Managing Chronic Low Back Pain Study title: Evidence-informed management of chronic low back pain with spinal manipulation and mobilization Author: Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S Publication information: The Spine Journal 2008; 8: 213-225. Summary: Below C Dr. Shawn Thistle is the founder and president of Research Review Service Inc., an online, subscription- based service designed to help busy practitioners to integrate current, relevant scientific evidence into their practice. Shawn graduated from CMCC and holds an Hon- ours Degree in Kinesiology from McMaster University. He also holds a certificate in Contemporary Medi- cal Acupuncture from McMaster University, and is a Certified Active Release Techniques (ART®) Pro- vider. For more information about the Research Review Service, visit www.researchreviewservice.com. hronic low back pain (CLBP) remains a challenging condition to manage, one that carries a signifi cant socioeconomic burden. There are a plethora of non-sur- gical treatments for CLBP, which can overwhelm stakeholders such as patients, third party payers, health care providers, researchers, and policy makers. Although all involved should strive for the most effective treatment that utilizes minimal health-care resources, there is often clinical uncertainty as to which treatment is most appropriate for the individual patient. In order to better understand the state of existing literature on non-surgical treat- ments for CLBP, the North American Spine Society sponsored a special focus issue of The Spine Journal. This review of spinal manipulation/mobilization was one of the papers featured in this issue. An executive summary of background information and pertinent fi ndings will be presented in this review. TERMINOLOGY: For the purpose of this review, spinal manipulation was defi ned in a standard manner as: the application of a high-velocity, low-amplitude manual thrust applied to the spinal joints “slightly beyond the passive range of motion”. Spinal mobilization was defi ned as the application of a manual force to the spinal joints within the passive range of motion that does not involve a thrust. The authors acknowledge that many subtypes of manipulation exist in manual medi- cine. The most common is called “Diversifi ed”, as it incorporates aspects taught in many of these subtypes. This is the type familiar to most chiropractors. It should be noted that instrument assisted (ex. Activator), and low-force manual procedures were not included for consideration in this review. THEORIES REGARDING MECHANISM OF ACTION: Many hypotheses exist which attempt to explain how spinal manipulation/mobilization (SMT/MOB) exert their effects. Generally, they focus on either the consequences of ap- plying external forces to the tissues of the spine, or the internal neurological effects of these forces. The former has several studies investigating the immediate effects of SMT/ MOB on tissue displacement/deformation including: altering orientation or position of anatomical structures unbuckling of structures release of entrapped structures disruption of tissue adhesions • • • • It is however, the latter idea of internal neurological effects that has the greatest body of evidence indicating that SMT/MOB impacts primary afferent neurons in paraspinal tissues, the motor system in general, and various pain pathways. The authors emphasize that, at present, the exact mechanism(s) of action for SMT/MOB remain unknown. Al- though this does not negate their clinical effi cacy, it has likely hindered the widespread acceptance of these techniques by the broader scientifi c and healthcare communities. INDICATIONS AND CONTRAINDICATIONS TO SMT/MOB: 12 • CANADIAN CHIROPRACTOR | JUNE 2008 Various countries and organizations have established clinical practice guidelines for the www.canadianchiropractor.ca Shawn Thistle, BKin (Hons), DC, CSCS
Chiropractic + Naturopathic Doctor June 2008: Page 12
