Julie M. Fritz

Professor, Department of Physical TherapyAssociate Dean for Research,

College of HealthUniversity of Utah

The University Of UtahDepartment of Physical Therapy

Common Therapies for Back Pain:

Manual Therapies

The University of UtahDepartment of Physical Therapy

Manual Therapies Encompasses a broad array of treatments provided

by several different professional disciplines.

manual therapy: the use of hands-on techniques to evaluate, treat, and improve the status of neuro-musculoskeletal conditions

– Soft Tissue Techniques

– Joint Techniques

The University of UtahDepartment of Physical Therapy

What Do Patients with Back Pain Think About Manual Therapies?

Sherman et al, Spine 2004

The University of UtahDepartment of Physical Therapy

What Do Patients with Back Pain Think About Manual Therapies?

Surgery

Massage

Manipulation

Strength Exercises

Aerobic Exercise

Pain Medication

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Completely disagree

Somewhat Disagree

Neutral

Somewhat Agree

Completely Agree

Data from 371 patients with back pain receiving physical therapy

The University of UtahDepartment of Physical Therapy

Manipulation - Definitions

NIH/NCCAM

Manipulation = “The application of a controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems.”

The University of UtahDepartment of Physical Therapy

Manipulation - Definitions

Guide to Physical Therapy Practice-

Mobilization/Manipulation = “A manual therapy technique comprised of a continuum of skilled passive movements to joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement”

The University of UtahDepartment of Physical Therapy

What is the Evidence for Manipulation for Low Back Pain?

Practice Guideline Acute LBP Chronic LBP

American College Physicians (2007) Recommended Recommended

American College of Occupational and Environmental Medicine (2010)

Recommended“Manipulation or mobilization for

select acute LBP based on Clinical Prediction Rule”

Recommended“Manipulation or mobilization

for sub-acute LBP

Not RecommendedRegular or routine manip-ulation or mobilization (several times a month for years)

The University of UtahDepartment of Physical Therapy

What is the Evidence for Massage for Low Back Pain?

Practice Guideline Acute LBP Chronic LBP

American College Physicians (2007) Not recommended“Evidence is insufficient”

Recommended

American College of Occupational and Environmental Medicine (2010) Recommended

Recommended“Time limited use as adjunct to

conditioning program”

Spinal Manipulative Therapy for Chronic Low Back PainHigh-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. (2011)

Spinal Manipulative Therapy for Acute Low Back Pain SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation. (2013)

The University of UtahDepartment of Physical Therapy

Six economic evaluations were included which evaluated the cost-effectiveness of SMT compared to other treatment options for people with neck and back pain.

Regardless of the perspective employed or the region of pain, SMT appears to be a cost-effective treatment when used alone or in combination with GP care or advice and exercise compared to GP care alone, exercise or any combination of these.

2012

Massage for Low Back PainMassage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.(2009)

The University of UtahDepartment of Physical Therapy

Some Observations on the Evidence Findings from primary research studies and

guidelines/reviews offer conflicting recommendations.

Systematic reviews often focus on isolated comparisons of manipulation to alternative treatments

Practice guidelines focus on more comprehensive management decisions including considerations of:

– costs

– patient preferences/expectations

– alternatives

The University of UtahDepartment of Physical Therapy

“The limited data available do not provide support for a hypothesis that RCTs of manual therapy for NSLBP show a greater therapeutic effect when participating clinicians have discretion regarding treatment selection.”

The University of UtahDepartment of Physical Therapy

Some Observations on the Evidence

Manipulation and massage cover a diverse set of techniques

Little evidence that selection of a particular technique or provision by a particular provider-type impacts outcomes

The University of UtahDepartment of Physical Therapy

Some Recent Trials of Note

401 patients age 21-65 with non-specific chronic LBP

Treatment groups:– Structural massage: intended to identify and alleviate musculoskeletal

contributors to back pain, comprised myofascial, neuromuscular, and other soft-tissue techniques. Therapists could recommend a home exercise consisting of psoas stretch to enhance and prolong any benefits of structural massage.

– Relaxation massage: intended to induce general sense of relaxation, using effleurage, petrissage, circular friction, vibration, rocking and jostling, and holding. Therapists could provide a compact disk of a 2.5-minute relaxation exercise to be done at home to enhance and prolong treatment benefits.

– Usual Care: no special care provided.

RESULTS

Treatment adherence was 93% for relaxation massage and 88% for structural massage

Compared to usual care, RDQ scores were 2.9 points lower (95% CI,

1.8, 4.0) for relaxation massage and 2.5 points (CI, 1.4, 3.5) lower for structural massage

There were no differences between the two types of massage

4% relaxation massage recipients and 7% structural massage recipients reported adverse events possibly related to massage, mostly increased pain.

The University of UtahDepartment of Physical Therapy

131 Patients with LBP Referred to Physical Therapy

Manipulation + Stabilization

Exercise

Stabilization Exercise

R

+Manipulation

responder

Childs JD, Fritz JM, Flynn TW, et al. A Clinical Prediction Rule To Identify Patients with Low Back Pain

Most Likely To Benefit from Spinal Manipulation: A Validation Study. Annals Intern Med, Dec. 2004

▬Manipulation

responder

+Manipulation

responder

▬Manipulation

responder

The University of UtahDepartment of Physical Therapy

Significant Group x Responder Status x Time interaction

From Childs et al. Annals Intern Med, Dec. 2004

112 LBP patients + Manipulation Responder(at least 4 of the following: duration<16 days, no symptoms below knee(s), stiffness,

decreased hip int rotation, low fear avoidance beliefs)

Supine Manipulation (n=37)

1-Week

Side-Lying Manipulation (n=38) Supine Mobilization (n=37)

4-Week

6-Month

R

Cleland JA, Fritz JM, Kulig K, et al. Spine, Dec 2009

The University of UtahDepartment of Physical Therapy

Oswestry

0

5

10

15

20

25

30

35

40

Baseline 1-Week 4-Weeks 6-Months

Osw

estr

y S

core

Supine Thrust Manipulation

Side-Lying Thrust Manipulation

Non-Thrust Manipulation

** *

The University of UtahDepartment of Physical Therapy

Summary Manual therapies are commonly used by many

types of providers for patients with back pain.

Patients generally view manual therapies favorably.

Like most treatments for back pain, treatment effects are modest.

More research needed to optimize use of manual therapies for patients with back pain.

The University of UtahDepartment of Physical Therapy

Thank you