Review
Patient-centered outcomes of high-velocity, low-amplitude spinal manipulation for low back pain: A systematic review

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Abstract

Low back pain (LBP) is a well-recognized public health problem with no clear gold standard medical approach to treatment. Thus, those with LBP frequently turn to treatments such as spinal manipulation (SM). Many clinical trials have been conducted to evaluate the efficacy or effectiveness of SM for LBP. The primary objective of this paper was to describe the current literature on patient-centered outcomes following a specific type of commonly used SM, high-velocity low-amplitude (HVLA), in patients with LBP. A systematic search strategy was used to capture all LBP clinical trials of HVLA using our predefined patient-centered outcomes: visual analogue scale, numerical pain rating scale, Roland-Morris Disability Questionnaire, and the Oswestry Low Back Pain Disability Index. Of the 1294 articles identified by our search, 38 met our eligibility criteria. Like previous SM for LBP systematic reviews, this review shows a small but consistent treatment effect at least as large as that seen in other conservative methods of care. The heterogeneity and inconsistency in reporting within the studies reviewed makes it difficult to draw definitive conclusions. Future SM studies for LBP would benefit if some of these issues were addressed by the scientific community before further research in this area is conducted.

Introduction

Low back pain (LBP) is a well-recognized public health problem with lifetime prevalence ranging from 11% to 84% and median cost per quality-adjusted life year of $13,015 (Dagenais et al., 2008, Walker, 2000). Point prevalence within the last 3 months is estimated at 17% (Deyo et al., 2006). At the most recent meeting of the Tenth International Forum for Primary Care Research on Low Back Pain participants concluded that “the LBP epidemic remains a burden in Western countries” (Pransky et al., 2011).

There is no single standard approach to medical care for LBP. Carey et al. recently conducted a survey examining health care utilization patterns in patients with chronic LBP (Carey et al., 2009). They found high health care utilization in this group, with an average of 21 visits to 2.7 provider-types annually. Many of the tests and treatments used did not conform to evidence-based practice. The authors concluded that (1) care utilization for chronic LBP is very high, including high use rates for advanced imaging, narcotics, and physical treatments; (2) use of evidence-based treatments are low when compared with current best evidence; and (3) many treatments are over-utilized. A recent review of clinical practice guidelines for the treatment of LBP found that acute LBP management recommendations included three interventions: patient education, acetaminophen or nonsteroidal anti-inflammatory and spinal manipulation (Dagenais et al., 2010).

Spinal manipulation (SM) is commonly used to treat low back pain (LBP). SM is the therapeutic application of a load (force) to specific body tissues (usually vertebral joints). Load delivery varies with respect to velocity, amplitude, frequency, choice of lever, and direction of force application (Herzog, 2000, Triano, 2000).

Because little is understood about the pathophysiology of most LBP, and the exact mechanism(s) of action of SM’s effect on LBP is largely unknown, clinical trials have primarily depended upon patient-perceived outcomes such as pain level and functional health status (Bronfort et al., 2008, Lawrence et al., 2008). These have traditionally been considered “soft” outcomes by the scientific community. However, the recent creation of the Patient-Centered Outcomes Research Institute (PCORI) in Washington, DC within the 2010 Patient Protection and Affordable Care Act by the US Congress has brought more focus and a growing acceptance of patient-perceived or “patient-centered” outcomes, at least in the context of comparative effectiveness research. While this has been a recent phenomenon, a patient-centered perspective has always been the primary focus of SM research because of a lack of other available outcomes. A recent article found that the most commonly used patient-based outcome assessments in chiropractic SM research were a mix of both pain and functional health status measures, including the Visual Analogue Scale (VAS), the Numerical Rating Scale (NRS), the Roland Morris Disability Questionnaire (RM), the Oswestry Low Back Pain Disability Index (OSW) and the Short Form-36 (SF-36) (Khorsan et al., 2008).

Numerous systematic reviews evaluating the effects of various SM techniques for low back pain have been conducted over the past 10 years (Assendelft et al., 2003, Bronfort et al., 2010, Ferreira et al., 2003, Furlan et al., 2010, Koes et al., 2010, Pengel et al., 2002, Rubinstein et al., 2011, van Tulder et al., 2005, van and Koes, 2006, Walker et al., 2010). The majority have found that SM conveys a modest but consistent benefit for patients with LBP at least as large as commonly used alternative treatments. This is despite marked heterogeneity in study design and quality.

Our review is unique in that only studies comparing high-velocity, low-amplitude (HVLA) SM are included – because HVLA SM is commonly used both in clinical trials and in the clinical setting (Christensen et al., 2010). We also present these data in a way that allows us to separately consider the data from specific patient-centered outcome instruments. In this paper we present tables showing the two most commonly used pain rating scales (NRS and VAS) and the two most commonly used patient-reported measures of low back function (RM and OSW) in order to discern both similarities and differences in use and meaning. Included studies were restricted to those whose primary or secondary outcome was VAS, NRS, RM, and/or OSW. This allowed us to concentrate on studies that had similar outcome measures, decreasing heterogeneity while still including the most recent studies available. The primary objective of this paper was to describe the current literature on patient-centered outcomes in randomized controlled trials of HVLA SM in patients with low back pain.

Section snippets

Sources of information

The relevant studies were identified using the following databases: PubMED (an index to Medline), the Cochrane Library, and Index to Chiropractic Literature (ICL). All databases were searched from inception through April 2011.

Search terms and delimiters

Search terms for all databases (except ICL) were “low back pain” OR “back” OR “back pain” OR “back injuries” OR “sciatica” OR “LBP” AND “manip*” OR “mobili*” OR “manual therap*.” The ICL database was searched using “low back pain” OR “back” OR “back pain” OR “back

Results

Of the 1294 articles identified by our initial search, 38 articles met the selection criteria (Fig. 1). The first three tables show studies that were: (1) excluded based on abstract (Table 1); (2) excluded based on full article assessment (Table 2); and (3) included (Table 3). Table 4, Table 5, Table 6, Table 7 give with-in group mean changes and between-group mean differences with 95% CIs of the VAS, NRS, RM and OSW, respectively, for the studies included in this review. Below is a description

Discussion

Although this review specifically focused on studies with HVLA SM as the primary treatment of interest, our findings are consistent with those found in the latest reviews of SM for LBP that incorporate the most recently published trials (Assendelft et al., 2003, Bronfort et al., 2010, Ferreira et al., 2003, Furlan et al., 2010, Koes et al., 2010, Pengel et al., 2002, Rubinstein et al., 2011, van Tulder et al., 2005, van and Koes, 2006, Walker et al., 2010). We agree with previous conclusions

Conclusion

We found that HVLA SM for LBP appears to convey a small but consistent treatment effect at least as large as that seen in other conservative methods of care. This finding is similar to that in other systematic reviews of SM of LBP. The heterogeneity and inconsistency in reporting within the studies reviewed makes it difficult to draw definitive conclusions or adequately summarize patient-centered outcomes for clinical trials of HVLA SM for LBP. These are issues that should be addressed by the

Acknowledgments

We gratefully acknowledge the contributions of: clinical research fellows James Boysen, Christopher Woslanger, Julie Kumar, Christopher Roecker, Amin Neekomand, and Connie Mitchell; summer intern Laura Macko; Ying Cao; Leah Cafer; and Paige Morgenthal for help in literature searching, data extraction and manuscript preparation. We also thank Dana Lawrence and Joel Pickar for their critical review of the manuscript.

Christine M. Goertz, D.C., Ph.D. is Vice Chancellor of Research and Health Policy at Palmer College of Chiropractic and currently serves on the Board of Governors for the Patient Centered Outcomes Research Institute, is a member of the American Medical Association PCPI Measurement, Instrumentation and Evaluation Committee and Chair of the American Chiropractic Association Performance Measurement Task Force. She received her Doctor of Chiropractic (D.C.) degree from Northwestern Health Sciences

References (47)

  • R. Khorsan et al.

    Measures in chiropractic research: choosing patient-based outcome assessments

    J Manipulative Physiol Ther

    (2008)
  • D.J. Lawrence et al.

    Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis

    J Manipulative Physiol Ther

    (2008)
  • R.W. Ostelo et al.

    Clinically important outcomes in low back pain

    Best Pract Res Clin Rheumatol

    (2005)
  • J.J. Triano et al.

    Procedural skills in spinal manipulation: do prerequisites matter?

    Spine J

    (2004)
  • M.W. van Tulder et al.

    Complementary and alternative therapies for low back pain

    Best Pract Res Clin Rheumatol

    (2005)
  • W.J. Assendelft et al.

    Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies

    Ann Int Med

    (2003)
  • C. Bombardier et al.

    Minimal clinically important difference. Low back pain: outcome measures

    J Rheumatol

    (2001)
  • G. Bronfort et al.

    Effectiveness of manual therapies: the UK evidence report

    Chiropr Osteopat

    (2010)
  • T.S. Carey et al.

    A long way to go: practice patterns and evidence in chronic low back pain care

    Spine (Phila Pa 1976)

    (2009)
  • R. Chou et al.

    Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society

    Ann Int Med

    (2007)
  • Christensen MG, Kollasch MW, Martin W, Hyland JK. Practice Analysis of Chiropractic 2010: A project report, survey...
  • R.A. Deyo et al.

    The back pain outcome assessment team

    Health Serv Res

    (1990)
  • R.A. Deyo et al.

    Back pain prevalence and visit rates: estimates from US national surveys, 2002

    Spine (Phila Pa 1976)

    (2006)
  • Cited by (0)

    Christine M. Goertz, D.C., Ph.D. is Vice Chancellor of Research and Health Policy at Palmer College of Chiropractic and currently serves on the Board of Governors for the Patient Centered Outcomes Research Institute, is a member of the American Medical Association PCPI Measurement, Instrumentation and Evaluation Committee and Chair of the American Chiropractic Association Performance Measurement Task Force. She received her Doctor of Chiropractic (D.C.) degree from Northwestern Health Sciences University and her Ph.D. in Health Services Research, Policy and Administration from the University of Minnesota.

    She came to Palmer in January, 2007, with more than 15 years of experience as a scientist and in science administration. She has extensive experience in the administration of Federal grants, as a PI and as a NIH Program Official. Prior to joining the PCCR, she spent 4 years as an independent scientist and in research administration positions of increasing responsibility at the Samueli Institute. Before joining the Institute, she was a Program Officer at the National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health (NIH), managing a $50 million portfolio focused on musculoskeletal disease, pain, and health services research. Prior to the NIH, she was Vice-President of Research and Policy at the American Chiropractic Association and an NIH-funded post-doctoral fellow at the University of Minnesota. Her research interests have focused on CAM treatments for cardiovascular disease and pain.

    Cynthia R. Long is professor and director of research at Palmer College of Chiropractic in Davenport, IA. She was awarded an M.S. in statistics from Iowa State University in 1989 and a Ph.D. in biostatistics from the University of Iowa in 1995. She directs the Office of Data Management and Biostatistics at the Palmer Center for Chiropractic Research and the M.S. in Clinical Research Program at Palmer College.

    James W. Brantingham graduated from Southern California University of Health Sciences with his DC in 1983. In 2000 he became a senior lecturer in the Programme of Chiropractic at the University of Surrey in Guildford, England where in 2005 he earned his PhD. From 2005 until 2011he was the director of research at Cleveland Chiropractic College, Los Angeles. Currently he is a Research Consultant in the areas of spinal and extremity manipulation.

    Robert D. Vining is assistant professor and director of the research clinic at the Palmer Center for Chiropractic Research. He earned his Doctor of Chiropractic from Logan College of Chiropractic in 1989. Prior to joining Palmer, he was Clinic Director at the Logan College of Chiropractic Southroads Health Center and Staff Physician at the VA Medical Center (Jefferson Barracks Division), both in St. Louis, Missouri. He has more than 14 years of experience in private practice. His research interests are in the areas of musculoskeletal diagnosis, radiographic findings as they relate to clinical decision-making for manual therapy providers, and understanding mechanisms associated with spinal manipulative procedures.

    Katherine A. Pohlman is a clinical project manager at the Palmer Center for Chiropractic Research. She earned her Doctor of Chiropractic and MS in Clinical Research from the Palmer College of Chiropractic and is a PhD candidate at the University of Alberta. Her research interests include the safety and effectiveness of spinal manipulative therapy.

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