massage cover a diverse set of techniques
Little evidence that selection of a particular technique or provision by a particular provider-type impacts outcomes

16. Some Recent Trials of Note

17. 401 patients age 21-65 with non-specific chronic LBP Treatment groups:
Structural massage: intended to identify and alleviate musculoskeletal contributors to back pain, comprised myofascial, neuromuscular, and other soft- tissue techniques. Therapists could recommend a home exercise consisting of psoas stretch to enhance and prolong any benefits of structural massage.
Relaxation massage: intended to induce general sense of relaxation, using effleurage, petrissage, circular friction, vibration, rocking and jostling, and holding. Therapists could provide a compact disk of a 2.5-minute relaxation exercise to be done at home to enhance and prolong treatment benefits.
Usual Care: no special care provided.

18. RESULTS
Treatment adherence was 93% for relaxation massage and 88% for structural massage
Compared to usual care, RDQ scores were 2.9 points lower (95% CI, 1.8, 4.0) for relaxation massage and 2.5 points (CI, 1.4, 3.5) lower for structural massage
There were no differences between the two types of massage
4% relaxation massage recipients and 7% structural massage recipients reported adverse events possibly related to massage, mostly increased pain.

20. Manipulation + Stabilization Exercise Stabilization Exercise
Childs JD, Fritz JM, Flynn TW, et al. A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study. Annals Intern Med, Dec. 2004
131 Patients with LBP Referred to Physical Therapy R
Manipulation + Stabilization Exercise
Stabilization Exercise +
Manipulation responder ▬
Manipulation responder +
Manipulation responder ▬
Manipulation responder

21. Significant Group x Responder Status x Time interaction
From Childs et al. Annals Intern Med, Dec. 2004
EMGO Instituut - Common Mental Disorders

22. R 1-Week 4-Week 6-Month 112 LBP patients + Manipulation Responder
Cleland JA, Fritz JM, Kulig K, et al. Spine, Dec 2009
112 LBP patients + Manipulation Responder
(at least 4 of the following: duration<16 days, no symptoms below knee(s), stiffness, decreased hip int rotation, low fear avoidance beliefs) R
Supine Manipulation (n=37)
Side-Lying Manipulation (n=38)
Supine Mobilization (n=37)
1-Week
4-Week
6-Month

23. Oswestry * * *

24. 50% Reduction in Oswestry Scores
p<.01
p<.001
p<.001

25. Summary
Manual therapies are commonly used by many types of providers for patients with back pain.
Patients generally view manual therapies favorably.
Like most treatments for back pain, treatment effects are modest.
More research needed to optimize use of manual therapies for patients with back pain.

26. Thank you