Recent clinical practice guidelines for the management of low back pain: a global comparison.

BACKGROUND: Low back pain (LBP) is a significant health problem worldwide, with a lifetime prevalence of 84% in the general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world. METHODS: MEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-specific LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS: Our analysis identified a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to different stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-inflammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal manipulation. For subacute LBP, the guidelines recommended the use of NSAIDs, therapeutic exercise, staying active, and spinal manipulation. For chronic LBP, the guidelines recommended therapeutic exercise, the use of NSAIDs, spinal manipulation, and acupuncture. CONCLUSIONS: Current CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. Some recommendations lack clarity and overlap with other treatments within the guidelines.

Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy: A Randomized Controlled Trial.

OBJECTIVE: We evaluated the efficacy of spinal manipulation for the management of nonacute lumbar radiculopathy. METHODS: In a university hospital we performed a randomized controlled trial with 2 parallel arms. Patients (n = 44) with unilateral radicular low back pain lasting more than 4 weeks were randomly allocated to manipulation and control groups. The primary outcome was the intensity of the low back pain on a visual analog scale. The secondary outcome was the Oswestry Disability Questionnaire score. We also measured spinal ranges of motion. The assessments were carried out at the baseline, immediately after intervention, and at 3 months' follow-up. All patients underwent physiotherapy. The manipulation group received three sessions of manipulation therapy 1 week apart. For manipulation, we used Robert Maigne's technique. RESULTS: Both groups experienced a decrease in back and leg pain significantly (all P ≤ 0.003). However, only the manipulation group showed significantly favorable results in the Oswestry scores (P < 0.001), and the straight leg raise test (P = 0.001). All ranges of motion increased significantly with manipulation (all P < 0.001), but the control group showed favorable results only in right and left rotations and in extension (all P < 0.001). Between-group analyses showed significantly better outcomes for manipulation in all measurements (all P ≤ 0.009) with large effect sizes. CONCLUSION: Spinal manipulation improves the results of physiotherapy over a period of 3 months for patients with subacute or chronic lumbar radiculopathy.

Optimization of Spinal Manipulative Therapy Protocols: A Factorial Randomized Trial Within a Multiphase Optimization Framework.

Spinal manipulative therapy (SMT) is a common nonpharmacological treatment for low back pain (LBP). Although generally supported by systematic reviews and practice guidelines, clinical trials evaluating SMT have been characterized by small effect sizes. This study adopts a Multiphase Optimization Strategy framework to examine individual components of an SMT delivery protocol using a single-blind trial with the goal of identifying and optimizing a multicomponent SMT protocol. We enrolled 241 participants with LBP. All participants received 2 SMT treatment sessions in the first week then were randomly assigned additional treatment based on a fully factorial design. The 3 randomized treatment components provided in twice weekly sessions over 3 weeks were multifidus activating exercise, spinal mobilizing exercise, and additional SMT dose. Primary outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (spinal stiffness, multifidus muscle activation) measures assessed at baseline, 1, 4, and 12 weeks. Significant differences were found for the Oswestry index after 12 weeks for participants receiving multifidus activating exercise (mean difference = -3.62, 97.5% CI: -6.89, -0.35; P= .01). There were no additional significant main or interaction effects for other treatment components or different outcome measures. The optimized SMT protocol identified in this study included SMT sessions followed by multifidus activating exercises. PERSPECTIVE: Optimizing the effects of nonpharmacological treatments such as SMT for LBP is challenging due to uncertainty regarding mechanisms and the complexity of multicomponent protocols. This factorial randomized trial examined SMT protocols provided with differing co-interventions with mechanistic and patient-centered outcomes. Patient-centered outcomes were optimized by inclusion of lumbar multifidus strengthening exercises.

A randomized controlled study for the treatment of middle-aged and old-aged lumbar disc herniation by Shis spine balance manipulation combined with bone and muscle guidance.

ABSTRACT: Ninety percent of elderly patients with lumbar disc herniation (LDH) have problems with the mechanics of the spine and muscle tissue. Shi-style spine balance manipulation combined with guidance (Daoyin) of muscle and bone as an alternative therapy for LDH can tone the muscle groups around the spine and maintain optimal mechanical and static sagittal balance of the spine. This study will be performed to investigate the effect of a combination of Shi-style spine balance manipulation and Daoyin therapy on LDH in middle-aged and elderly patients. In this non-blinded, randomized controlled trial, 72 eligible patients will be randomly divided into a treatment group (Shi-style spine balance manipulation combined with Daoyin therapy) and a control group (lumbar mechanical traction). Before and after the intervention, lumbar X-ray and magnetic resonance imaging examinations will be performed to observe the sagittal balance parameters of the spine and pelvis and the lumbar muscle strength. The visual analog scale score, Oswestry disability index score, and pressure pain threshold will be evaluated at baseline and at 2, 4, 12, and 24 weeks. During the treatment period, any signs of acute adverse events, such as paralysis of the lower extremities or cauda equina syndrome, will be recorded at each visit. Although Shi-style spine manipulation combined with Daoyin therapy has been used in the treatment of LDH in middle-aged and elderly people in China for many years, there is no consensus on its effectiveness. This experiment will provide convincing evidence of the efficacy of Shi-style spine manipulation combined with Daoyin therapy in the treatment of LDH in middle-aged and elderly people.

Comparing the range of musculoskeletal therapies applied by physical therapists with postgraduate qualifications in manual therapy in patients with non-specific neck pain with international guidelines and recommendations: An observational study.

The aim of this study is to compare Dutch usual care musculoskeletal therapy in patients with non-specific neck pain with recommendations from international clinical practice guidelines. Physical therapy is diverse, as it may consist of exercise, massage, advice, and other modalities. Physical therapists with post graduate qualifications in manual therapy (MT) may additionally apply spinal thrust manipulation or non-thrust mobilization techniques to treat neck pain. It is important that, in the absence of a Dutch clinical guideline for the treatment of patients with neck pain, musculoskeletal therapists use the available recommendations from international clinical practice guidelines when treating patients with neck pain. One updated clinical practice guideline was identified (Blanpied, 2017), a report from the Task Force on Neck Pain (Guzman et al., 2008) and the IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (Rushton et al., 2014). At baseline 1193 patients are included and data with regard to pain, disability, fear avoidance, expectations and applied treatment modalities are gathered. Outcome is measured using the Global Perceived Effect questionnaire. Results show that patients with acute neck pain are treated significantly more often with manipulation compared to patients with sub-acute or chronic neck pain (p < .000) and younger patients are treated with manipulation more often than older patients (p < .000). In the presence of comorbidity, the preference of spinal manipulation seems to diminish, in favour of mobilization and exercise. Almost every patient receives multimodal therapy (94.3%) and spinal manipulation and mobilization are rarely used as a stand-alone treatment (4.5% and 0.8%). Dutch musculoskeletal therapists choose treatment strategies that correspond with recommendations from international guidelines.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process.

OBJECTIVE: The purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities. METHODS: A consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range. RESULTS: Thirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool. CONCLUSION: This study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain.

BACKGROUND: Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered. METHODS: We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain. RESULTS: The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate. CONCLUSIONS: This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

Effectiveness of Kinesio Taping in Patients With Chronic Nonspecific Low Back Pain: A Systematic Review With Meta-analysis.

STUDY DESIGN: Systematic review. OBJECTIVE: To investigate the effects of Kinesio Taping (KT) in patients with nonspecific low back pain. SUMMARY OF BACKGROUND DATA: KT is widely used in patients with low back pain. METHODS: We conducted searches on PubMed, EMBASE, PEDro, SciELO, and LILACS up to February 26, 2018. We included only randomized controlled trials (RCTs) in adults with chronic nonspecific low back pain that compared KT to no intervention or placebo as well as RCTs that compared KT combined with exercise against exercise alone. The methodological quality and statistical reporting of the eligible trials were measured by the 11-item PEDro scale. The quality of the evidence was assessed using the GRADE classification. We considered pain intensity and disability as the primary outcomes. Whenever possible, the data were pooled through meta-analysis. RESULTS: We identified 11 RCTs for this systematic review (pooled n = 743). Two clinical trials (pooled n = 100) compared KT to no intervention at the short-term follow-up. Four studies compared KT to placebo (pooled n = 287) at short-term follow-up and two trials (pooled n = 100) compared KT to placebo at intermediate-term follow-up. Five trials (pooled n = 296) compared KT combined with exercises or electrotherapy to exercises or spinal manipulation alone. No statistically significant difference was found for most comparisons. CONCLUSION: Very low to moderate quality evidence shows that KT was no better than any other intervention for most the outcomes assessed in patients with chronic nonspecific low back pain. We found no evidence to support the use of KT in clinical practice for patients with chronic nonspecific low back pain. LEVEL OF EVIDENCE: 1.

Australian musculoskeletal physiotherapist's perceptions, attitudes and opinions towards pre-manipulative screening of the cervical spine prior to manual therapy: Report from the focus groups.

BACKGROUND: The Australian Physiotherapy Association 2006 VBI Guidelines are used by many of the member organisations of IFOMPT. These Guidelines are due for revision incorporating recent research findings, international guides, and member's recommendations. PURPOSE: To identify and consider Australian musculoskeletal physiotherapists' recommendations to inform revision of the 2006 VBI Guidelines. METHODS: Focus groups were conducted in the five larger Australian state capitals by an independent qualitative researcher and a subject expert. Qualitative data were collected from 41 musculoskeletal physiotherapists who were purposefully recruited for their broad range of experience and qualifications. The five stage Framework Analysis approach was used to analyse and interpret data. RESULTS: Participants recommended that the revised Guidelines have a new title reflecting a broader risk assessment and management approach, encompassing both musculoskeletal and relevant cardio-vascular risks and informed by contemporary research evidence and clinical experience. Participants requested a positively worded stepwise guide to clinical reasoning for all cervical spine manual treatment scenarios including the process of gaining and recording consent. Participants advised on individual components of the Guidelines needing to be revised or removed. The revised Guidelines, once approved, need to be disseminated in written and electronic formats to all clinicians. Training and education are required to ensure appropriate uptake within and beyond the profession. CONCLUSIONS AND IMPLICATIONS: To ensure their clinical acceptance and utility, the Revised Guidelines need to reflect the current use and recommendations of musculoskeletal physiotherapists. Sound knowledge translation processes are then needed to ensure that the Guidelines are incorporated into practice.

Nonpharmacologic treatment of chronic pain: What works?

Which therapies should you recommend for chronic low back pain, osteoarthritis, or fibromyalgia? This review-with 3 handy tables-summarizes the evidence.

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative.

OBJECTIVE: The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments. METHODS: The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee. RESULTS: For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises). CONCLUSIONS: A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions: Part I.

OBJECTIVES: The purpose of this article is to report on the Center of Excellence for Research on Complementary and Alternative Medicine at RAND Corporation. The overall project examined the appropriateness of chiropractic spinal manipulation and mobilization for chronic low back pain and chronic cervical pain using the RAND and University of California Los Angeles Appropriateness Method, including patient preferences and costs, to acknowledge the importance of patient-centered care in clinical decision-making. METHODS: This article is a narrative summary of the overall project and its inter-related components (ie, 4 Research Project Grants and 2 centers), including the Data Collection Core, whose activities and learning will be the subject of a following series of methods articles. RESULTS: The project team faced many challenges in accomplishing data collection goals. The processes we developed to overcome barriers may be of use to other researchers and for practitioners who may want to participate in such studies in complementary and integrative health, which previously was known as complementary and alternative medicine. CONCLUSION: For this large, complex, successful project, we gathered online survey data, collected charts, and abstracted chart data from thousands of chiropractic patients. The present article delineates the challenges and lessons that were learned during this project so that others may gain from the authors' experience. This information may be of use to future research that collects data from independent practitioners and their patients because it provides what is needed to be successful in such studies and may encourage participation.

Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain.

The Royal Dutch Society for Physical Therapy (KNGF) issued a clinical practice guideline for physical therapists that addresses the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, in Dutch primary care. Recommendations were based on a review of published systematic reviews.During the intake, the patient is screened for serious pathologies and corresponding patterns. Patients with cervical radiculopathy can be included or excluded through corresponding signs and symptoms and possibly diagnostic tests (Spurling test, traction/distraction test, and Upper Limb Tension Test). History taking is done to gather information about patients' limitations, course of pain, and prognostic factors (eg, coping style) and answers to health-related questions.In case of a normal recovery (treatment profile A), management should be hands-off, and patients should receive advice from the physical therapist and possibly some simple exercises to supplement "acting as usual."In case of a delayed/deviant recovery (treatment profile B), the physical therapist is advised to use, in addition to the recommendations for treatment profile A, forms of mobilization and/or manipulation in combination with exercise therapy. Other interventions may also be considered. The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar.In case of a delayed/deviant recovery with clear and/or dominant psychosocial prognostic factors (treatment profile C), these factors should first be addressed by the physical therapist, when possible, or the patient should be referred to a specialist, when necessary.In case of neck pain grade III (treatment profile D), the therapy resembles that for profile B, but the use of a cervical collar for pain reduction may be considered. The advice is to use it sparingly: only for a short period per day and only for a few weeks.

Reconceptualising manual therapy skills in contemporary practice.

With conflicting evidence regarding the effectiveness of manual therapy calls have arisen within some quarters of the physiotherapy profession challenging the continued use of manual skills for assessment and treatment. A reconceptualisation of the importance of manual examination findings is put forward, based upon a contemporary understanding of pain science, rather than considering these skills only in terms of how they should "guide" manual therapy interventions. The place for manual examination findings within complex, multidimensional presentations is considered using vignettes describing the presentations of five people with low back pain. As part of multidimensional, individualised management, the balance of evidence relating to the effectiveness, mechanisms of action and rationale for manual skills is discussed. It is concluded that if manual examination and therapeutic skills are used in a manner consistent with a contemporary understanding of pain science, multidimensional patient profiles and a person-centred approach, their selective and judicious use still has an important role.

Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update.

OBJECTIVE: The purpose of this study was to update evidence-based recommendations on the best practices for chiropractic care of older adults. METHODS: The project consisted of a systematic literature review and a consensus process. The following were searched from October 2009 through January 2016: MEDLINE, Index to Chiropractic Literature, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine Database), Alt HealthWatch, Cochrane Database of Systematic Reviews, and Cochrane Registry of Controlled Trials. Search terms were: (manipulation, spinal OR manipulation, chiropractic OR chiropract*) AND (geriatric OR "older adult*"). Two reviewers independently screened articles and abstracts using inclusion and exclusion criteria. The systematic review informed the project steering committee, which revised the previous recommendations. A multidisciplinary panel of experts representing expertise in practice, research, and teaching in a variety of health professions serving older adults rated the revised recommendations. The RAND Corporation/University of California, Los Angeles methodology for a modified Delphi consensus process was used. RESULTS: A total of 199 articles were found; after exclusion criteria were applied, 6 articles about effectiveness or efficacy and 6 on safety were added. The Delphi process was conducted from April to June 2016. Of the 37 Delphi panelists, 31 were DCs and 6 were other health care professionals. Three Delphi rounds were conducted to reach consensus on all 45 statements. As a result, statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only. CONCLUSIONS: This document provides a summary of evidence-informed best practices for doctors of chiropractic for the evaluation, management, and manual treatment of older adult patients.

Manipulation Peak Forces Across Spinal Regions for Children Using Mannequin Simulators.

OBJECTIVE: The purpose of this work was to create an exploratory database of manipulation treatment force variability as a function of the intent of an experienced clinician sub-specializing in the care of children to match treatment to childhood category. Data of this type are necessary for realistic planning of dose-response and safety studies on therapeutic benefit. METHODS: The project evaluated the transmitted peak forces of procedures applied to mannequins of different stature for younger and older children. Common procedures for the cervical, thoracic, and lumbar spine and sacroiliac joint were administered to estimate variability by a single experienced practitioner and educator in pediatric manipulation attempting to modulate for childhood category. Results described for peak components in the cardinal axes and for peak total forces were cataloged and compared with consensus estimates of force from the literature. RESULTS: Mean force values for both components and total force peaks monotonically increased with childhood category analogous to consensus expectations. However, a mismatch was observed between peak values measured and consensus predictions that ranged by a factor of 2 to 3.5, particularly in the upper categories. Quantitative data permit a first estimate of effect size for future clinical studies. CONCLUSIONS: The findings of this study indicate that recalibration of spinal manipulation performance of experienced clinicians toward arbitrary target values similar to consensus estimates is feasible. What is unclear from the literature or these results is the identity of legitimate target values that are both safe and clinically effective based on childhood categories in actual practice.

Guideline for Reporting Interventions on Spinal Manipulative Therapy: Consensus on Interventions Reporting Criteria List for Spinal Manipulative Therapy (CIRCLe SMT).

OBJECTIVE: The aim of the Consensus on Interventions Reporting Criteria List for Spinal Manipulative Therapy (CIRCLe SMT) study was to develop a criteria list for reporting spinal manipulative therapy (SMT). METHODS: A Delphi procedure was conducted from September 2011 to April 2013 and consisted of international experts in the field of SMT. The authors formed a steering committee and invited participants, selected initial items, structured the comments of the participants after each Delphi round, and formulated the feedback. To ensure content validity, a large number of international experts from different SMT-related disciplines were invited to participate. A workshop was organized following the consensus phase, and it was used to discuss and refine the wording of the items. RESULTS: In total, 123 experts from 18 countries participated. These experts included clinicians (70%), researchers (93%), and academics working in the area of SMT (27%), as well as journal editors (14%). (Note: The total is more than 100% because most participants reported 2 jobs.) Three Delphi rounds were necessary to reach a consensus. The criteria list comprised 24 items under 5 domains, including (1) rationale of the therapy, (2) description of the intervention, (3) SMT techniques, (4) additional intervention/techniques, and (5) quantitative data. CONCLUSIONS: A valid criteria list was constructed with the aim of promoting consistency in reporting SMT intervention in scientific publications.

How should we teach lumbar manipulation? A consensus study.

BACKGROUND: Spinal manipulation is an effective intervention for low back pain, yet there is little consistency in how this skill is taught. OBJECTIVES: The purpose of this study was to identify what educators and clinicians believe are important characteristics of the patient and operator position prior to side-lying lumbar manipulation and the patient position and operator motion during the manipulative thrust. DESIGN: A multi-disciplinary correspondence-based Delphi method. METHODS: Three rounds of questionnaires were sent to physical therapists, osteopaths and chiropractors. Consensus was established in Round 3 if at least 75% of respondents identified a characteristic as very important/extremely important on a 5-point Likert scale. RESULTS: 265 educators and clinicians completed the three rounds of questioning. There was consensus that localization to target segment, patient comfort, table height, and logrolling the patient towards the operator are important characteristics of patient position during the preparatory phase. During the manipulation phase, respondents agreed that it is important to maintain localization to the segment and rotate the patient's pelvis and lumbar spine. For the operator characteristics, consensus was reached for the following items; moving up and over the patient, maintaining contact using forearms, and close contact between the operator and patient (preparatory phase); generating force through the body and legs, dropping the body downwards, maintaining localization, and providing a high-velocity and low-amplitude thrust (manipulation phase). CONCLUSIONS: This Delphi study successfully identified key characteristics of patient position and operator position and motion for effective delivery of side-lying lumbar spine manipulations.

Effects of individualised directional preference management versus advice for reducible discogenic pain: A pre-planned secondary analysis of a randomised controlled trial.

BACKGROUND: Low back disorders are prevalent and directional preference management is a common treatment with mixed evidence for effectiveness. OBJECTIVES: To determine the effectiveness of individualised directional preference management plus guideline-based advice versus advice alone in participants with reducible discogenic pain of 6-week to 6-month duration. DESIGN: Pre-planned secondary analysis of a multicentre, parallel group randomised controlled trial. METHODS: Participants were randomly allocated to receive a 10-week physiotherapy program of 10-sessions of individualised directional preference management plus guideline-based advice (n = 40) or 2-sessions of advice alone (n = 38). Primary outcomes were back pain, leg pain and activity limitation. Outcomes were taken at baseline and 5, 10, 26, and 52-weeks. RESULTS: Between-group differences significantly favoured directional preference management compared with advice for back pain at 5-weeks (1.28; 95% CI 0.34-2.23) and 10-weeks (1.45; 95% CI 0.51-2.40), and leg pain at 10-weeks (1.21; 95% CI 0.04-2.39). These short-term differences were not maintained. There were no significant differences between-groups for activity limitation. Secondary outcomes and responder analyses favoured directional preference management suggesting between-group differences were clinically important. CONCLUSIONS: In people with reducible discogenic pain, individualised directional preference management plus guideline-based advice resulted in significant and rapid improvement in short-term back and leg pain compared with advice alone. These effects were not maintained at long-term and there were no differences in activity limitation. Individualised directional preference management could be considered for patients with reducible discogenic pain seeking rapid pain relief however further research is indicated.