A study published in the August issue of Spine suggests that maintained spinal manipulation therapy in patients with non-specific chronic low back pain can improve pain and disability scores in the long term.
Spinal manipulation therapy is the use of a controlled force, by either hand or a device, to move a joint beyond its passive range of movement. It has already been shown to be an effective treatment for acute non-specific low back pain, but its use in chronic (lasting for at least six months) non-specific low back pain has not been determined. Also most of the available data focuses on the short-term benefits of spinal manipulation therapy.
The aim of the new study was to assess the benefits of spinal manipulation for chronic non-specific low back pain and assess whether maintaining spinal manipulation therapy had any long-term benefit in this patient population.
Patients in the study were randomised into three groups: those who received treatments of “sham” manipulation, the aim of which was to reduce the likelihood of therapeutic benefits by using manually applied forces of diminished magnitude and avoiding treatable areas of the spine; those who received 12 treatments of standard spinal manipulation therapy over a one month period; and those who received 12 treatments of standard spinal manipulation (again, over a one month period) plus maintenance spinal manipulation treatments every two weeks for nine months. All patients were given instructions on performing pelvic tilt range of motion (ROM) exercises after a manipulation session (whether sham or spinal).
Compared with the group who received sham manipulation therapy, patients in the second and third groups had significantly lower pain and disability scores after the first month. However, by the end of the study (10 months), the mean pain score in patients who discontinued treatment after the initial 12 sessions (group two) returned to near the baseline level. The mean disability score in this group also gradually returned towards the baseline level. By contrast, the group of patients who received maintenance spinal manipulation therapy sessions saw both their pain score and their disability score continue to improve. Investigators Senna et al reported: “The disability score difference (>14 points) observed after 10 months in the current study between the maintained spinal manipulation therapy and non-maintained spinal manipulation therapy is statistically and clinically important. Fritz and Irrgang showed that a six-point difference in the Oswerstry Questionnaire [the disability score used in the study] was the minimally clinically important difference.”
As well as improving disability and pain scores, spinal manipulation therapy was found to improve spinal mobility (as measured by spine flexion and lateral bending in patients’ ROM exercises). Again, this improvement continued to increase in patients receiving maintenance spinal manipulation therapy, but was found to decrease in patients whose sessions were discontinued after the initial 12 sessions.
According to Senna et al, further research “must focus” on how long spinal manipulation therapy must be maintained and when to stop it without relapse of pain. They added that studies to determine the required frequency of maintenance spinal manipulation therapy were also needed.
They concluded: “Spinal maintenance therapy is effective for the treatment of chronic non-specific low back pain. To obtain long-term benefit, this study suggests maintenance therapy spinal manipulation after the initial intensive spinal manipulative.”