Author Names

Walston Z., Yake D.

Reviewer Name

Ellie Berman, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

Study Design Case series. Background Low back pain (LBP) is an increasing problem in health care. The evidence for the use of spinal manipulative therapy to treat pediatric patients with LBP is minimal. The treatment of pediatrics with manual therapy, particularly spinal manipulation, is controversial within the medical community, primarily with respect to adverse events. The purpose of this case series was to illustrate the feasibility and safety of lumbar manipulation plus exercise in the adolescent population with mechanical LBP. Case Description Three patients-a 13-year-old adolescent girl, 15-year-old adolescent girl, and 13-year-old adolescent boy-were treated in an outpatient physical therapy setting for mechanical LBP. All 3 patients were assessed using a lumbar manipulation clinical prediction rule and treated with sidelying lumbar manipulation and exercise. Outcomes Patients were treated for a total of 10 to 14 visits over a course of 8 to 9 weeks. Pain (measured by a numeric pain-rating scale) and disability (measured by the modified Oswestry Disability Index) improved to 0/10 and 0%, respectively, in each patient. No adverse reactions to manipulation were reported. Discussion The results of this case series describe the use of lumbar thrust manipulation and exercise for the treatment of mechanical LBP in adolescents. The positive results indicate that lumbar manipulation may be a safe adjunct therapy. Further studies, including randomized controlled trials, are needed to determine effectiveness.

 

NIH Risk of Bias Tool

Quality Assessment Tool for Case Series Studies

  1. Was the study question or objective clearly stated?
  • Yes
  1. Was the study population clearly and fully described, including a case definition?
  • Yes
  1. Were the cases consecutive?
  • Yes
  1. Were the subjects comparable?
  • Yes
  1. Was the intervention clearly described?
  • No
  1. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
  • No
  1. Was the length of follow-up adequate?
  • Yes
  1. Were the statistical methods well-described?
  • Cannot Determine, Not Recorded, Not Applicable
  1. Were the results well-described?
  • Yes

 

Key Finding #1

Manual therapy and lumbar manipulation can be a safe and effective adjunct therapy to exercise for adolescents with mechanical low back pain.

Key Finding #2

Adolescents receiving lumbar manipulation in addition to exercise for the treatment of mechanical low back pain reported improvements in pain, mobility, and disability, demonstrated by the modified Oswestry Disability Index, the Visual Analog Scale, and the Fear-Avoidance Beliefs Questionnaire work subscale.

Key Finding #3

Clinical prediction rules set forth by Flynn et al., and Fritz et al., may have a place in the pediatric population for determination of lumbar manipulation as a safe and effective treatment, however further research is needed to assess the effectiveness outside of the originally studied population.

 

Please provide your summary of the paper

The purpose of this case series was to evaluate the safety and effectiveness of lumbar manipulation in addition to exercise for the treatment of low back pain in the pediatric population. This study included 3 adolescent patients aged 13-15 with mechanical low back pain. Outcome measures recorded at both the initial evaluation and discharge included the modified Oswestry Disability Index (mODI), the Visual Analog Scale (VAS), the Fear-Avoidance Beliefs Questionnaire work subscale (FABQ-W), and objective measurements included in the CPR developed by Flynn et al. The treatment included bilateral lumbar manipulation in sidelying at the start of each session followed by exercise tailored to patient’s directional preference. Once patients were able to complete exercises comfortably in all 3 planes of motion, combined movements were introduced. Exercises initially focused on endurance and motor learning and progressed to hypertrophy and return-to-sport training. A home exercise program was prescribed after the second visit as to adequately assess patient’s response to initial manipulations. Patients were discharged once they were able to complete multi-planar and sport-specific movements pain-free and with equal power bilaterally. All patients demonstrated improvements in pain and disability with scores of 0/10 and 0%, respectively, at discharge.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This case series resulted in improvements in subjective and objective measures for adolescents after treatment of mechanical low back pain with lumbar manipulation and exercise. While this case aimed to illustrate the effectiveness and safety of thrust manipulations for this population, the study design limits the external validity of the results, thus inhibiting the ability to generalize to greater populations and impact clinical practice. Due to the lack of research investigating the effectiveness of lumbar manipulation CPRs in the pediatric population, the outcome measures were held constant despite a lack of validity with this population. Further research is needed for use of validated pediatric outcome measures in replacement of the FABQ-W in order to better analyze the perceived disability of this population. Additionally, more research is needed within this population to better translate findings into clinical practice.