Directed vertebral manipulation is not better than generic vertebral manipulation in patients with chronic low back pain: a randomised trial.

QUESTION: In people with chronic low back pain, what is the average effect of directing manipulation at the most painful lumbar level compared with generic manipulation of the spine? DESIGN: Randomised controlled trial with concealed allocation, a blinded assessor and intention-to-treat analysis. PARTICIPANTS: 148 people with non-specific chronic low back pain with a minimum level of pain intensity of 3 points (measured from 0 to 10 on the Pain Numerical Rating Scale). INTERVENTIONS: All participants received 10 spinal manipulation sessions over a 4-week period. The experimental group received treatment to the most painful segment of the lower back. The control group received treatment to the thoracic spine. OUTCOME MEASURES: The primary outcome was pain intensity, measured at the end of the intervention (Week 4). Secondary outcomes were: pain intensity at Weeks 12 and 26; pressure pain threshold at Week 4; and global perceived change since onset and disability, both measured at Weeks 4, 12 and 26. RESULTS: Each group was randomly allocated 74 participants. Data were collected at all time points for 71 participants (96%) in the experimental group and 72 (97%) in the control group. There were no clinically important between-group differences for pain intensity, disability or global perceived effect at any time point. The estimate of the effect of directing manipulation at the most painful lumbar level, as compared with generic manipulation, on pain intensity was too small to be considered clinically important: MD 0 (95% CI -0.9 to 0.9) at Week 4 and -0.1 (95% CI -1.0 to 0.8) at Week 26. CONCLUSION: No clinically important differences were observed between directed manipulation and generic manipulation in people with chronic low back pain. TRIAL REGISTRATION: NCT02883634.

The contemporary management of nonspecific lower back pain.

Low back pain (LBP) is extremely common and causes an enormous burden on the society. This perspective article aims to provide an evidence-based summary in the field of LBP. More specifically, we aimed to present epidemiological data on cost, diagnosis, prognosis, prevention and interventions for patients with LBP. It is critical that both clinicians and policymakers follow best practices by using high-value care for patients with LBP. In addition, nonevidence-based procedures must be immediately abandoned. These actions are likely to reduce societal costs and will improve the quality of life of these patients.

Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial.

BACKGROUND: Manual therapists typically advocate the need for a detailed clinical examination to decide which vertebral level should be manipulated in patients with low back pain. However, it is unclear whether spinal manipulation needs to be specific to a vertebral level. OBJECTIVE: The purpose of this study was to analyze the immediate effects of a single, region-specific spinal manipulation defined during the clinical examination versus a single non-region-specific spinal manipulation (applied on an upper thoracic vertebra) in patients with chronic nonspecific low back pain for the outcome measures of pain intensity and pressure pain threshold at the time of the assessment. DESIGN: This was a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor. SETTING: The study was conducted in an outpatient physical therapy clinic in Brazil. PATIENTS: The study participants were 148 patients with chronic nonspecific low back pain (with pain duration of at least 12 weeks). RANDOMIZATION: The randomization schedule was generated by an independent statistician and was concealed by using consecutively numbered, sealed, opaque envelopes. INTERVENTIONS: A single high-velocity manipulation was administered to the upper thoracic region of the participants allocated to the non-region-specific manipulation group and to the painful lumbar levels of the participants allocated to the region-specific manipulation group. MEASUREMENTS: Pain intensity was measured by a 0 to 10 numeric pain rating scale. Pressure pain threshold was measured using a pressure algometer. LIMITATIONS: It was not possible to blind the therapist and participants. RESULTS: A total of 148 patients participated in the study (74 in each group). There was no loss to follow-up. Both groups improved in terms of immediate decrease of pain intensity; however, no between-group differences were observed. The between-group difference for pain intensity and pressure pain threshold were 0.50 points (95% confidence interval=-0.10 to 1.10) and -1.78 points (95% confidence interval=-6.40 to 2.82), respectively. No adverse reactions were observed. CONCLUSION: The immediate changes in pain intensity and pressure pain threshold after a single high-velocity manipulation do not differ by region-specific versus non-region-specific manipulation techniques in patients with chronic low back pain.