Manipulation of the Lumbar Spine

Introduction

This page is aiming to analyse and review the effectiveness of manipulations on the lumbar spine and sacroiliac joint (SIJ). Within this the common manipulation technique of the lumbar spine and SIJ will be described, the mechanisms and effects of manipulations will be reviewed, literature around efficacy and safety of lumbar and SIJ manipulations with be appraised and finally the contra-indications to manipulations will be explored.

What is a manipulation

A manipulation is where a therapist passively applies a directed thrust to a joint at the end of physiological range of movement (Rubinstein et al., 2011). This movement often causes an audible sound to be created by the joint (Rubinstein et al., 2011).

The use of manipulations

Lower back pain is the most common musculoskeletal problem globally and had a prevalence of 7.5% across all age groups in the world in 2017 and in the United States life-time prevalence may be as high as 84% (Wu et al., 2020, Balagué, Mannion, Pellisé and Cedraschi, 2012). Manipulations are aften used for patients with chronic non-specific lower back pain to benefit patients with lower back pain (Coulter et al., 2018). Manipulations as part of manual therapy to improve an individual’s movement potential is within a physiotherapists scope of practice (chartered society of physiotherapy, 2020).

When to use lumbar manipulations

https://www.youtube.com/watch?v=vky_6Nv0KK0

Example of a lumbar manipulation

https://www.youtube.com/watch?v=5EwC55PuU90

Mechanisms

Within the literature, the exact mechanism of how spinal manipulation hasn’t been established. It’s indicated that the mechanical stimulus provided by the manipulation causes a wide array of neurophysiological responses as suggested in literature review by Gyer et al, (2019), a selection of which are discussed below:

Motor neurone excitability  

Hyper-excitability of the A motor neuron leads to increased muscle activity, spinal manipulation has been thought to relax hyperactive muscles through modulating the A motor neuron activity.  

Muscle activity

Individuals with LBP experience greater amount of spinal muscle hyperactivity in static postures than healthy participants.

The pain-spasm cycle suggests that pain causes muscular hyperactivity (spasm) and this spasm can cause further pain.  

Pain -> Hyperactivity (spasm) -> Pain  

The mechanical stimulation of spinal manipulation is thought to cause the sensory receptors to inhibit muscle activity - disrupting the pain-spasm-model.

Activation of descending pain modulation  

Spinal manipulation is thought to activate the descending pain modulation circuit, specifically, the serotonin and noradrenaline pathways.

Segmental Inhibition

This theory proposes that nociceptive (small-diameter) A-δ and C sensory fibers carry the pain stimuli to the dorsal horn and “open” the substantia gelatinosa layer, whereas non-nociceptive (large-diameter) A-β fibers inhibit the transmission of pain signals by blocking the entry of A-δ and C fibers. Because mechanical stimulus applied during spinal manipulation may alter peripheral sensory input from paraspinal tissues, it has been presumed that manipulation may influence the gate closing mechanism by stimulating the A-β fibers from muscle spindles and facet joint mechanoreceptors.

Temporal Summation

Temporal summation is an increased perception of pain caused by repetitive nociceptive stimuli – it's related to aspects of central sensitization. Lumbar spine manipulation has been shown to reduce temporal summation of pain.

Endocrine response  

Manipulations at the thoracolumbar segment of the spine could result in excitation of the preganglionic sympathetic cells and subsequent stimulation of mechanoreceptors. These inputs would then travel to several regions of the brain stem and lead to opioid-independent analgesia by influencing the hypothalamus and periaqueductal gray (PAG) in the midbrain. The hypothalamic release of corticotropin-releasing factor would then occur to modulate the SNS and HPA axis response. The neuroendocrine (SNS–HPA axis) system would then release its end products (catecholamines and glucocorticoids) to initiate anti-inflammatory and tissue-healing actions.  

However, there is a lack of research to support with only one study looking at SNS and HPA.

Non-Specific responses  

The relevance of non-specific variables, for example expectations or psychosocial factors. It is not well understood how physiologically these factors effect various factors such as pain or psychological outcome measures, only that the evidence shows that manipulations of the Lower back improve these factors.

Efficacy of lumbar manipulations

Effectiveness as a sole treatment

Spinal manipulation can be used alongside other forms of treatments as well as an individual treatment, the effectiveness as a sole treatment approach is discussed below.

A 2016 systematic review and meta-analysis compared SM with sham manipulation for non-specific LBP showed that a greater reduction in pain scores was present in SM in comparison to those receiving a placebo (Ruddock, Sallis, Ness and Perry, 2016).  

A RCT compared the effectiveness of spinal manipulation and a functional MT technique involving breathing on improving pain, disability, quality of life and fear of movement. Over a short-term period, SM only reduced disability in patients with chronic LBP and the other outcomes weren’t improved. The small sample size (n=62) may be a reason why improvements in disability weren’t clinically significant; it was concluded that SM didn’t result in clinically meaningful short-term benefits (Castro-Sánchez et al., 2016).  

A RCT comparing the effectiveness of region specific and non-region-specific spinal manipulation for improving pain intensity within chronic LBP patients found that both groups experienced immediate decrease in pain intensity (de Oliveira et al., 2013).

Required treatment Sessions  

A study comparing a variety of spinal manipulation treatment sessions found that 12 sessions over a 6-week period yielded the greatest improvement in pain and functional disability. This quantity of treatment saw improvements in pain and functional disability in both the short term (12 weeks) and long term (52 weeks) stages (Haas et al., 2014).

Effectiveness as an adjunct to exercise

Nice guidelines state that for patients with lower back pain manual therapies including manipulation should be considered as a package of treatment including exercise with/ without psychological therapy (National Institute for Health and Care Excellence (2016)). Manipulations are commonly used alongside other therapies, and this has been shown to yield a statistically significantly better outcome in pain and function after 1 month of intervention (Rubinstein et al., 2019).

A randomised control trial by Balthazard, Goumoes, Rivier et al., (2012) analysed the use of manual therapies followed by exercises for patients with chronic nonspecific lower back pain. This study found that manual therapies (including manipulations) followed by exercises provided a statistically significant reduction in pain and disability compared with a sham therapy followed by exercises. This study was conducted on adults (20-65) with chronic nonspecific lower back pain without co-morbidities so may not be generalisable to all populations. Another randomised trial on adolescent (12-18) patients with non-specific lower back pain showed that spinal manipulations alongside exercise is more effective than exercise alone for lower back pain (Evans, Haas, Schulz, 2018).

Manipulations as adjuncts to other treatments for lower back pain such as myofascial release and kinesio taping have been found to produce no significant benefit compared with manipulations alone (Kamali, Sinaei, and Taherkhani,. (2018); Boff, Pasinato, Ben et al., (2020))

Chronic vs acute  

Due to the different mechanisms of pain between acute and chronic pain it is important to analyse the effectiveness of treatments between these two patient groups (Crofford, 2015). The manipulations for chronic lower back pain have been found to be effective in multiple studies (Coulter, Crawford, Hurwitz et al., (2018); Haas, Vavrek, Peterson et al., (2014)).  

A randomised control trial found that manipulations are significantly effective in reducing pain for chronic and sub-acute lower back pain with radiculopathy and improving range of motion (Ghasabmahaleh, Rezasoltani, Dadarkhah et al., 2021). However, all participants to the study were given pain killers (paracetamol and gabapentin) which may have had an effect in reducing pain.  

For patients with acute lower back pain spinal manipulations may not be effective for many of these patients who will recover quickly with or without intervention (Hancock, Maher and Latimer, 2008). Furthermore, a randomised control trial found that patients with acute lower back pain do not recover more quickly with the addition of manipulation to first line care (Hancock, Maher, Latimer et al., (2007)). A Cochrane review be Rubinstein, Terwee, Assendelft et al in 2012 found low to very low-quality evidence suggesting that spinal manipulation was no more effective than other recommended therapies for acute lower back pain.

Safety of Spinal Manipulations

Safety

The research around safety and adverse events in lumbar manipulation is limited by the amount of good quality research. A review by Nielsen et al (2017) looked at spinal manipulation as a whole and show stroke (1 in 20,000–2,000,000 manipulations) or Vertebrobasilar accident (1 in 228,050–1,000,000 manipulations) as the most common serious adverse events. However, these events are caused by cervical manipulations and in the sole study looking at lumbar manipulation, the adverse event caused was lumbar disc hernia which the risk was assessed at 1 in 3.8m. The review was inconclusive about the overall safety of spinal manipulation as 46% conclude it was safe, 13% unsafe and 42% unclear. Further research needs to be done, especially into Lumbar manipulation safety as the anatomy would suggest it to be safer than cervical or thoracic, with most common adverse event being mild soreness, however there is a lack of research in to the area.

Swait and Finch also conducted a review in 2017 on the risks of manual techniques on the spine. 250 articles were included in the review, including observational studies, randomised studies and systematic reviews. Swait and Finch’s findings are in agreement with the findings of Neilson et al 2017. Benign adverse advents are commonplace in both adolescence and adults:

• Benign adverse events are common, affecting 23–83% of adult patients.

• These are mostly mild-moderate, transient (usually resolve within 24 h) and commonly include musculoskeletal pain, stiff-ness and headache.

• Dizziness, tiredness, feeling faint/lightheaded or tingling in the arms might also be experienced following neck treatment.

Serious adverse events appear to be rare and, as a result, estimates of the level of risk are problematic.

• However, cases of serious adverse events, including serious spinal or neurological problems as well as strokes affecting arteries in the neck, have been reported.

• Serious adverse events could result from pre-existing pathologies, therefore assessment for signs or symptoms of these is important.

• Where a serious adverse event is thought to have occurred following manual spinal intervention, use of a patient safety incident reporting system enables dissemination of accurate case details.

Safety of Lumbar Manipulation in Different populations

Under 18

A review by Corso et al (2020) looked at the safety of spinal manipulation in children under 10 years old, using studies from 1990 to 2019.

Most adverse events found were mild (crying or soreness) but once case described a rib fracture to 3-week-old. The incidence of mild adverse events ranges from 0.3% (95% CI: 0.06, 1.82) to 22.22% (95% CI: 6.32, 54.74)

It was inconclusive as to whether spinal manipulative therapy was safe in under 10s. However, had poor study quality and quantity and may have had a conflicting interest as they were mandated by the College of Chiropractors of British Columbia to review the evidence which was the published in a chiropractic journal.

RCTs carried out by Selhorst et al (2015) and Watson et al. (2016) looked at exercise and manual therapy in adolescents and both concluded there were no adverse reactions to the manipulations but also no benefit reported vs exercise alone.

Age 18-65

The review by Rubinstein et al (2019) of patients aged 35-60, found One study powered enough to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT.

Over 65

In a systematic review by De Luca et al (2017), which looked at effectiveness and safety of manipulations in the elderly, they found no conclusive result due the lack of studies investigating the area and the quality of those studies as well as a need for a standardised adverse event reporting system. They also found no difference in the number of adverse events in the ‘sham’ manipulation group vs the intervention group.

References  

Balagué, F., Mannion, A., Pellisé, F. and Cedraschi, C., 2012. Non-specific low back pain. The Lancet, [online] 379(9814), pp.482-491. Available at: <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60610-7/fulltext> [Accessed 22 May 2021].

Balthazard, P., de Goumoens, P., Rivier, G., Demeulenaere, P., Ballabeni, P. and Dériaz, O., 2012. Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial. BMC Musculoskeletal Disorders, [online] 13(1). Available at: <https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-13-162#citeas> [Accessed 24 May 2021].

Boff, T.A., Pasinato, F., Ben, Â.J., Bosmans, J.E., van Tulder, M. and Carregaro, R.L., 2020. Effectiveness of spinal manipulation and myofascial release compared with spinal manipulation alone on health-related outcomes in individuals with non-specific low back pain: randomized controlled trial. Physiotherapy, [online] 107, pp.71-80. Available at: [1] [Accessed 22 May 2021]

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Chartered Society of Physiotherapy (CSP), 2020 CSP Accreditation of Qualifying Programmes in Physiotherapy quality assurance processes. Available at: https://www.csp.org.uk/documents/csp-accreditation-qualifying-programmes-physiotherapyqualityassuranceprocesses [Accessed 22 May 2021].

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