Spinal Manipulations a Treatment for Chronic Low Back Pain

Perla Perez
Central Michigan University: Manual Therapy II
 There is a global condition that is the leading cause of disability, with a pervasiveness

that has increased by 42% in the past 20 years.2,5 It is commonly found more in women than in

men and in individuals between 40 and 80 years old.1 However, chronic low back pain (CLBP)

has been recently detected more frequently in adolescents making the search for a noninvasive

treatment a matter of extreme importance.2 Chronic low back pain (CLBP) not only negatively

affects the individuals in a functional and financial manner, but also negatively impacts health

systems, and economies.5 Despite CLBP being so prevalent and not a new topic of conversation,

there has still been no consensus of an efficacious treatment for this condition. Nonetheless,

researchers’ efforts to find an efficacious treatment for spinal pain have found some hope and

supported results in spinal manipulation (SM) as a treatment for CLBP.1,2,3,4,5

The Osteopathic Research Center at the college of osteopathic medicine in Fort Worth,

Texas held a randomized, double-blind study with the hopes of analyzing the effects of an

osteopathic manipulative treatment (OMT) in patients with mechanical CLBP. 455 men and

women from ages 21 to 69, who had nonspecific CLBP with at least 3 months of symptoms

participated in the study. Participants were assigned to 2 groups where 230 would receive a

generalized OMT and 225 would receive a sham treatment that consisted of manual contact,

active and passive range of motions, and manual techniques that simulated an OMT. The study

was conducted for 12 weeks, where treatments were administered at weeks 0, 1, 2, 4, 6, and 8.3

After analyses, results indicated that a SM was most efficacious in CLBP pain reduction

and improvements in back-specific functions. Curiously, they also found that patients who were

diagnosed with depression were less likely to experience the recovery benefits from an OMT.

These conclusions have clinical relevance in supporting SM as an efficacious intervention,

before considering other invasive treatments.3

 Muller and Giles5 investigated the long-term effects of SM, medication, or needle

acupuncture in patients with chronic spinal pain issues. In their research trials they included

adults with more than 13 weeks of mechanical pain symptoms. 69 participants were divided into

one of the three treatments including medicine (Celebrex, Viox, or Acetaminophen), acupuncture

(HWATO Chinese Acupuncture Guide Tube Needles), and HVLA manipulation (at specific

spinal level).5

In regard to short-term benefits, results indicated similar benefits between participants

who received acupuncture treatment and those who received SM; differences were significant

when considering broad-based, long-term benefits. After a one-year follow up, participants that

received SM had greater satisfaction in their treatment, and significant improvements in pain

levels and functional outcomes, when compared to those who received acupuncture or

medication.5 These outcomes support SM as a possible treatment for individuals with CLBP. The

results not only yield short-term benefits, but long-term benefits as well; making it an efficacious

intervention.

SM for CLBP has been supported by many studies to be used as a possible, efficacious

treatment before considering a more invasive procedure. It has been seen to improve pain levels

and functional outcomes for the individual experiencing CLBP.1,3,5 However, in the physical

therapy practice, treatments are not administered independently; they are accompanied with

exercises and education to teach patients about preventative measures and how to maintain the

benefits achieved by such treatments. SM are no exception and have been evidentially supported

by researchers to further benefit individuals with CLBP.2,4,6

For instance, Evans2 and colleagues investigated the effectiveness of exercise therapy

(ET) alone, compared to SM with ET in adolescents experiencing mechanical CLBP. ET

consisted of supervised exercises and instructions to a home exercise program that included

stretching and strengthening for abdominal and low back muscles. Both conditions were

implemented for 12 weeks and outcome measures were taken periodically throughout the study

up to 52 weeks.

Data from their randomized study with 185 participants, suggested no significant

difference in pain levels, disability, or medication levels at the end of 12 weeks between

conditions. However, data after one year concluded that SM combined with ET significantly

improved pain levels and disability, when compared to ET alone. Both conditions reported an

80% reduction in medication intake at the end of 12 weeks and then further decreased their

intake after 1 year.2

Similar results were found in another study where researchers compared the effectiveness

of SM with exercise and ultrasound with exercise as treatments for CLBP. Data from 120

participants was analyzed and although both conditions showed improvements in pain and

functional levels, SM with exercise showed a greater significant difference of improvement in

pain, function and spinal mobility initially and after 6 months.4

Results from the latter two studies indicate great clinical importance in short-term

benefits and predominantly in long-term benefits when SM is combined with ET, improving an

individual’s with CLBP pain levels, disability, spinal mobility and medication intake. With SM

with ET providing short-term and long-term benefits, it yields to the fact that SM can be

considered as an efficacious treatment in CLBP cases and further benefit an individual when it is

combined with ET.2,4

 Pain and prevention education are other factors that have been found to further enhance

the effects of SM in individuals who experience CLBP. Education is a key piece in a person’s

rehabilitation process and plays a more imperative role in chronic pain, since it can have positive

psychosocial factors that can help decrease pain levels. A biopsychosocial application to reduce

behavioral fears or thoughts about pain and movement has been encouraged to provide to

patients to positively influence their perception on pain. Combining its effects with SM in

patients with CLBP can help serve as an efficacious treatment for individuals.2,6

In consideration of all evidence provided, it is of clinical importance that SM in

conjunction with education and ET be considered as an efficacious treatment for CLBP in

adolescents and adults. SM has also been found to decrease pain and improve back-specific

functions.3 When compared to acupuncture and medication, SM yielded long-term effects by

providing greater satisfaction in treatment and improving pain and functional outcomes in

individuals with CLBP.5 Similarly, SM in combination with ET suggested long-term

improvement in pain and disability levels, and even helped decrease medication intake after one

year in people with CLBP.2,4 Education has also served as an important adjunct to SM by

improving peoples’ pain levels.6 Comorbidities also need to be considered in the treatment of

CLBP, since it has been found that individuals with depression are less likely to obtain recovery

benefits from SM.3

CLBP has been recently found at an earlier age and continues to negatively affect

individuals worldwide.1,2 An efficacious and noninvasive treatment for this worldwide disability,

with evidential support in decreasing pain levels and improving function is SM. To optimize its

short-term and long-term affects it is advised to administer SM treatment in conjunction with ET

and education.
 References

1. De Oliveira R. F., Liebano R. E., Costa Lda. C., Rissato L. L., Pena Costa L. O.,

Immediate effects of región-specific and non-resion-specific spinal manipulative therapy

in patients with chronic low back pain: A randomized controlled trial. Physical Therapy.

2013; 93(6): 748-756. Doi: 10.2522/ptj.20120256.

2. Evans R., Haas M., Schulz C., Leininger B., Hanson L., Bronfort G., Spinal manipulation

and exercise for low back pain in adolescents: A randomized trial. Pain. 2018; 159(7):

1297-1307. doi: 10.1097/j.pain.0000000000001211.

3. Licciardone J. C., Gatchel R. J., Aryal S., Recovery from chronic low back pain after

osteopathc manipulative treatment: A randomized controlled trial. The Journal of the

American Osteopathic Association. 2016; 116(3): 144-155. doi:10.7556/jaoa.2016.031.

4. Mohseni-Bandpei M. A., Critchley J., Staunton T., Richardson B. A prospective

randomised controlled trial of spinal manipulation and ultrasound in the treatment of

chronic low back pain. Phyiotherapy. 2006; 92(1): 34-42.

doi:10.1016/j.physio.2005.05.005.

5. Muller R., Giles L. G. F., Long-term follow-up of a randomized clinical trial assessing

the efficacy of medication, acupuncture and spinal manipulation for chronic mechanical

spinal pain syndromes. Journal of Manipulative and Physiological Therapeutics. 2005;

28(1): 3-11. doi:10.1016/j.jmpt.2004.12.004.

6. Vier C., Bracht M.A., Neves M. L., Junkes-Cunha M., Santos A. R. S., Effects of spinal

manipulation and pain education on pain in patients with chronic low back pain: A

protocol of randomized sham-controlled trial. Korea Institute of Oriental Medicine. 2018;

7(3): 271-278. Doi:10.1016/j.jmr.2018.04.003.