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Treatment of the Sacroiliac joint in Patients with Leg Pain: a randomized-controlled trial

Author Names

Visser LH, Woudenberg NP, de Bont J, van Eijs F, Verwer K, Jenniskens H, Den Oudsten BL.

Reviewer Name

Emilija Peleckas, SPT, B.S

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract Purpose: The sacroiliac joint (SIJ) may be a cause of sciatica. The aim of this study was to assess which treatment is successful for SIJ-related back and leg pain. Methods: Using a single-blinded randomized trial, we assessed the short-term therapeutic efficacy of physiotherapy, manual therapy, and intra-articular injection with local corticosteroids in the SIJ in 51 patients with SIJ-related leg pain. The effect of the treatment was evaluated after 6 and 12 weeks. Results: Of the 51 patients, 25 (56 %) were successfully treated. Physiotherapy was successful in 3 out of 15 patients (20 %), manual therapy in 13 of the 18 (72 %), and intra-articular injection in 9 of 18 (50 %) patients (p = 0.01). Manual therapy had a significantly better success rate than physiotherapy (p = 0.003). Conclusion: In this small single-blinded prospective study, manual therapy appeared to be the choice of treatment for patients with SIJ-related leg pain. A second choice of treatment to be considered is an intra-articular injection.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Manual therapy was the most successful short-term treatment in reducing SIJ-related leg pain compared to intra-articular injections or physiotherapy.

Key Finding #2

Patients in the group just receiving manual therapy were shown to have a significant improvement on social functioning, physical and mental health, and vitality.

Please provide your summary of the paper

The article found manual therapy was the most successful short-term treatment in reducing SIJ-related leg pain compared to intra-articular injections or physiotherapy. The results of this study were based on a specific patient population group that was defined by having radiating pain below the buttocks (more than 4 weeks and less than 1 year), pain present in the region of SIJ, and positive provocation sacroiliac pain on three or more tests (present at two consecutive visits). Any causes of sciatica or radiating leg pain identifiable on MRI-imaging (including sacroilitis) were excluded. Patients were randomly assigned into one of three treatment groups and then followed up with at 6- and 12-weeks post treatment. Manual therapy was found to be 72% successful making it the primary choice of treatment followed by the next choice of intra-articular injection with local corticosteroids found to be 50% effective in patients with SIJ-related leg pain and only seeing positive results in 20% of patients in the physiotherapy group.

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

The study had very specific inclusion criteria and a very large percent of participants drop out limiting the results of this study from being generalizable to larger populations with SIJ pain. In addition, the study only followed up with patients at a 1.5 and 3-month mark, again limiting the findings of manual therapy on SIJ pain producing short term effects. There also exists a lack of a gold standard for diagnosing SIJ related leg pain resulting in different studies having variable methods for diagnosis and subsequently criteria for inclusion. This makes it challenging for studies to be comparable and uniform in recruitment of samples. The study did ensure its patients in each group did the same exercises and received the same treatment respectfully to standardize results. However, due to such a small sample size and only short term effects being explored more studies are needed to confirm the results and the success of manual therapy for SIJ related leg pain.

The effects of manual manipulation therapy on pain and dysfunction in patients with lumbar spinal stenosis

Author Names

Oh H, Choi S, Lee S, Lee K, Choi J

Reviewer Name

Rachel Plzak

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

This study investigated the effects of manual manipulation therapy on the pain and dysfunction of patients with lumbar spinal stenosis. [Participants and Methods] In this study, 30 patients with chronic back pain were evenly divided into an experimental group, who received manual traction therapy, and a control group, who received intermittent traction therapy. Both groups received therapy three times a week for eight weeks. A visual analogue scale was used to measure participants’ back pain, and the Oswestry disability index (ODI) was used to check the functional impediment they experienced as a result. [Results] The intragroup comparison showed that the visual analog scale and the ODI significantly decreased in the control group and the experimental group, respectively. The intergroup comparison after treatment showed that the visual analog scale and the ODI of the experimental group were significantly lower than in the control group. [Conclusion] The results of this study suggest that manual manipulation therapy is an effective intervention for treating pain and dysfunction in patients with lumbar spinal stenosis.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Cannot Determine, Not Reported, or Not Applicable

Were study participants and providers blinded to treatment group assignment?

Cannot Determine, Not Reported, or Not Applicable

Were the people assessing the outcomes blinded to the participants’ group assignments?

Cannot Determine, Not Reported, or Not Applicable

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The flexion-distraction technique combined with conservative physiotherapy significantly decreased pain levels in the experiment group measured by the Visual Analogue Scale and Oswestry Disability Index compared to the control group who only received conservative physiotherapy.

Key Finding #2

There are many limitations to this study due to the small sample size, short term treatment, and lack of control over external factors which could contribute to change in pain levels.

Please provide your summary of the paper

This study looked at the effects of manual manipulation therapy in decreasing pain levels for patients with lumbar spinal stenosis. With a small sample size of 30 patients, the study found that patients in the experimental group who received flexion distraction manual therapy in combination with conservative physiotherapy demonstrated a significant decrease in pain levels according to their VAS and ODI scores. The scores of the experimental group were also significantly lower than the control group scores. This study also demonstrated that the control group, having only received conservative physiotherapy treatment, also showed a significant decrease in pain levels as well.

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

This study may lead to further exploration of the effects and benefits of manual manipulation therapy for patients with lumbar spinal stenosis. I do not believe this study provided any groundbreaking information regarding this topic due to the limitations listed above. I think this study may impact clinical practice on a smaller scale due to the limitations, however I believe clinicians could utilize the information provided to see if their patients with lumbar spinal stenosis benefit from manual therapy on an inter-session basis.

Manual therapy directed at the knee or lumbopelvic region does not influence quadriceps spinal reflex excitability

Author Names

Grindstaff, T., Pietrosimone, B., Sauer, L., Kerrigan, D., Patrie, J., Hertel, J., Ingersoll, C.

Reviewer Name

Wes Pritzlaff, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Manual therapies, directed to the knee and lumbopelvic region, have demonstrated the ability to improve neuromuscular quadriceps function in individuals with knee pathology. It remains unknown if manual therapies may alter impaired spinal reflex excitability, thus identifying a potential mechanism in which manual therapy may improve neuromuscular function following knee injury. Aim: To determine the effect of local and distant mobilisation/manipulation interventions on quadriceps spinal reflex excitability. Methods: Seventy-five individuals with a history of knee joint injury and current quadriceps inhibition volunteered for this study. Participants were randomised to one of five intervention groups: lumbopelvic manipulation (grade V), lumbopelvic manipulation positioning (no thrust), grade IV patellar mobilisation, grade I patellar mobilisation, and control (no treatment). Changes in spinal reflex excitability were quantified by assessing the Hoffmann reflex (H-reflex), presynaptic, and postsynaptic excitability. A hierarchical linear-mixed model for repeated measures was performed to compare changes in outcome variables between groups over time (pre, post 0, 30, 60, 90 min). Results: There were no significant differences in H-reflex, presynaptic, or postsynaptic excitability between groups across time. Conclusions: Manual therapies directed to the knee or lumbopelvic region did not acutely change quadriceps spinal reflex excitability. Although manual therapies may improve impairments and functional outcomes the underlying mechanism does not appear to be related to changes in spinal reflex excitability.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

There were no differences in H-reflex, presynaptic, or postsynaptic excitability between lumbopelvic joint manipulation (Grade V), lumbopelvic manipulation positioning (no thrust), medial patellar mobilization (Grade IV and Grade I), and control groups at 0, 30, 60, and 90-minutes post-intervention.

Key Finding #2

Included participants had knee joint injuries with quadriceps inhibition due to knee osteoarthritis (grades IeII), patellofemoral joint pain, or participants who have undergone arthroscopic surgery for anterior cruciate ligament reconstruction, meniscotomy, plica removal, or debridement.

Key Finding #3

There were several limitations acknowledged in this study including 1) short duration of mobilization interventions (two minutes of medial patellar mobilization at one oscillation per second) compared to other studies, 2) participants not currently seeking medical care for knee pain, 3) joint mobility was not assessed prior to or after the intervention, and 4) pain and function were not assessed (mechanistic focus).

Please provide your summary of the paper

This randomized control trial utilized methods to measure spinal reflex excitability, presynaptic inhibition, and postsynaptic inhibition that were consistent with other studies. The researchers took care in ensuring that all participants received treatment from the same physical therapist and followed the same morning pre-testing protocol to limit confounding variables. Other studies have found that lumbopelvic manual therapy interventions briefly decrease spinal reflex excitability in other body regions (e.g. gastrocnemius and soleus) and increase voluntary quadriceps activation; however, this study does not support that a decrease in spinal reflex excitability is the mechanism for increased voluntary quadriceps activation. While all participants in the lumbopelvic manipulation positioning group (no thrust), patellar mobilization (Grade IV and Grade I), and control groups received the same treatment, it was curious that participants in the lumbopelvic joint manipulation group received varying numbers of manipulations (between one to four manipulations with a maximum of two per side starting with the ipsilateral side of knee pain) depending on whether or not a cavitation was heard or felt by the physical therapist or participant. In the results section, the authors acknowledged literature that supported a cavitation may not be necessary for clinically relevant outcomes; therefore, it seems that the variability in the number of lumbopelvic joint manipulations received and lack of tracking/reporting of this variability is inconsistent with the literature and a limitation of this study. Additionally, while this study did not find any differences between manipulation, mobilization, and control groups on a mechanistic level (spinal reflex excitability), it did not report on other biopsychosocial factors (e.g. pain, patient-reported function) that may be affected by manual therapy treatment.

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

The results of this study do not immediately impact clinical practice. As other research supports that manual therapy provided in addition to exercise and best care leads to the greatest improvements, physical therapists will continue to provide lumbopelvic joint manipulation and patellar mobilizations to treat knee pain. However, the physical therapist providing these treatments will not be able to defend a decrease in spinal reflex excitability as the mechanism for a decrease in pain, improvement in function, or improvement in voluntary quadriceps activation based on the results of this paper. The results of this paper may inspire this team of researchers or others to pursue future randomized control trials to better understand the mechanism of manual therapy treatments, as well as further explore the effects of manual therapy on patient-reported pain and function in individuals with knee pain.

The Effectiveness of Manual Therapy and Proprioceptive Neuromuscular Facilitation Compared to Kinesiotherapy: a Four-Arm Randomized Controlled Trial

Author Names

Zaworski K., Latosiewicz R

Reviewer Name

Beautiful Reed, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

BACKGROUND: Low back pain (LBP) has a negative impact on patients’ life, not only from the physical point of view, but also in terms of psychic, social and economic wellbeing. The increasing costs of treatment and health care encourage the search for the most effective methods of treatment. AIM: The aim of the study was to determine whether the use of combined therapy consisting of manual therapy and proprioceptive neuromuscular facilitation (PNF) is more effective than the use of manual therapy techniques, PNF or traditional kinesiotherapy as single methods in the treatment of LBP. DESIGN: A four-arm RCT. SETTING: Rehabilitation Department of Hospital in Parczew (Poland). METHODS: The study was designed as four-arm randomized comparative controlled RCT and conducted on a group of 200 patients aged 27- 55y. (44.9±9.2 years). The patients were randomly divided into four 50-person groups: 1) group A – manual therapy; 2) B – PNF; 3) C – manual therapy and PNF; and 4) group D – traditional kinesiotherapy and control group. Pain intensity was measured using VAS and Laitinen’s questionnaire. Functional disability was assessed using Oswestry Disability Index (ODI) and Back Pain Functional Scale (BPFS). RESULTS: There was a statistically significant difference in pain reduction (VAS Scale) between Group C (4.8 points) and Group D (3.9 points). In all the groups there was a statistically significant reduction in a degree of disability as measured by the ODI. A level of functional capabilities (BPFS) increased significantly only in Group C (8.8 points) as compared to Group D (5.7 points). CONCLUSIONS: All the evaluated methods caused pain reduction which lasted for at least 2 weeks after the end of treatment. The degree of disability as measured by ODI lowered evenly in all groups. Patients’ functional ability assessed with BPFS improved significantly in the group treated with combined therapy (manual therapy and PNF) as compared to the group of traditional kinesiotherapy. CLINICAL REHABILITATION IMPACT: The therapy consisting of manual therapy and the PNF method seemed to be more effective than the traditional kinesiotherapy in improving functioning of patients with non-specific low back pain.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The patients’ functional ability assessed with the Stratford Back Pain Functional Scale (BPFS) improved significantly in the group treated with both manual therapy and PNF as compared to the group treated with only traditional exercise.

Key Finding #2

Degree of disability as measured by the Oswestry Disability Index (ODI) lowered evenly in all groups

Key Finding #3

Statistically significant decrease in pain on the Visual Analog Scale (VAS) following the 10-day treatment bout and 14 days following said treatment in all groups (PNF + MT, PNF, MT, and exercise)

Please provide your summary of the paper

This is a decent randomized-controlled trial that helps show the value in using manual therapy in conjunction with other treatment options in the low back – specifically PNF. The study states that the patients who had both PNF and MT found significant improvements in their functional abilities. Each group (PNF/MT, MT, PNF, exercise) also had statistical decreases in their pain on the VAS as well as a lowering in score on the ODI. This data was taken at the end of the 10 days of treatment as well as 2 weeks post the treatment bout – both of which showed similar patient outcomes.

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

This article helps demonstrate the positives in using manual therapy in conjunction with other treatments for patients with low back pain. All patients in the combined group had a decrease in pain, and an increase in their functional abilities. The patients who only had manual therapy also had decreases in pain and increases in functional abilities, but may have had more success had their treatments been combined with something else (i.e., PNF or exercise). This just goes to show that manual therapy, as other treatment types, may be most effective when integrated as part of a clinician’s “bag of tools” and not just the definitive tool.

Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial

Author Names

Ferreira, M.; Ferreira, P.; Latimer, J.; Herbert, R.; Hodges, P.; Jennings, M.; Maher, C.; Refshauge, K.

Reviewer Name

Beautiful Reed

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Practice guidelines recommend various types of exercise and manipulative therapy for chronic back pain but there have been few head-to-head comparisons of these interventions. We conducted a randomized controlled trial to compare effects of general exercise, motor control exercise and manipulative therapy on function and perceived effect of intervention in patients with chronic back pain. Two hundred and forty adults with non-specific low back pain ≥3 months were allocated to groups that received 8 weeks of general exercise, motor control exercise or spinal manipulative therapy. General exercise included strengthening, stretching and aerobic exercises. Motor control exercise involved retraining specific trunk muscles using ultrasound feedback. Spinal manipulative therapy included joint mobilization and manipulation. Primary outcomes were patient-specific function (PSFS, 3–30) and global perceived effect (GPE, −5 to 5) at 8 weeks. These outcomes were also measured at 6 and 12 months. Follow-up was 93% at 8 weeks and 88% at 6 and 12 months. The motor control exercise group had slightly better outcomes than the general exercise group at 8 weeks (between-group difference: PSFS 2.9, 95% CI: 0.9–4.8; GPE 1.7, 95% CI: 0.9–2.4), as did the spinal manipulative therapy group (PSFS 2.3, 95% CI: 0.4–4.2; GPE 1.2, 95% CI: 0.4–2.0). The groups had similar outcomes at 6 and 12 months. Motor control exercise and spinal manipulative therapy produce slightly better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects, in patients with chronic non-specific back pain.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Both the spinal manipulative therapy and motor control exercise groups had better short-term function and short-term perceptions of global effect of treatment than the general exercise group.

Key Finding #2

Spinal manipulative therapy did not give better medium- or long-term effects than general exercise.

Key Finding #3

Treatment was not controlled after the first eight weeks. Participants may have had better long-term effects in the exercise group due to subsequent co-interventions sought out following the first eight weeks.

Please provide your summary of the paper

This is a randomized controlled trial to differentiate which package of therapy (spinal manipulative therapy (SMT), motor control exercises, and general exercise) are most effective in a population with non-specific chronic low back pain lasting greater than 3 months. The double-blind trial found that general exercise is not as effective in short-term function and perceptions of global effect of treatment compared to the SMT, and motor control groups. However, general exercise was more effective than the other groups in medium and long-term effects. The was a yearlong study with follow ups at 8 weeks, 6 months, and 12 months. After the first 8 weeks, patients were not required to follow protocol for their group and could find alternative methods of treatment if they so wished.

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

This article builds upon the concept that SMT is potentially more useful in treatment of chronic low-back pain as a stand-alone option than general exercise for short-term function and perceptions of global effect of treatment. However, it also shows that it has a smaller effect on the long-term compared to just general exercise alone. The authors admit that because they did not “package” SMT with a home exercise program (HEP) like the other groups were, that the study may have underestimated the effect of SMT. I think that this just goes to show that if we “package” manual therapy with an effective HEP, we may gain better medium and long-term effects for this population.

Treating low back pain in athletes: a systematic review with meta-analysis

Author Names

Thornton, J.; Caneiro, J.; Hartvigsen, J.; Ardern, C.; Vinther, A.; Wilkie, K.; Trease, L.; Ackerman, K.; Dane, K.; McDonnell, S.; Mocker, D.; Gissane, C.; Wilson, F.

Reviewer Name

Abigail Leigh Reichow

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To summarise the evidence for non-pharmacological management of low back pain (LBP) in athletes, a common problem in sport that can negatively impact performance and contribute to early retirement. Data sources: Five databases (EMBASE, Medline, CINAHL, Web of Science, Scopus) were searched from inception to September 2020. The main outcomes of interest were pain, disability and return to sport (RTS). Results: Among 1629 references, 14 randomised controlled trials (RCTs) involving 541 athletes were included. The trials had biases across multiple domains including performance, attrition and reporting. Treatments included exercise, biomechanical modifications and manual therapy. There were no trials evaluating the efficacy of surgery or injections. Exercise was the most frequently investigated treatment; no RTS data were reported for any exercise intervention. There was a reduction in pain and disability reported after all treatments. Conclusions: While several treatments for LBP in athletes improved pain and function, it was unclear what the most effective treatments were, and for whom. Exercise approaches generally reduced pain and improved function in athletes with LBP, but the effect on RTS is unknown. No conclusions regarding the value of manual therapy (massage, spinal manipulation) or biomechanical modifications alone could be drawn because of insufficient evidence. High-quality RCTs are urgently needed to determine the effect of commonly used interventions in treating LBP in athletes.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Were eligibility criteria for included and excluded studies predefined and specified?

Did the literature search strategy use a comprehensive, systematic approach?

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Were the included studies listed along with important characteristics and results of each study?

Was publication bias assessed?

Cannot Determine, Not Reported, Not Applicable

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Key Finding #1

Spinal manipulation, when used as an adjunct treatment for athletes with both acute and chronic low back pain, was found to be an effective pain management intervention.

Key Finding #2

There is poor-quality evidence that supports the use of massage therapy in conjunction with herbal ointment or thermal magnetic therapy, and spinal manipulation for short-term benefits in treating low back pain in athletes.

Key Finding #3

The evidence supporting the use of manual therapy as a standalone treatment for low back pain in athletes is insufficient, including both spinal manipulation and massage.

Please provide your summary of the paper

Despite the prevalence of low back pain (LBP) in athletes across a variety of sports ranging from 18% to as high as 65%, there is insufficient evidence investigating the efficacy of non-pharmacologic treatment methods in this population. As a result, current treatment for athletes with LBP is modeled after treatment recommendations for the general population. While there are some shared risk factors for developing LBP between athletes and the general population, athletes have a host of risk factors that are unique to the demands of their sport. This population therefore, requires different rehabilitation considerations in order to achieve return to sport. Upon conducting a systematic review and meta-analysis, 14 randomized clinical trials were included in this study that assessed the impact of exercise, biomechanics modifications, and manual therapy on pain (visual analog scale, VAS) and disability (Oswestry Disability Index, ODI) in recreational to international level athletes. Five trials investigated the effects of manual therapy in this population, specifically spinal manipulation and massage. The review found that spinal manipulation, when used as an adjunct treatment for athletes with both acute and chronic low back pain, was found to be an effective pain management intervention. There is poor-quality evidence that supports the use of massage therapy in conjunction with herbal ointment or thermal magnetic therapy, and spinal manipulation for short-term benefits in treating low back pain in athletes. However, the evidence supporting the use of manual therapy as a standalone treatment is insufficient, including both spinal manipulation and massage.

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

Manual therapy, when used in conjunction with other treatment interventions has been shown to improve VAS and ODI scores in athletes with acute and chronic LBP. However, this population is under-researched and requires more high-quality randomized controlled trials to determine if manual therapy, as well as other interventions, are effective treatment options to optimize return to sport.

Manual therapy versus advice to stay active for nonspecific back and/or neck pain: a cost-effectiveness analysis

Author Names

Aboagye, E., Lilje, S., Bengtsson, C., Peterson, A., Persson, U., & Skillgate, E.

Reviewer Name

Hope Reynolds, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Low back and neck pain are the most common musculoskeletal disorders worldwide, and imply suffering and substantial societal costs, hence effective interventions are crucial. The aim of this study was to evaluate the cost-effectiveness of manual therapy compared with advice to stay active for working age persons with nonspecific back and/or neck pain. Methods: The two interventions were: a maximum of 6 manual therapy sessions within 6 weeks, including spinal manipulation/mobilization, massage and stretching, performed by a naprapath (index group), respectively information from a physician on the importance to stay active and on how to cope with pain, according to evidence-based advice, at 2 occasions within 3 weeks (control group). A cost-effectiveness analysis with a societal perspective was performed alongside a randomized controlled trial including 409 persons followed for one year, in 2005. The outcomes were health-related Quality of Life (QoL) encoded from the SF-36 and pain intensity. Direct and indirect costs were calculated based on intervention and medication costs and sickness absence data. An incremental cost per health related QoL was calculated, and sensitivity analyses were performed. Results: The difference in QoL gains was 0.007 (95% CI −0.010 to 0.023) and the mean improvement in pain intensity was 0.6 (95% CI 0.068–1.065) in favor of manual therapy after one year. Concerning the QoL outcome, the differences in mean cost per person was estimated at −437 EUR (95% CI −1302 to 371) and for the pain outcome the difference was −635 EUR (95% CI −1587 to 246) in favor of manual therapy. The results indicate that manual therapy achieves better outcomes at lower costs compared with advice to stay active. The sensitivity analyses were consistent with the main results. Conclusions: Our results indicate that manual therapy for nonspecific back and/or neck pain is slightly less costly and more beneficial than advice to stay active for this sample of working age persons. Since manual therapy treatment is at least as cost-effective as evidence-based advice from a physician, it may be recommended for neck and low back pain. Further health economic studies that may confirm those findings are warranted.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Cannot Determine, Not Reported, or Not Applicable

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

Manual therapy appears to lead to larger clinically meaningful improvements in pain intensity and pain related disability in those with nonspecific back and/or neck pain after one year when compared to those who received evidenced based advice to remain active.

Key Finding #2

Differences in mean costs per person demonstrated that manual therapy achieves better outcomes at lower costs compared advice to stay active, however, the differences in cost were not statistically significant between groups.

Key Finding #3

Overall, manual therapy is more cost-effective than advice to stay active because it is both slightly less costly and results in better health related QoL and improved pain intensity.

Please provide your summary of the paper

Back and neck pain are among the most common reasons individuals seek out medical care. Therefore, it is important to not only understand the effectiveness of various interventions, but also the cost associated with them in order to control the cost imparted on the individual and healthcare system. This cost-effectiveness analysis showed that manual therapy for nonspecific back and/or neck pain is slightly less costly and more effective than advice to remain active among working age individuals. Due to the fact that this analysis was based on a large RCT, it includes minimal risk from confounding differences in prognostic factors between the index and control groups. However, the larger loss-to-follow-up experienced by the index group may have introduced selection bias, although this is not suspected to have affected the conclusions of this study. It is important to note that this study was performed in 2005 and therefore estimated cost per person for both groups are likely to have changed since then, but since this change would affect both groups, the main conclusions of this study should remain valid. Also of importance, this study did not report any methods or data related to how diligently the individuals in the control group followed the advice to remain active. Therefore, this study only represents those who received advice to remain active and should not be used as a comparison between manual therapy and following advice to remain active.

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

The results of this study indicate that manual therapy can be a lower cost, higher impact treatment for those experiencing nonspecific back and/or neck pain when compared to evidence based advice to remain active and education on pain coping strategies. Therefore, if a clinician must chose one over the other, it appears to be more beneficial to focus on manual therapy interventions. However, both groups showed improvements in pain intensity and disability and, therefore, the best treatment for these patients is likely a combination of both manual therapy techniques and advice on remaining active and how to use different pain coping strategies.

Does adding hip strengthening exercises to manual therapy and segmental stabilization improve outcomes in patients with nonspecific low back pain? A randomized controlled trial

Author Names

Fukuda, T. Y., Aquino, L. M., Pereira, P., Ayres, I., Feio, A. F., de Jesus, F. L. A., & Neto, M. G.

Reviewer Name

Abbrianna Robert

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: The literature is unclear on the need for hip strengthening in persons with low back pain (LBP).

Objectives: To investigate the effectiveness of hip strengthening exercises when added to manual therapy and lumbar segmental stabilization in patients with chronic nonspecific LBP.

Methods: Seventy patients with chronic nonspecific LBP were randomly assigned to either the manual therapy and lumbar segmental stabilization group or the manual therapy and lumbar segmental stabilization plus specific hip strengthening group. A 10 cm visual analogue scale and the Rolland-Morris Questionnaire were the primary clinical outcome measures at baseline, at the end of treatment (posttreatment), and 6- and 12-months posttreatment. Hip strength and kinematics were measured as secondary outcomes .

Results: While within-group improvements in pain, disability, and hip extensors strength occurred in both groups, there were no significant between-group differences at posttreatment or follow-ups. Mean difference in changes in pain level between groups at posttreatment and at 6- and 12-month follow-up were 0.5 points (95% confidence interval [CI]: -0.5, 1.5), 0.3 points (95% CI: -0.9, 1.5), and 0.0 points (95% CI: -1.1, 1.1), respectively. The mean differences in changes in disability were 0.8 points (95% CI: -1.3, 2.7), 0.0 points (95% CI: -2.4, 2.4), and 0.4 points (95% CI: -2.0, 2.8), respectively. Finally, we did not observe any between-group differences for any of the other outcomes at any timepoint.

Conclusion: The addition of specific hip strengthening does not appear to result in improved clinical outcomes for patients with nonspecific LBP.

NIH Risk of Bias Score: 12/14

Key Finding #1

Specific hip strengthening exercises, in addition to manual therapy and lumbar segmental stabilization, did not provide additional benfits in pain and function for individuals with nonspecific low back pain.

Key Finding #2

Both groups (manual therapy and lumbar segmental stabilization and specific hip strengthening plus manual therapy and lumber segmnatal stabilization) showed imporvements in pain, disability, and hip extensor strength compared to baseline.

Reviewer Summary:

This study compared the effects of specific hip strengthening exercises when combined with manual therapy and lumbar segmental stabilization to manual therapy and lumber segmental stabilization alone, for individuals with nonspecific low back pain. Although participants in both experimental groups experienced improvements in pain, disability, and hip extensor strength, there was no significant difference between groups in these outcomes. One limitation of this study includes the lack of a home exercise program, as participants were instructed not to perform exercises at home and were seen in physical therapy twice a week. Further, this study did not consider biopsychosocial factors that may be contributing to the individual’s experience of nonspecific low back pain.

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

This study reported that specific hip strengthening exercises did not add any additional benefit to manual therapy and lumbar segmental stabilization for patients with nonspecific low back pain. Since there was improvement in pain, disability, and hip strength overall, these interventions could be used together for positive therapeutic effect. Further, the treatment did not incorporate a home exercise plan or assess biopsychosocial factors, and these components may be beneficial to implement when treating individuals with chronic pain.

Decreased Risk of Low Back Pain During Pregnancy Associated With the Use of Orthopedic Manual Therapy: A Nested Case-Control Study

Author Names

Chang, W, Livneh, H, Chieh-Tsung, Y, Min-Chih, H, Ming-Chi, L, Wei-Jen, C, and Tzung-Yi, T

Reviewer Name

Lauren Schaeffer, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background Recent evidence suggests that the use of orthopedic manual therapy (OMT) may lessen the subsequent risk of low back pain (LBP), but this association has not been examined among pregnant women who are at higher risk of LBP. This study aims to determine whether the addition of OMT to conventional LBP treatment before pregnancy could decrease the subsequent risk of LBP during pregnancy. Methods From Taiwan’s National Health Insurance Research Database, we identified 68,960 women, 20–55 years of age, with first pregnancy between 2001 and 2012. We then performed a nested case-control study in which 3,846 women with newly diagnosed LBP were matched to 3,846 controls according to age and cohort entry year. Multivariate conditional logistic regression was employed to estimate the association between OMT use before pregnancy and LBP during pregnancy. Results OMT users had a lower risk of LBP than did non-users, with an adjusted OR of 0.86 (95% CI, 0.78–0.93). Subgroup analysis showed that women with high intensity use of OMT treatment prior to pregnancy reported the lowest level of LBP during pregnancy by nearly 30%. Conclusion The pre-pregnancy use of OMT treatment significantly decreased LBP risk during pregnancy, especially with high-intensity use. Thus, clinicians may consider recommending OMT for pregnant women to avoid possible obstetric complications during the pregnancy.

NIH Risk of Bias Tool

Quality Assessment of Case-Control Studies

Was the research question or objective in this paper clearly stated and appropriate?

Was the study population clearly specified and defined?

Did the authors include a sample size justification?

Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?

Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?

Were the cases clearly defined and differentiated from controls?

If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible?

Was there use of concurrent controls?

Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?

Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?

Were the assessors of exposure/risk blinded to the case or control status of participants?

Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?

Key Finding #1

Orthopedic manual therapy interventions before pregnancy are significant in decreasing low back pain during pregnancy.

Key Finding #2

There is an inverse relationship with intensity of orthopedic manual therapy and risk of low back pain during pregnancy.

Please provide your summary of the paper

This study retrospectively investigated the effect of orthopedic manual therapy intervention on decreasing the risk of low back pain (LBP) during pregnancy. Low back pain was defined based on ICD-9-CM code as the diagnosis with at least 3 outpatient visits (within a year) or 1 inpatient visit all indicating the appropriate code for low back pain as the primary diagnosis. First-time pregnant patients between 20 and 55 years old with and without low back pain were recruited. The control group randomly selected 3846 patients without LBP that corresponded with the index date, age, and baseline characteristics including income and comorbidities of the intervention group 3846 participants. The focus was to determine if orthopedic manual therapy and the intensity of the intervention decreased the risk for developing low back pain. Logistic regression models determined that orthopedic manual therapy correlated with a decreased risk of low back pain with an inverse dose-dependent relationship. Ultimately, the higher intensity of the therapy, the lower risk of LBP occurring during pregnancy. This study included a large sample size and structurally had minimal bias; however, there are several limitations including the inability to determine the type of manual therapy performed, subject information, and potential inconsistent diagnosis with ICD-9-CM codes which may compromise the validity of the study. Due to the potential anti-inflammatory effects that orthopedic manual therapy is hypothesized to provide, further investigation of the benefits of OMT in reducing pregnancy-related low back pain may provide a conservative method for LBP treatment and reduce negative pregnancy-related side effects of NSAIDs.

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

This study supports orthopedic manual therapy as a dose-dependent intervention to reduce the risk of low back pain associated with pregnancy. This is a great initial investigation into the topic and the results suggest benefits to using orthopedic manual therapy in treatment; however, there are many limitations that should be considered and controlled in future research studies. It is imperative to determine the manual therapy interventions that are being performed and contributing to the reduced occurrence of low back pain. Future studies should consider whether results seen were from a combination of various techniques or the individual effect of specific intervention. Additionally, it will be beneficial to determine the doses that permit the greatest improvements. Ultimately, establishing if specificity matters in the treatment will help determine the impact of the findings in clinical practice and which treatments to implement in the clinic.

Short-term effect of spinal manipulation on pain perception, spinal mobility, and full height recovery in male subjects with degenerative disk disease: A randomized controlled trial

Author Names

Vieira-Pellenz, F., Oliva-Pascual-Vaca, Á., Rodriguez-Blanco, C., Heredia-Rizo, A. M., Ricard, F., & Almazán-Campos, G

Reviewer Name

Marie-Adelaide Robinson, SPT

Reviewer Affiliations

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Objective: To evaluate the short-term effect on spinal mobility, pain perception, neural mechanosensitivity, and full height recovery after high-velocity, low-amplitude (HVLA) spinal manipulation (SM) in the lumbosacral joint (L5-S1). Design: Randomized, double-blind, controlled clinical trial with evaluations at baseline and after intervention. Setting: University-based physical therapy research clinic. Participants: Men (N=40; mean age ± SD, 38±9.14y) with diagnosed degenerative lumbar disease at L5-S1 were randomly divided into 2 groups: a treatment group (TG) (n=20; mean age ± SD, 39±9.12y) and a control group (CG) (n=20; mean age ± SD, 37±9.31y). All participants completed the intervention and follow-up evaluations. Interventions: A single L5-S1 SM technique (pull-move) was performed in the TG, whereas the CG received a single placebo intervention. Main Outcome Measures: Measures included assessing the subject’s height using a stadiometer. The secondary outcome measures included perceived low back pain, evaluated using a visual analog scale; neural mechanosensitivity, as assessed using the passive straight-leg raise (SLR) test; and amount of spinal mobility in flexion, as measured using the finger-to-floor distance (FFD) test. Results: The intragroup comparison indicated a significant improvement in all variables in the TG (P<.001). There were no changes in the CG, except for the FFD test (P=.008). In the between-group comparison of the mean differences from pre- to postintervention, there was statistical significance for all cases (P<.001). Conclusions: An HVLA SM in the lumbosacral joint performed on men with degenerative disk disease immediately improves self-perceived pain, spinal mobility in flexion, hip flexion during the passive SLR test, and subjects’ full height. Future studies should include women and should evaluate the long-term results.