Manipulation vs Mobilization for Acute Low Back Pain, Neither Work

Spinal manipulative therapy for acute low-back pain. Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Cochrane Database Syst Rev. 2012 Sep 12;9

Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention. This report is an update of the earlier Cochrane review, first published in January 2004 with the last search for studies up to January 2000.

To examine the effects of SMT for acute low-back pain, which is defined as pain for less than six weeks duration.

A comprehensive search was conducted on 31 March 2011 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature. Other search strategies were employed for completeness. No limitations were placed on language or publication status.

Randomized controlled trials (RCTs) which examined the effectiveness of spinal manipulation or mobilization in adults with acute low-back pain were included. In addition, studies were included if the pain was predominantly in the lower back but the study allowed mixed populations, including participants with radiation of pain into the buttocks and legs. Studies which exclusively evaluated sciatica were excluded. No other restrictions were placed on the setting nor the type of pain. The primary outcomes were back pain, back-pain specific functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. SMT was defined as any hands-on therapy directed towards the spine, which includes both manipulation and mobilization, and includes studies from chiropractors, manual therapists, and osteopaths.

Two review authors independently conducted the study selection and risk of bias (RoB) assessment. Data extraction was checked by the second review author. The effects were examined in the following comparisons: SMT versus 1) inert interventions, 2) sham SMT, 3) other interventions, and 4) SMT as an additional therapy. In addition, we examined the effects of different SMT techniques compared to one another. GRADE was used to assess the quality of the evidence. Authors were contacted, where possible, for missing or unclear data. Outcomes were evaluated at the following time intervals: short-term (one week and one month), intermediate (three to six months), and long-term (12 months or longer). Clinical relevance was defined as: 1) small, mean difference (MD) < 10% of the scale or standardized mean difference (SMD) < 0.4; 2) medium, MD = 10% to 20% of the scale or SMD = 0.41 to 0.7; and 3) large, MD > 20% of the scale or SMD > 0.7.

We identified 20 RCTs (total number of participants = 2674), 12 (60%) of which were not included in the previous review. Sample sizes ranged from 36 to 323 (median (IQR) = 108 (61 to 189)). In total, six trials (30% of all included studies) had a low RoB. At most, three RCTs could be identified per comparison, outcome, and time interval; therefore, the amount of data should not be considered robust. In general, for the primary outcomes, there is low to very low quality evidence suggesting no difference in effect for SMT when compared to inert interventions, sham SMT, or when added to another intervention. There was varying quality of evidence (from very low to moderate) suggesting no difference in effect for SMT when compared with other interventions, with the exception of low quality evidence from one trial demonstrating a significant and moderately clinically relevant short-term effect of SMT on pain relief when compared to inert interventions, as well as low quality evidence demonstrating a significant short-term and moderately clinically relevant effect of SMT on functional status when added to another intervention. In general, side-lying and supine thrust SMT techniques demonstrate a short-term significant difference when compared to non-thrust SMT techniques for the outcomes of pain, functional status, and recovery.

SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies. Our evaluation is limited by the small number of studies per comparison, outcome, and time interval. Therefore, future research is likely to have an important impact on these estimates. The decision to refer patients for SMT should be based upon costs, preferences of the patients and providers, and relative safety of SMT compared to other treatment options. Future RCTs should examine specific subgroups and include an economic evaluation.

My comments:
“Spinal manipulative therapy” in this review, which was pretty exhaustive, included both manipulation (frequently used by chiropractors, but also osteopaths and more and more physical therapists) are the high velocity short amplitude thrusts that often result in that audible “crack.” Mobilizations are usually of larger ranges of motion with slower passive movements, popularized among physical therapists by Geoffrey D. Maitland. What does it matter you ask? Not much because according to this Cochrane review neither have any effect, at least compared to sham (fake treatment) or placebo (also fake treatment) with regards to lessening pain or disability in those with acute (less than 6 weeks) low back pain.

I talk with patients and colleagues about manipulation and mobilizations all the time and often say, given what we know about the mechanisms and causes of spinal pathologies (excluding magic or placebo), what would or even what could a manipulation/mobilization do? Funny that I never get an answer. You would think a doctor who uses such methods (DC, DPT or DO) could answer that. This paper said it MIGHT work by two principle means. One mechanical mode of action to lessen a vertebral subluxation, is a hypothesis which has already been largely discredited. The second being neurophysiologic explanation that just sounds like a  weak use of gate control theory, which does seem to be a real phenomenon, but whether manipulations/mobilizations can effectively exploit gate control theory is another matter. The authors concluded the mechanism of action was “remains debatable” but considering the primary finding of this review I think a better question is, “since back pain isn’t reduced any better than with a sham/placebo treatment, is there any further mechanism of action that needs explaining?” To me saying, “it’s probably all in your head” really sums it up best.

Another interesting finding was that though manipulation and mobilization didn’t work any better than sham or placebo treatments, it compared favorably to other conventional treatments for low back pain. This was puzzling to the authors. I have already blogged on Mckenzie Method of physical therapy with research showing that it was no more effective than advice to stay active, but better than Williams flexion stretches. I often comment that if you go to a Chiropractor for manipulation for low back pain he may not help you but at least he won’t make you worse. Contrast this with a lot of physical therapists who are going to treat back pain with a lot of stretching, often immediately having the patient lay on their back and stretch their knees to their chests. Well that knee to chest stretch might loosen some tight muscles but that’s spine flexion and spine flexion is the principle cause of vertebral disc bulges, herniations and CAUSES tight muscles. Following up the knee to chest stretch with a bunch of rotation stretching bringing the knees side to side and physical therapy absolutely can make you worse.

With acute back pain, the hippocratic oath seems a good place to start, “First do no harm.” Stretches and aggressive exercises are likely going to worsen the patient, however light motor control exercises which place minimal stress on the spine and teaching patients to keep the spine neutral, bend at their hips, and use good lumbar support when sitting will go a long way towards allowing the spine to heal. Later more aggressive core, hip and leg exercises can begin. Electric muscle stimulation actually does do a good job at lessening pain via gate control theory and helps strengthen core muscles, and my patients frequently report it lessens the feeling of muscle spasms as well, but I’ll have to look the latter up to see if there is any evidence to support that. [edit to add, it does]

The abstract conclusion above makes the paper sound as if results are preliminary. In the paper itself, the authors (the principle is a chiropractor who uses manipulation in his daily practice) are more blunt:

“At least one lesson should be drawn from this review, continuing in the same vein seems pointless. After all, there are currently more than 100 RTTS of SMT for low back pain (Rubinstein 2012). Despite the disappointing quality of the evidence examined here, a more precise estimate of the effect of SMT for acute low-back pain, a condition with a rather benign natural history, does not appear to be the way forward. Preventing the onset of chronic low-back pain, which is disabling and expensive may be a much more clinically relevant question.”

All I can say is, “here here,” however there has been a good bit of research over the last couple decades that helps answer that question. The best answer being to teach patients with acute back pain to avoid what probably caused their acute pain in the first place. That generally being to avoid repeated or sustained spine motions in extension, twisting and most frequently flexion. Don’t slouch, set up chairs with adequate lumbar support to avoid sustained spine flexion. Exercise to be fit enough to do the former without fatigue, preferably using exercises that teach good motor control, and avoid said aggravating spine motions. How does manipulation/mobilization help with any of that? It doesn’t.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

3 thoughts on “Manipulation vs Mobilization for Acute Low Back Pain, Neither Work”

  1. Chad,
    I really need your assistance. In order to get information on my pain and to try and educate myself, I discovered your website as well as Stuart McGill and his approach. I was hoping you have a recommendation on who I could see in Austin, Texas. In the past 3 weeks, I’ve visited two individual “sports” chiropractors and an Arrosti office. Two of these just wanted me to do McKenzie stretches even though that seemed to make things worse. They said it’s just because of tight hamstrings, psoas and hip flexors and once they are loose, I’ll get better. The other doctor said there’s not much he could do other than recommend me to a pain management doctor because I’m too far gone for physical therapy to work. He said the pain management doctor is also a runner and he’d know how to help you. I went to see him last week and he got me a new MRI. It showed a herniated disc, a little worse than my last MRI from 2010. He said I need to get an epideral shot which will give me some time to be pain free and the best thing might be for me to have surgery to cut out the herniated part and get it off the nerve. I called another place this morning and they said they have a DRX9000 machine that they want to get me into, but when I read on that and a blog you have and other various articles on this, it doesn’t look like this isn’t the cure all as I’m being told and it’s extremely expensive. I’m extremely frustrated that anywhere I go, all anyone wants to do is give me drugs and eventually surgery, and these are supposed sports experts. I also get a lot of people recommending some sort of yoga, Bikram or regular. I also get people telling me to use only ice, some say heat and ice, some say heat. I recently sat in a hot tub for an hour and I felt great for a little while, but became worse over the next day. I’m even having people tell me that even though I have a herniated disc, most people do. What I probably have is piriformis syndrome. I’ve been trying to mash on my piriformis on a lacrosse ball and I’m not sure if it’s helping or hurting. So far, none of the doctors can truly tell me what the sciatic pain is coming from. Just this past weekend, I was at a race and talked to a runner that had the shots and back surgery. He told me he regretted this and he still has pain and I should not have this done.

    Again, if you had any recommendations on who I can see in this area or even how I can go about finding someone and what questions to ask, that would be extremely helpful. At the moment, the only way I can be somewhat pain-free is to take Tylenol and Motrin as well as use an EMS/TENS unit on me. My wife is a massage therapist and she has this machine. We aren’t exactly sure what settings it should be on, but we play around with it and when it’s on at night, it can help make the pain a little bearable.

    Here’s a little more about me. I’m an ultrarunner and have suffered off and on with a herniated disc at L5/S1. In the past, when I had pain, I could do McKenzie stretches and various core exercises and I’d be back pretty quickly. This isn’t happening now. Lately, my back pain went from having back pain to the back pain is very minimal but my sciatic nerve is on fire most of the day and night. In the past, it was only my back that was ever sore. Now, my back doesn’t bother me at all, it’s this sciatic nerve that’s killing me. I’m still figuring the cause of this is the herniated disc because if I push on a certain spot on my lower back, I can make the pain shoot down the nerve.

    I love Austin, but at the moment, I wish I lived in so I could come see you. It’s obvious from your blogs and your site, that you have a passion for helping people the correct way and I wish there was more like you around. If you don’t know anyone specific in the Austin area, what sort of things should I be looking for or asking when I call a place? Any help would be so appreciated.

    • Hi Thomas,

      Thanks very much for the kind words. I wish I knew someone to send you too. Physical therapy is so erratic for back pain. Most clinicians are doing a hodgepodge of William’s and/or McKenzie stretches and what they consider spine stabilization is a bunch of mat and ball balancing exercises, all followed by scraping your muscles with ASTYM, dry needling or whatever is in fashion right now. It’s really a sad state of affairs. I’m sure I’m not the only one doing the kind of stuff I’m doing, I just don’t know anyone else who is, even here in my town. You could maybe call around your area and see if any PTs or chiropractors utilize McGill’s treatment approach as that’s more evidence based than anything else I am aware of. I do things a little bit differently in my office, and I have a write up of my basic approach here, with videos of some of my favorite exercises being performed, that you could maybe work towards with home or preferably gym based exercises. Another option is that I just received McGill’s new book Back Mechanic, and though I haven’t read it yet, the idea is that it’s written for laymen to treat their own back pain. I can’t speak for everything in it yet, but thumbing through, it looks really good. For $35 I’d consider it money well spent. McGill’s stuff is certainly no secret, so calling around locally for someone who’s a fan of his material would be the first thing I would ask about, and reading his book would let you know if you were being treated in a way that wasn’t good. Increasing back pain with any exercise or technique would be another way to know to stop.

      As you can tell I’m not a fan of most McKenzie stretches, and I certainly wouldn’t do them if they are causing pain. I imagine your hip flexors and hamstrings might be tight, and if so it would be good to stretch them (without stretching the spine), but I don’t think you should be working through increasing back or leg pain to do so. If you have a herniated disc, more likely (almost for sure) the cause is too much spine flexion either with movements, or in a sitting posture throughout your day. Stretches aren’t really going to address that; what you need is “awareness” of what positions are bad, and discipline to avoid them. Given that you are a runner I would guess that your cardiovascular system is awesome but core and leg strength could use some work 2-3 days per week. 3 sets of 15 reps is what I usually recommend for all my weight training exercises done with an easy warm up set, a medium set, and a hard set, increasing resistance levels only if you can do the exercises properly, without increasing pain AT ALL. “Core” exercises often don’t work the core that well, and often in back pain the core isn’t that weak. Hip and leg muscles are weak so that when people with back pain bend over to pick something up they use their core too much and their legs too little, thus injuring the spine. Definitely check out my blog on reverse ergonomics for more on that.

      I have seen epidurals work great, but they are kind of hit and miss and they don’t address the cause of the herniation. I wouldn’t get surgery for a herniated disc unless you were losing motor function, as generally your body will reabsorb the material on its own in time if you can wait it out. You just need to stop doing what caused the herniation or caused it to worsen in the first place. Pain management is usually pills, so that just masks pain while bad habits let the spine further worsen. I wouldn’t expect traction to work for real, but I just read a paper that says the more they charge for a placebo treatment, the more people think it helps. That’s probably going to be my next blog.

      In your circumstance, I think the best thing you can do is start a general strength training program, but leave out all the exercises that flex, extend or twist your spine. If running hurts right now, recumbent cycling (with good lumbar support) might be good for cardio. I like to progress my patients to a Stepmill because it’s intense and doesn’t have the impact of running.

      Now that I do EMS regularly for back pain (these settings) I don’t ever do heat or ice. Not that either are bad, EMS is just better and strengthens while it decreases pain. If your spine is neutral in the jacuzzi, that’s fine too. Note that there is nothing that will help long term, not even my exercises and EMS, if when you are done you sit at a computer or watch TV with your spine flexed (stick a couple throw pillows in the small of your back).

      It’s true that studies show a lot of people have or have had herniated discs without symptoms, but if the herniation is fresh and causing inflammation and either the inflammation or disc material is pinching on a nerve, that is likely to be the source of your leg pain. Piriformis syndrome is a sketchy diagnosis and one I don’t believe in, rather I attribute the pain to the aforementioned pathology within the spine.

      On the dark side it sounds like most everything everyone is telling you is crap, but on the bright side it seems like you are smart enough to avoid it. Think about how much money you are saving. The disc *most likely* should heal, and with my blog and video’s, McGill’s book, and your wife’s EMS machine you should be able to figure out rehabilitation on your own. Otherwise, Phoenix is nice this time of year, maybe take a short vacation. In the meantime, feel free to ask more questions if anything isn’t clear.

  2. Chad, thank you for taking the time to answer this for me. I really value what you say and I’ll be looking into all of this. I do have a new update on what’s going on with me that I wanted to see what you think now. Last night, my pain was so unbearable that my wife took me to the ER. They gave me soma, and an IV with dilaudid and morphine to ease the pain. Then they gave me a CT scan. In about an hour later, the doctor came back and said I have spinal stenosis and that’s what’s going on.

    What should I do now?


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