Author Names
Daniels, C., Cupler, Z., Gliedt, J., Walters, S., Schielke, A., Hinkeldey, N., Golley, D., & Hawk, C.
Reviewer Name
Sarah Stokes, SPT
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Division
Paper Abstract
Abstract Background and Purpose Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events. Methods Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events. Results Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria. Conclusion There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.
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?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Yes
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
There is a lack of quality research regarding the use of manual and manipulative therapy following lumbar surgery, so no conclusions about its efficacy can be drawn from the existing literature.
Key Finding #2
No significant adverse events from the use of manual therapy following lumbar surgery were found in any of the studies.
Key Finding #3
Some evidence suggests that following a lumbar fusion surgery, patients benefit more from a combination of neural mobilization and stabilization exercise than a combination of myofascial release and stabilization exercises or solely stabilization exercises.
Please provide your summary of the paper
Manual therapy is commonly used in the treatment of chronic low back pain, however there is a lack of consensus on the use of manual therapy for post-surgical patients. The authors sought to evaluate the current research regarding the use of manual therapy in patients post-lumbar surgery through a systematic review. 51 studies were reviewed including case reports, randomized control trials, systematic reviews, narrative reviews, and cross-sectional surveys. Findings were grouped by type of lumbar surgery. A lack of quality research specific to the use of manual therapy following discectomies, disc replacements, and lumbar fusion made it difficult to create recommendations for or against the use of manual therapy following these procedures. For laminectomy, one randomized control trial found that grade 3 or 4 mobilizations post-surgery increase lumbar extension ROM but had no effect on pain or function. However, there is no other evidence available for laminectomies, so no conclusions can be drawn based on this one study. For lumbar fusion, there is some evidence to suggest that neural mobilizations in conjunction with stabilization exercises has a greater effect than myofascial release in conjunction with stabilization exercises or stabilization exercises alone. There is no evidence, however, for the use of manual or manipulative therapies following lumbar fusion. Overall, the lack of research on this topic makes it difficult for any recommendations for or against the use of manual therapy for patient post-spinal surgery and identifies an area in need of further research in the profession.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
There is a significant gap in the literature regarding the use of manual and manipulative therapies for patients who have had lumbar surgeries. This is important research to have because many of the individuals who undergo these procedures will have recurrence of chronic low back pain post-surgery. Some of the low-level studies suggest that manual therapy could be a viable pain management strategy for this population, but more research is needed to draw any conclusions. While there is a CPG for chronic low back pain, there are no existing guidelines for the treatment of this special sub-section of the chronic low back pain population regarding the use of manual therapy. One positive finding from the current research is that of all 51 studies included in this systematic review, none had any adverse events following the application of manual therapy. This means, at the very least, manual therapy is not significantly harmful to this population. The use of manual therapy for the treatment of patients post-lumbar surgery lacks high-quality research and no findings from this paper can be applied to clinical practice. This topic must be investigated further in order to determine how to best treat this patient population.
